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How Telehealth is Changing Healthcare · CareTalk: Healthcare. Unfiltered.

• 0:01
  - Welcome to CareTalk, America's home for incisive debate about healthcare, business, and policy.
• 0:06
  I'm David Williams, president of Health Business Group.
• 0:10
  - And I am John Driscoll, CEO emeritus of CareCentrix and the incoming president of healthcare at Walgreens.
• 0:18
  David, I got a promotion.
• 0:21
  - Well, John, it's about time, and you know what?
• 0:23
  I don't know if they're paying you anymore, but I'm glad they gave you a hat at least, you know?
• 0:26
  That's like-- I got a great hat.
• 0:29
  - That looks like an awesome hat.
• 0:30
  Well, Walgreens, John, that is an outstanding company.
• 0:32
  We've talked about them for sure on the show.
• 0:34
  Congratulations to you and all CareCentrix team.
• 0:39
  I'm gonna expect more from you though, John.
• 0:40
  We expect more from a leader.
• 0:42
  - Well, (laughs).
• 0:44
  Well, I think that Walgreens is an extraordinary opportunity to show what the lower paid, but constantly in contact with patients clinicians can do.
• 0:55
  I think it's a really amazing platform to leverage, not just the assets of Walgreens and so you should watch your own, whatever, David, but also all of these wonderful, the 90,000 clinicians, the pharmacists, and pharm techs who work at Walgreens.
• 1:15
  And the fact that Walgreens is within three miles of every household in the U.S.
• 1:20
  gives us an amazing opportunity to potentially lower costs and improve outcomes.
• 1:23
  But David, we are here to talk about your sort of old fashioned view, again,- Yeah.
• 1:30
  - of technology.
• 1:31
  So telehealth,- For sure.
• 1:32
  Yeah.
• 1:34
  - Let's start with not why you are against it, why you don't understand it, but perhaps we could start by just defining what is telehealth?
• 1:44
  - Well, John, it's a good question.
• 1:45
  I mean, I think about telehealth as really sort of care at a distance.
• 1:48
  It certainly implies, you know, a telephone.
• 1:51
  And that's how it was originally used about you getting care by calling the doctor and getting a review.
• 1:57
  Sometimes, it was actually one doctor talking to another doctor.
• 2:00
  But the way I think about it, it's care at a distance, John.
• 2:02
  You had a patient, you have a provider, and they're not in the same room, but the provider's caring for the patient.
• 2:08
  - And David, people like you prevented telehealth from expanding for decades.
• 2:15
  The telephone was created by Bell over a hundred years ago.
• 2:22
  - Yeah.
• 2:23
  - We've had cell phones and smartphones for almost 20 years.
• 2:29
  It took a public health emergency and COVID, really to break this open as an opportunity.
• 2:36
  I think that's crazy, but maybe you could give some context for why, you know, creakiness people like yourself who didn't wanna innovate, thought telehealth and where we stand today post the public health emergency or COVID.
• 2:51
  - Well, John, if I had any concerns that you working for one of these big companies was gonna soften the edges, I guess they haven't had a chance to bring in the image shakers yet.
• 3:00
  So I'm glad to have you while you're still calling me out.
• 3:03
  like how you see it.
• 3:04
  John, here's what happened with telehealth.
• 3:06
  You know, physicians got paid typically for when someone would come to the office.
• 3:10
  And then when the telephone came, they found themselves answering the phone and not getting paid for it.
• 3:15
  And so even though we had the internet, as you said for some time, in fact around the year 2000 is when this, you know, sort of versions of telehealth started, it was very slow to catch up because when emails started to come, doctors said,"Hey, email's gonna be like the phone.
• 3:32
  I'm not gonna get paid for it.
• 3:33
  I don't wanna do it." And that's one of the things that's really has slowed it down.
• 3:37
  Now, John, the public health emergency, what happened, of course, is that the physicians are only gonna do what they could get paid for.
• 3:43
  And when the pandemic came and all of a sudden, offices were shut.
• 3:48
  And the only way you could have an appointment was via telehealth.
• 3:51
  Well then, like you said, it exploded and it really exploded, John.
• 3:55
  For example, in Medicare, which had offered some telehealth, it went up by a factor of 63 from 2019 to 2020.
• 4:04
  And so you'd seen a chart that looks like this.
• 4:06
  You know, like 0.3% of Medicare eligible patients had used telehealth in 2019.
• 4:12
  And it went up way up, just like completely off.
• 4:15
  - It was the only way you could actually see and talk to a doctor.
• 4:20
  You know, the reality is that telehealth or asynchronous or synchronous care at the same time or care delivered or recommended at different times via technology has been available, to your point, since the internet that there were innovators like Teladoc and and MDLIVE and others that were aggregators of technology that they would provide to doctors.
• 4:45
  But doctors fought it because, to your point, they're already working on the habit trail of hard work, feeling like they're running up the down escalator with all of the work they have and all the paperwork they have.
• 4:58
  Insurance companies didn't like to pay for it because their fear was that it's just, you know, another thing to pay for between the time a person actually gets to see the doctor.
• 5:09
  But I think what we saw under the crisis of a time when the most dangerous thing you could do, one of the most dangerous things you could do outside of getting COVID was visiting a place where people with COVID were getting care was actually leveraging technology.
• 5:26
  I mean, we did it with home health agencies.
• 5:29
  Doctors did it in their offices.
• 5:31
  Mental health specialists did it over the phone.
• 5:35
  And whether it's video or chat.
• 5:38
  And chat could be in real time or it could be text.
• 5:41
  I think a lot of patients actually felt really good about it.
• 5:45
  It was like a one-time massive social test.
• 5:48
  So take that, you anti-technology regulator.
• 5:55
  What do you have to say about it now?
• 5:57
  - Well, John, certainly what happened, you know, was that this also occurred, the emergency occurred at the same time that people were already starting to use, you know, video conferencing, desktop video conferencing like Zoom in particular and all the other competitors.
• 6:10
  So, John, listen people are ready to do it.
• 6:13
  So if you think about, you know, who's the most tech savvy?
• 6:16
  It tends to be the younger people in general and who needs care the most?
• 6:19
  It's the older people.
• 6:19
  - Ageist.
• 6:20
  - No.
• 6:20
  - Ageist.
• 6:21
  You are insulting people like me who are over the age of 60.
• 6:24
  - No.
• 6:25
  - Stop it.
• 6:26
  - You're not over the age of 60.
• 6:28
  - If you look at what happened during the public health emergency, people over the age of 65, David, take that, actually enjoyed using technology.
• 6:38
  They don't all have access to smartphones.
• 6:41
  And not all of them have technology savvy kids like yours or grandchildren like yours.
• 6:46
  I don't know how old you really are anymore.
• 6:50
  - And they found that the phone and the computer, the society found that Medicare eligibles actually rather enjoyed using technology.
• 7:01
  And it became a critical link in them accessing care.
• 7:06
  - So John, there was a, you know, two decades of very, very slow growth because people just sort of assumed it wouldn't work.
• 7:11
  You know, why it didn't change.
• 7:13
  And then there was this huge change.
• 7:15
  And now there is some reversion back to the mean, you know.
• 7:18
  So we went from like in Massachusetts where I am, you know, telehealth visits were like 80% of visits at the height of the pandemic, had gone from 1% to 80%.
• 7:27
  And now they've drifted back down more toward 20% or so.
• 7:30
  And we wanna make sure we don't lose out on what we learned during the pandemic.
• 7:35
  Now one thing about, you know, where the people like telehealth, the surveys have and some studies have shown that like 80 to 95% of patients said, yeah, they like telehealth.
• 7:44
  And actually there was one study that said 41% would've chosen telehealth even if an in-person visit was available.
• 7:51
  So we can't forget this when the, you know, the public health emergency ends and we're sort of back to normal.
• 7:57
  - It's a really good point.
• 7:58
  I think the assumption of healthcare, the system, the sort of the industry that represents healthcare is it massively undervalues the time of the patients and their families and caregivers.
• 8:11
  And often, healthcare, I mean, how do you have a consumer industry that's about caring for vulnerable people, that always ask you to wait for an appointment to access it?
• 8:23
  I think that one of the great things about telehealth, to your point, is really the convenience.
• 8:28
  - They knew how patient you were that's why they make you wait.
• 8:30
  Maybe if they called, instead of calling a patient, they called them the inner hurries, what service would be better?
• 8:35
  - You don't have a choice, David.
• 8:38
  I mean, in the People's Republic of Massachusetts where you live, try to get an appointment at Mass General.
• 8:44
  I've tried to do it for my mother.
• 8:45
  It was brutal.
• 8:47
  And the system is not set up for access.
• 8:51
  And I think what telehealth does is it levels the playing field.
• 8:53
  Some of the most interesting innovations during the public health and emergency were things like texting for teens who have vulnerable mental health issues.
• 9:02
  Telehealth visits for therapists that helped calm down a lot of the anxiety and depression that people had.
• 9:11
  And the avoidance of an ER visit for an ear ache or a sore throat where doctors and nurse practitioners could take care of young mothers over the phone, I think you're absolutely right.
• 9:23
  We have to make sure we preserve this because there's still a long regulatory overhang of local doctors' associations and hospitals and some insurance companies that are skeptical, but we prove this can work.
• 9:39
  And in a time when really we know that we need to provide more on-ramps for vulnerable patients, I'm really concerned, David, that the system will snap back and create either a regulatory or a reimbursement challenge for visits that actually are leading to healthier lives for people.
• 9:59
  - So John, let's talk about a couple of those things.
• 10:01
  We certainly talked about the age piece before and you're right.
• 10:04
  I was actually gonna make the point that older people who might have not wanted to learn how to use Zoom, all of a sudden, that was how they could do it in order to be in touch with people.
• 10:11
  And they also started to use telehealth.
• 10:12
  Now there is a difference, about 75% of younger people use video with telehealth and about 50% of older people do.
• 10:19
  But you can do telehealth with a telephone, it doesn't have to be the video.
• 10:23
  You talked about vulnerable populations.
• 10:25
  And I think it's very interesting that if you think about the convenience, like for someone like you or I, who works for a company that offers, you know, the leave policy, you can take off a half a day and go to the doctor.
• 10:38
  It's not convenient, but you could do it.
• 10:40
  Somebody who's actually gonna lose their half day wage can't do it, right?
• 10:44
  But they probably have a phone so they can get access to telehealth that way.
• 10:49
  Mental health, behavioral health is an area where the demand totally spiked during the public health emergency.
• 10:55
  And it tends to be a great use case actually for telehealth.
• 10:59
  It works very well just'cause of the nature of the condition.
• 11:01
  It makes it easier to treat at a distance.
• 11:04
  And then also the shortage of mental health workers and the need to try to match people up with somebody who's gonna be a fit for them means that the broader geographic scope is gonna be better.
• 11:13
  So it's not as good for things where you need to do a lot of really hands-on with the patient.
• 11:18
  But mental health by its nature is not something where, you know, there's a lot of physical exam.
• 11:23
  - Oh, I hear a little bit of a desire to narrow the approach here.
• 11:25
  - Focus.
• 11:27
  - Why don't we maximize- Yeah.
• 11:30
  - and take advantage of technology.
• 11:32
  We could actually do more home-based tests.
• 11:36
  I mean we have a system, David.
• 11:37
  Are you paying attention to the fact that we have 10,000 people becoming Medicare eligible every day?
• 11:43
  We've got an access problem for poor people around the country.
• 11:47
  We've got doctors who are burnt out because they're working so hard.
• 11:50
  And you're gonna start to cut off some of the technology leverage that we get from texting, telephones, and computers.
• 11:58
  I mean, what's your problem, David?
• 12:01
  - Yeah, that's, well, John.
• 12:02
  That's the first step to answering the question.
• 12:04
  But let's talk about telehealth a little bit because you slid a couple little things in there, okay?
• 12:09
  So I talked about it as care at a distance, right?
• 12:11
  We're putting a provider and a patient.
• 12:14
  But you mentioned asynchronous, which is a fancy way of saying not at the same time, but then there's also, do we consider,- Explain that.
• 12:21
  - Yeah, do we consider that to be telehealth?
• 12:23
  And what about stuff like remote patient monitoring or chronic care management?
• 12:27
  I mean there's some things that are not purely, my point is, not purely a telehealth visit.
• 12:33
  - Don't make it complicated.
• 12:34
  - Okay.
• 12:35
  - How about patient monitoring using technology?
• 12:37
  - Yeah.
• 12:38
  - How about care management?
• 12:39
  Like, this isn't that hard, David.
• 12:41
  You just have to embrace the 20th century, now that we're in the 21st.
• 12:46
  - Yeah.
• 12:46
  - I mean, come on.
• 12:48
  David, I'll give you an example of how stuck we are as a healthcare system.
• 12:51
  There's this wonderful example of the Indian Health Services has had a really hard time, as you know, to get dental services in Northern Alaska.
• 13:02
  Because as I know, you are very focused on that part of the world.
• 13:05
  - Yeah.
• 13:07
  - What's happened is there're not enough dentists to go around, particularly, in remote parts of the Indian Health Association.
• 13:15
  And the Indian Health Association started to leverage telehealth to teach local people to actually provide a basic set of dental services.
• 13:26
  And you know what the American Dental Association did, even though it wouldn't provide a dentist?
• 13:31
  They sued the local authorities that were teaching people leveraging telehealth.
• 13:35
  We need to embrace these tools because there are plenty of places where there's either lack of access because we don't have the specialists or lack of access because the time that a patient can actually connect in a safe way with the system is more consistent with care at a distance with technology as opposed to care in person.
• 13:57
  I mean, embrace the future, David.
• 13:59
  - Well, John, I think you're gonna have a lot less time for leisure trips to Alaska, nevermind Northern Alaska.
• 14:04
  You did a little fishing.
• 14:05
  I mean they get your dental work done.
• 14:07
  - My teeth.
• 14:08
  - Yeah, somewhere else.
• 14:09
  I am familiar with the Indian Health Service, John, as they may mention that.
• 14:12
  But you know, my brother who was actually worked at the Northern Navajo Medical Center in Shiprock, New Mexico, so I've actually been out there.
• 14:20
  It's actually fascinating, fascinating kind of a place.
• 14:23
  They used to call him the helicopter guy'cause when a patient would be in trouble, he'd send him off by helicopter to Santa Fe.
• 14:31
  Nonetheless, not for dental work.
• 14:34
  - I just think what you've seen is, over time, the healthcare system has a really hard time with new, novel, and not specialist-driven.
• 14:45
  We have to embrace new access points and lower cost solution or we're gonna be stuck with this system that costs too much and doesn't perform.
• 14:54
  - So John, here's the thing.
• 14:55
  So we talked about the public health emergency, also known as the pandemic.
• 14:59
  Now the fact that it's declared as a public health emergency actually has some implications for telehealth.
• 15:05
  So Medicare expanded the use of telehealth and a lot of those things snap back when the public health emergency ends.
• 15:13
  I think, three to five months after it ends.
• 15:16
  So there are some actually implications of declaring that the, you know, that the emergency isn't over yet.
• 15:21
  So I'm some ways, of course, we want the pandemic to be over.
• 15:23
  We want the emergency to be over, but it's actually, there's a positive thing about, you know, declaring that it's not at an end yet.
• 15:31
  Maybe that get some time to make it more permanent, these changes.
• 15:34
  - But are we at the end?
• 15:35
  I mean, you seem kinda like hedging here.
• 15:36
  Like, what's going on?
• 15:37
  Are we at the end of the emergency or not?
• 15:39
  - I think that the pandemic, it's fair enough to say that the emergency is over, but, so I'd say, yeah, declare the emergency over, but when you do that.
• 15:48
  - I've listened to President Biden, he says we're done.
• 15:52
  - He said a lot of things.
• 15:53
  Some of them that get walked back by the White House after he says them.
• 15:57
  And I won't veer into foreign policy'cause I don't want anything to be censored here.
• 16:00
  But I think it's important to say, yeah, let's end the emergency, but let's maybe extend it if ending it means that, hey, people on Medicare are not gonna have access to telehealth anymore.
• 16:13
  So I wouldn't jump to to end it so quickly.
• 16:17
  - I think unfortunately, we are at the end, but we need to embrace the speed in decision making and willingness to try and test new things that we had during the emergency.
• 16:27
  But perhaps we could at least agree on that, David.
• 16:30
  - Sure, John, I'd love to agree with you.
• 16:31
  Now, here's a chance to disagree or agree.
• 16:34
  And I wanna ask for last question about, do you think telehealth can deliver on its promises or is it overhyped?
• 16:43
  - Well, I think with people like you, you have to overhype it for people to even get access.
• 16:49
  But I think it overdelivered in mental health.
• 16:52
  It overdelivered in terms of access to basic primary care.
• 16:56
  And we're kind of figuring it out with specialist care, but I think we're very much in the early innings of accessing technology to kind of give people the self care options and to actually extend more care, which is absolutely essential.
• 17:14
  What about you?
• 17:15
  - I don't think it's overhyped, John.
• 17:17
  I think that telehealth can have a gigantic impact and we have to make sure that we don't put back the restrictions that were in place from an insurance and administrative standpoint and that we don't let ourselves forget, you know, the silver lining of the pandemic as really to say, I don't need to be a patient sitting at the doctor's office forever.
• 17:37
  I don't need to cut off care from people that can't take off a half day from work.
• 17:41
  So no, I wanna see it go there.
• 17:43
  And I think it's too bad that it's taken 20 years, you know, for us to start to have that.
• 17:48
  I don't wanna see it come back down to 20%, 5%, 2%.
• 17:51
  I wanna see it go 50%, 75%.
• 17:54
  I think that's where it belongs.
• 17:56
  - Awesome.
• 17:57
  - Well, John, that's it for yet another edition of CareTalk.
• 18:00
  Although, it is different since you're shifting jobs.
• 18:03
  I'm gonna have to think of a fancy new title for myself for next time.
• 18:06
  But anyway, for now, I'm David Williams, president and chief operating officer of Health Business Group.
• 18:14
  - And I'm John Driscoll, the president at Walgreens for Health for U.S. Healthcare.
• 18:18
  Thanks for listening and if you like what you heard, or you didn't, please subscribe on your favorite service.