Telehealth: Déjà vu all over again?

By Dr. Joel Cooper  |  October 6, 2020  |  Industry Shifts, Working in Healthcare

History tends to repeat itself. And telehealth offers us a striking example.

The COVID-19 pandemic has made telehealth the undeniable centerpiece of our healthcare system in fewer than ten months. Telehealth’s growth has been nothing short of stellar.

It’s predicted to become a quarter-trillion-dollar post-COVID-19 reality, according to a recent McKinsey report.

But telehealth has important parallels with urgent care, and they’re giving some physicians serious pause, with a fight brewing between marketplace forces and major medical associations.

In one corner are the major retail telehealth players such as Teladoc, Amwell, and MDLive, which have the resounding support of healthcare consumers as evidenced by the greatly expanded use of telehealth services.

In the other corner are major players such as the American Academy of Family Physicians (AAFP), with its 136,700 members across the US and internationally.

Although AAFP supports greater access to care for patients made possible by telehealth, the organization has many compelling concerns.

AAFP fears that retail telehealth providers might “undermine the (patient-centered) medical home (model) and fracture relationships and care.”

Further fragmentation of our nation’s healthcare delivery system is almost certainly a given. The more choices consumers are given, the more they will take the path of least resistance.

Primary care offers patients preventive care, early diagnosis, continuity of care, appropriate management of chronic disease, referrals to subspecialists, and enhanced quality of life throughout the life cycle. But primary care demands more of healthcare consumers and is not always so easy to access.

There is a growing fear that consumers will use telehealth as a substitute for primary care, compromising the patient-PCP relationship, which has already suffered during our public health emergency.

There is also the fear that health inequities will not be addressed by the big retail telehealth companies. Indeed, both Teladoc and Amwell are public companies having to answer to shareholders as well as patients. People who can easily hop online and pay for their telehealth visits will do fine, whereas individuals with neither the ability to pay nor requisite technological savvy will be left out in the cold.

“The AAFP supports expanded use of telehealth as an appropriate and efficient means of improving health, when conducted within the context of appropriate standards of care,” says AAFP.

But what exactly constitutes “appropriate standards of care?”

Who should define these standards, healthcare pundits in ivory towers, telehealth docs on the front lines of virtual care, healthcare consumers with the power of the purse in a competitive marketplace swayed by patient-satisfaction scores, and Google reviews…or someone else?

There are now 9,616 urgent care clinics in the U.S., according to the Urgent Care Association, and the urgent care market size is forecast to reach $30.6 billion by 2025.

Urgent care flourished into a multi-billion-dollar industry largely because patients did not have primary care physicians, could not get in to see their PCPs in a timely manner, or simply preferred the convenience of urgent care.

Adding insult to injury was an overburdening of primary care physicians with dramatically increased patient volume, which was thought necessary to compensate for shrinking reimbursements and higher overhead.

PCPs couldn’t prevent urgent care clinics and pharmacy-based healthcare providers from popping up on every street corner in America – marketplace forces were too strong.  And urgent care took patient visits away from them.

At the same time, health plans applauded urgent care, since it logically seemed to mean fewer acutely ill patients going to much more costly ERs.

Yet overall health system costs continued to rise, because urgent care, quite apart from doing what it was supposed to do – namely, reduce ER visits – created its own robust demand.

And now we’ve come full circle – retail telehealth serves as the latest poster child for “convenience care.”

Retail telehealth threatens to take even more patients away from our nation’s PCPs at a time when many PCPs are already struggling financially to the point of near-collapse amid the COVID-19 crisis.

Any government or private payor support of telehealth must consider the current plight – and largely unmet promise — of primary care.

Telehealth as an access expander is a good thing. But like any shiny object in the room, it can easily divert attention away from what matters most: quality care yielding the best outcomes.

If telehealth further fragments our system and encourages multiple quick fixes among healthcare consumers instead of enduring evidence-based primary care, its value should be scrutinized and relentlessly questioned.

About the author:

Dr. Joel Cooper is a board-certified family physician in the Phoenix, Arizona area. He has many years of experience practicing medicine in the clinic environment and has been working exclusively as a telehealth doctor from home since May of this year. He is also a professional medical writer/reporter and award-winning journalist. He may be reached at:

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