MEHROTRA: If we can go back to March and April of 2020, beyond all of the issues with the virus itself, there was tremendous concern that patients weren’t going to get care. And we were going to see, as some people called it, the “second pandemic.”
In the spring of 2020, while most of us were concerned with the first pandemic, Dr. Ateev Mehrotra and other health care providers worried that patients who needed care for conditions other than COVID — for diabetes or for high blood pressure — weren’t going to get it. Hospitals were overloaded with sick COVID patients, and many medical offices were closed to prevent the spread of the virus. Luckily, there was a solution, but it was untested.
MEHROTRA: It’s not that telemedicine didn’t exist before the pandemic. It just was happening in very small numbers.
Suddenly, telemedicine wasn’t happening in very small numbers. According to a C.D.C. report from 2020, there was a 154 percent increase in telemedicine visits during the last week of March in 2020, compared to that same week the year before. This sudden and widespread shock to medicine was unlike anything we’d seen before.
MEHROTRA: When we usually have change in the U.S. healthcare system, it’s pretty slow, right? We’ll develop a new technology, we’ll start using it, and then we’ll learn how that works and we’ll advance on that. And slowly but surely — maybe too slowly, sometimes — we’ll change how we provide care.
When the pandemic started, there wasn’t time for health care providers and policy makers to consider the implications of this technological shift. And Ateev and others are still trying to figure it out.
LAWRENCE: I think there was a lot of resistance to really changing that fundamental dynamic of a patient-provider relationship. And obviously all of that just got blown out of the water when the pandemic happened.
Over the course of the pandemic, telemedicine has made delivering care safer, and more convenient. But how has it affected patients? And has it also changed the way doctors work? From the Freakonomics Radio Network, this is Freakonomics, M.D. I’m Bapu Jena. Today on the show, we’re going to talk with Ateev Mehrotra about the telemedicine explosion of the last two and a half years.
MEHROTRA: How did it impact the quality of care that patients receive? That’s the No. 1 question that physicians are worried about and that patients are worried about.
And how has telemedicine impacted quality of life for physicians? Dr. Kate Lawrence will discuss her new research on after hours work, and some of the unexpected burdens that technology can bring.
LAWRENCE: It wasn’t like a learning curve where they figured out how to work the system and then were actually more efficient.
MEHROTRA: Telemedicine, at its basic core, is the idea that a clinician and a patient are going to have clinical care, but not face to face. It’s across a distance, using technology to have that visit. But it also includes, “Hey, I’m going to send a portal message to my doctor. I’m going to have monitoring of my vital signs at home.” So, it encompasses any form of technology to connect a clinician, and a patient.
Ateev Mehrotra is a Professor at Harvard Medical School, and an internist at Beth Israel Deaconess Medical Center in Boston. He also appeared in episode 35 of Freakonomics, MD, “Are More Expensive Hospitals Better?”
A lot of his research has focused on innovations in health care delivery, like telemedicine, and how these advances impact quality and cost.
MEHROTRA: When you make care more convenient, that drives up more visits and therefore it results in increased spending. Now, this is such a “Duh” finding. You know, my dad was asking me, you know, “What kind of research are you doing, son? And I said, you know, “Dad, we’re finding when you make care more convenient, more people get care.” And, you know, he had that look on his face, you know, like “fancy Harvard professor proving the obvious.” And —
JENA: Yeah, he had that look. “I came to this country from India, and this is what my son is working on?”
MEHROTRA: Exactly, exactly. “Can’t you do something more sophisticated than that? In my defense, it is an important message to keep on iterating that yes, there’s a lot of advantages in getting care more convenient. And I don’t want to say that that’s a problem, but it does have the likely impact of increasing utilization and therefore increasing spending.
Telemedicine use has dropped steadily since its peak at the height of the pandemic, and it now accounts for about five percent of all medical claims. That might sound small, but it’s still well above pre-pandemic levels. Patients seem to like having it as an option, even if in-person care is still the default.
So, how is this technology evolving as we segue out of the pandemic? And has telemedicine been good for health care?
MEHROTRA: We’re starting to get some preliminary evidence that telemedicine is increasing the number of visits that patients receive, and thereby increasing spending. If it’s increasing spending, in certain clinical situations, it’s great. We’re going to be happy that more patients are getting care and that leads to better health outcomes. But in other clinical areas, it may drive up spending and patients’ health doesn’t improve. It would be low-value care, and we need to develop mechanisms to curb those excess visits.
JENA: One of the drivers of inequity in our healthcare system just stems from the fact that it’s hard for people who live in certain geographic areas or who are poor, to take time off from work to go to the doctor. What impact, if any, has telemedicine had on that issue?
MEHROTRA: What we’re hoping for is that people who can’t get the care that they need — who live in a rural community far from a clinician, or who work, you know, two jobs and they can’t get in, between nine and five to their say, cardiologist, telemedicine can be a mechanism for them to get the care that they need and therefore really address the inequities we have in the U.S. healthcare system. And that’s both across race, income, and where people live. The major concern that has come up during the pandemic has really, focused on what has been called the “digital divide” and the digital divide is that unfortunately, in the U.S. lower income folks have less access to technology or they also lack the skills to potentially use that technology. And the concern is that we move to video visits, the underserved will be less likely to get care. And if anything, we’re not going to narrow those disparities. We’re actually going to widen them. And so that’s been a major tension with telemedicine so far, during the pandemic. Some research has found that wealthier patients are more likely to have a telemedicine visit than poor patients. But other research, interestingly, has found the opposite — that underserved communities, communities of color, and lower-income communities are more likely to have had a telemedicine visit during the pandemic. One thing is very clear is that unfortunately, during the pandemic, rural communities have used telemedicine at a much lower rate than those who live in cities. And that’s surprising, because prior to the pandemic, rural communities is where the telemedicine action was happening. And so, I had assumed that because they kind of had a head start, those communities were more familiar with this kind of crazy way of getting healthcare, that they would use it at a much higher rate during the pandemic. But, unfortunately, we’ve seen the opposite.
JENA: Can you talk a little bit about the ramp up of telemedicine when COVID hit? So, what did states, what did the government do, to promote the adoption of telemedicine and what’s the future of that look like?
MEHROTRA: Private health plans, the federal government, the state government, medical boards, everyone did whatever they could to encourage the use of telemedicine so that patients would get the care that they needed. “We’re going to start paying for video visits uniformly across the nation. They can happen in patients’ homes. We’ll start paying for phone visits,” which never really has happened in the U.S. healthcare system. There were a bunch of changes that were made — temporarily — to encourage the use of telemedicine. And, oh my gosh, was there a change. Just within the span of a month, I sometimes describe it as the changes that I would’ve expected over a decade.
MEHROTRA: You asked the question, “Where are we headed?” And I don’t know, obviously., I think we are sort of plateauing at a place where roughly 5 to 10 percent of visits in the United States are provided via telemedecine.
JENA: There’s a lot of reasons to think that patients might value a telemedicine visit, even though it’s not face to face. I’m curious as to what the research says about the quality of telemedicine care.
MEHROTRA: You know, if I can wax philosophical for a moment — In the setting of telemedicine, all of a sudden in March of 2020, we moved the healthcare system to the use of telemedicine. And we’re still playing catch up in 202,. And you asked a very reasonable question: how did it impact the quality of care that patients receive? That’s the No. 1 question that physicians are worried about and that patients are worried about. But I don’t know if we have a definitive answer for you because it happened so quickly, we’re still learning.
JENA: But, clearly we’d want to know something about the benefit, which I guess why it’s so important to figure out: all right, if we’re spending more on telemedicine, on telehealth, what are we getting for it? That’s probably the big question, then.
MEHROTRA: When we evaluate new things in the healthcare system, it’s not just about the money. It’s about how much healthcare benefits we’re going to get for that increase in spending. So, if telemedicine leads to patients with diabetes who — it’s poorly controlled, you know, we offer telemedicine that leads to, improvements in their diabetes control and a better quality of life, fewer complications down the road, I’m on a chair celebrating. That’s what we need. We need to improve health. And if that leads to, increased spending, that’s good. However, if telemedicine is leading to a lot of worried well getting more care, but not really leading to any commensurate improvement in health, that’s a problem. And also, as we mentioned before the equity issues too, like who’s getting this care.
JENA: The examples that you just provided, those are almost two extremes. So, on one hand we spend more money because of more people using medical care. And that may have benefits for patients. On the other side, you might generate more wasteful care — people who didn’t need to see the doctor were seeing the doctor. And so, that’s sort of wasteful. Then there’s this place in between, which is where a lot of the benefit that patients may get is just from the convenience of care.
MEHROTRA: One of the interesting things that we’re seeing is that there’s a whole industry that’s been developed to try to bring some of that technology home. So, more and more patients are being sent home with blood pressure cuffs and oxygen monitors and heart rate monitors and scales that send the information to their doctor. There’s even, home E.K.G. monitors. There’s this amazing technology that folks have where mom can be given an otoscope and she can put it in her child’s ear, and, the otoscope takes a video of the eardrum and then sends it via technology to the doctor. And the doctor can use that to diagnose. The telemedicine of 2022 and the telemedicine for, say, a couple years from now might look very different because we’ll have provided some of that technology into the patient’s home. And, therefore really improves the ability of clinicians to make an accurate diagnosis.
JENA: I think that makes total sense to me because the potential for telemedicine isn’t what happens when you just turn the switch on and doctors start doing telemedicine. You’ve got to anticipate that the market will respond to this, dramatically increased demand and develop technologies that’ll be cost effective to allow patients at their homes to get clinical information that a doctor can respond to. I mean, if this gets used a lot, why wouldn’t we expect that sort of technology to develop?
MEHROTRA: We talked a little bit about the technology that can come to a patient’s home, but it’s still built on this whole idea that you’re going to do a video visit. I don’t know if that’s really what the future of telemedicine might look like and it may be quite different. Remote patient monitoring is this idea that let’s say the most common use is for high blood pressure. Right now, what do we do for high blood pressure? We say, have a patient come in, every month, every couple months. We check their blood pressure in the clinic and we adjust their medications and we say, “Hey, will you bring in your blood pressure cuff’s, measurements from home?” and we’ll use that to adjust. We kind of wait for the visit to happen to make any changes. In remote patient monitoring, we send the patient home with a fancy blood pressure cuff that’s Bluetooth enabled, and we say, “Please check your blood pressure every day.” And that blood pressure measurement goes to the doctor’s office on a daily basis. And if the doctor sees that the blood pressures are too high or too low, they can proactively contact the patient and say, “Hey, we need to make some adjustments.” In that situation, telemedicine is being used to try to take care of patients, but there’s not the video visit or the in-person visit anymore. It’s just happening on a more continuous basis as opposed to these, visits, say, every three months.
JENA: When you talk about the impact of telemedicine on patients, there’s the convenience component. And I can imagine that might also be true for doctors as well, but that convenience to doctors might spill over into something that’s not as ideal, which is just increased physician workload. You know, they’re seeing their patients in the office. They’re trying to squeeze in telemedicine visits in between those in-person visits in the office. Maybe they’re doing them at the end of the day. Is there any evidence, or at least thinking about how telemedicine is going to impact physician workload?
MEHROTRA: I think it’s a fascinating question. There’s a lot of holes in telemedicine, and I think this area is where there’s a lot to learn.
We’re starting to figure it out. As in-person visits have resumed to pre-pademic levels, telemedicine use persists. Are physicians being burned out by delivering all this care?
LAWRENCE: There may actually be something more inherent in the telemedicine experience that makes it potentially less efficient than any of the current models of care.
I’m Bapu Jena, and this is Freakonomics, MD.
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LAWRENCE: I think there’s two camps of people in medicine in general. There’s the camp of people who said, “I always knew I wanted to do medicine.” And then there’s the other camp that says, “Oh, just sort of fell into it.” I’m generally speaking the latter of those camps
Dr. Kate Lawrence is an Assistant Professor at N.Y.U. Grossman School of Medicine, and she’s also an internist at the Manhattan V.A. Hospital. During her training at a large public health system in New York City, Kate noticed how much of her learning was sometimes not about medicine at all.
LAWRENCE: We went through a transition in residency where we were switching out our electronic health record from an older legacy system to a newer one., and I was really struck by, how much of my training was centered around the electronic health record and people really weren’t even talking about the impact that it was having on us as residents and our experience of becoming physicians.
Electronic health records, also called E.H.R.s, have become critical, but they’re also cumbersome. A study published earlier this year in JAMA Internal Medicine found that on average, physicians in the U.S. spend nearly two hours each day on E.H.R. work. And while these records are useful, like many things in medicine, they come with side effects. Patients hear a lot about E.H.R. work in the abstract, so I thought it would be helpful to have Kate describe what it really entails.
LAWRENCE: I don’t know how to not give your audience nightmares because it really is just a kind of a nightmare-ish process, actually. So, there was always administrative work that was done, even before the electronic health record. And it was things like, reviewing insurance referrals or prior authorizations. It was closing out your notes. It was reviewing, labs or something that had come in for a patient that you were worried about. And sometimes it was making after-hour phone calls to, a patient that you were really worried about that you hadn’t seen in the clinic or something like that.
What we think has changed is sort of two things. One with the electronic health record. For some reason, a lot of that work has shifted from what used to be the physician support staff — so, the M.A.s or the nurses or the front desk — a lot of that has shifted back to the clinician. We think that has to do with the in-basket, which for people who aren’t familiar with that term, that’s essentially just a physician email that runs through the E.H.R. And it’s great for patients because it allows you to, instantly message your doctor through the patient portal if you have a question about something. It creates a lot more work. But then the other part of it certainly the electronic health record, really pushes people into a documentation morass where they spend all of this time just trying to fulfill documentation requirements. And it takes a thousand clicks to, you know, get through a note
Naturally, more patients means more electronic health records. Kate and some colleagues at N.Y.U. recently wondered how the increased use of telemedicine might be contributing to physician workload, through EHR work. Was making care more convenient for patients also helping providers be more efficient? Or could there be some unintended consequences?
LAWRENCE: Yeah, that’s a huge question. There’s so much that I think we’re learning about what’s happening in the virtual and telemedicine space and so much that we still don’t even really have a great handle on that we’re just sort of starting to explore. I think, the obvious benefits are things around access and convenience, both for patients and providers. For the people who, didn’t really have challenges with access before — meaning they had insurance, they had a regular doctor, they knew how to navigate the healthcare system —, it’s just an added layer of convenience to be able to access care in this way. And that’s great. I think the more sort of fundamental potential positive change is that for people who weren’t like that, who didn’t have insurance, who had trouble navigating the system, or for whom the system really just wasn’t built, this provides just critical access in a way that we’ve never really been able to do before.
JENA: How would you describe, what telehealth looked like, before the pandemic started? And was there enthusiasm and support for it within medicine at that time?
LAWRENCE: I would say that there were some places and institutions that had sort of chosen to invest in digital and virtual infrastructure rather than sort of brick-and-mortar expansions, and kind of leaned into the idea of a virtual-supported model of care. There were a lot of barriers on sort of the payer and the regulatory side., and then there was a lot of resistance just to changing workflows in general. I mean, even if this was something that patients said they wanted, and certainly there were concierge and app-based programs that were coming up even before the pandemic, I think there was a lot of resistance to really changing that fundamental dynamic of a patient-provider relationship. And obviously all of that just got blown out of the water when the pandemic happened.
JENA: So, tell me a little bit about your work on how providers, interact with the E.H.R. and use telehealth. What are the implications for them in terms of how they spend their time? When they spend their time?
LAWRENCE: One of the areas we were interested in was the impact of the electronic health record on the physician’s experience of work. And a huge portion of it is really dedicated to the experience of after-hours work for clinicians. We looked at, over 2000 physicians, across our, both medical and surgical specialties. And we tried to separate them out by people who were doing, relatively little telemedicine, some telemedicine, and then a lot of telemedicine, and try to look across specialties, what were the trends. We were primarily interested in looking at, the relationship between what we call telemedicine intensity — the sort of proportion of visits that you were doing that were dedicated to the telemedicine platform versus the in-person platform— and the association between that and what we called the “work outside of work.” So, this was sort of an internally derived metric that we developed. That was a combination of, the work that you spent outside of your scheduled clinical hours, plus any time on the weekends, or any time that you were logging into your system, that you really just sort of weren’t supposed to be there. And we really wanted to do justice to the fact that they were doing quite a lot of work outside of work.
JENA: And what does that work look like? So, are you talking about after work hours doctors doing actual telemedicine visits with patients? Are you talking about like documentation and things like that?
LAWRENCE: Well, we looked at the non-clinical work. So, what that looks like is, documentation time, time spent doing administrative tasks, time spent managing in-basket messages, those kinds of things. We tried to pull out, anything that was sort of a clinical patient-facing encounter, because we understood that clinicians, especially during the disruption of the pandemic, were probably trying to see patients, whenever they could.
JENA: And so, what’d you find?
LAWRENCE: The take home finding which we think is really important, and, a little bit antithetical is that clinicians who had a higher telemedicine intensity — so, those clinicians who were spending more proportionate time providing telemedicine care — had more hours of work outside of work, than clinicians who were doing relatively less telemedicine. We found that in both what we called the acute pandemic period — so those first couple of months In New York City when the pandemic hit really hard — we found that that was higher than it was in the pre-pandemic period. But then we also found that in subsequent periods of the pandemic, sort of later in the cycle of the pandemic, that clinicians who were doing telemedicine more intensely were still doing more work outside of work.
LAWRENCE: So, it wasn’t like a learning curve where they figured out how to work the system and then were actually more efficient. Something was happening. There may actually be something more inherent in the telemedicine experience that makes it potentially less efficient than any of the current models of care.
JENA: It seems like what you’re saying is that, whenever you see a patient, whether it’s in person or through a telemedicine visit, you’ve got to figure out what’s going on. You’ve got to think about what additional tests you need to order. You need to spend time looking at what other doctors or clinicians have said about that patient. But that process is perhaps less efficient when done in a telemedicine context. And one reason might be that you don’t have the patient sitting there in front of you. So, you might have to be a little bit more, diligent in sort of evaluating the full patient.
LAWRENCE: I think that is certainly one option. I think the honest answer is we don’t know yet, and we really need to get into the room where the physicians are sitting and sort of pick their brains about, how their telemedicine experience of providing care is fundamentally different than the in-person. I think we may find that there’s something inherent to a video-based conversation that just places different time pressures. There may be something about the setups of the technology, right? If you’re working on two different computer screens, you’ve gone from zero computer screens in a patient interaction to one to now two, and they’re separate and you got to look back and forth and I can only imagine how disruptive, that is for people. It may actually not be something inherent to telemedicine. It could be something outside of the telemedicine experience — for example, the electronic health record — not being set up in any way to facilitate a virtual style of care., and then we may need to make some more fundamental changes about other aspects of our work that have nothing to do with telemedicine.
JENA: Can you think of ways in which technology might be able to lighten physician’s workload?
LAWRENCE: Depending on how, techno-pessimistic I am in any given day, I sometimes can. And I sometimes can’t. I think the obvious answer — the easy answer is yes, right? Technology should offload the non-cognitive work burden that clinicians have, through things like automations and streamlining and that sort of stuff. And really nice user interfaces that make it incredibly easy to move through large volumes of data, and synthesize it and make meaningful clinical decisions. So, I think there’s a lot of potential there. the reality of it being applied — I think there’s — there’s a ways to go.
JENA: Do you think, we can take anything from the pandemic experience with telehealth to improve and refine the technology along these lines of making things better for both patients and doctors?
LAWRENCE: We just need to get better at being able to connect our various technologies and platforms to one another. So, it’s not just such a miserable experience to try to introduce new tools and integrate them into an existing system and have it not be a nightmare for physicians and patients.
So, I think that’s the obvious one. The one that I worry will get lost as we move out of the crisis feeling of the pandemic is the application of these technologies to issues of equity, access, and inclusion. I think this again is where telemedicine is going to potentially be really revolutionary but it is a shift in thinking about telemedicine for convenience, and maybe revenue generation to thinking about using technology to actually improve equity and address disparities. That’s a much more fundamental challenge. And I think if we don’t keep that in front of our minds as we move forward, it will get lost.
JENA: Do you think the quality of care is sufficient with telemedicine to make a difference in those issues?
LAWRENCE: I was just thinking today about whether or not we’ve sort of reached, with this proof of concept of telemedicine during the pandemic, a sort of clinical equipoise, in which we could now kind of excitingly move into, large scale clinical trials comparing, fully virtual-first care model to a more traditional model. I think we have proved the concept that telemedicine can provide certainly non-inferior care. But I think the real question we have to ask is, was the traditional care experience really a good quality experience at baseline?
As Kate’s work suggests, telemedicine has led to a real, and sustained, uptick in after-hours work for physicians. Health care worker burnout was a problem before the pandemic, and for a lot of reasons, it’s a bigger problem now. A report published earlier this year by Medscape found that 47 percent of physicians reported feeling burned out in 2021, an increase of five percentage points from the year before. By far the leading factor mentioned by survey respondents was bureaucratic tasks like charting and paperwork.
Telemedicine has broken down barriers between physicians and patients. It could also eventually give patients access to the top doctors in any field, regardless of where they live. Here’s Ateev Mehrotra again.
MEHROTRA: If we were to fast forward 10, 20 years, it sort of starts to challenge our kind of regionalized healthcare. Maybe there’s this expert, pathologist who diagnoses leukemia and lymphoma — why is she just reading, things of her area? Why don’t we send every single, new bone marrow biopsy to her where there’s a concern? So, you can start to see an interesting future which I think is pretty exciting., and then obviously the hope is that that leads to better health outcomes.
That’s it for today’s show. I’d like to thank my guests, Ateev Mehrotra and Kate Lawrence. And thanks to you, of course, for listening.
Coming up next week: In the spring of 2021, health care experts were trying all sorts of tools to get people to take the COVID vaccine.
MILKMAN: We started talking and trying to figure out, okay, this is a good idea, we should try a vaccine lottery.
Was a vaccine lottery a good idea? We’ll look at how nudges and incentives work in medicine, what happens when they don’t, and why the pandemic may have fundamentally changed the game.
CHANG: Maybe this event, as singular as it is, has shifted the way the public interacts with health.
That’s all coming up next week on Freakonomics, M.D. Thanks again for listening.
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Freakonomics, M.D. is part of the Freakonomics Radio Network, which also includes Freakonomics Radio, No Stupid Questions, and People I (Mostly) Admire. All our shows are produced by Stitcher and Renbud Radio. You can find us on Twitter at @drbapupod. This episode was produced by Julie Kanfer and mixed by Eleanor Osborne, with help from Jasmin Klinger. We also had help this week from Lyric Bowditch. Our staff also includes Neal Carruth, Gabriel Roth, Greg Rippin, Rebecca Lee Douglas, Morgan Levey, Zack Lapinski, Ryan Kelley, Jeremy Johnston, Emma Tyrrell, Jacob Clemente, Alina Kulman, and Stephen Dubner. Original music composed by Luis Guerra. If you like this show, or any other show in the Freakonomics Radio Network, please recommend it to your family and friends. That’s the best way to support the podcasts you love. As always, thanks for listening.
JENA: You know, I got to be honest with you, though. When — when I see patients now, if I’m running behind, I just give them an episode of Freakonomics M.D., And it’s — the hours just pass by. They listen to 50 episodes. “And Dr. Jena, I thought you were supposed to see me today.
JENA: “Oh, it’s tomorrow.”
- “The Impact of Telemedicine on Physicians’ After-hours Electronic Health Record ‘Work Outside Work’ During the COVID-19 Pandemic: Retrospective Cohort Study,” by Katharine Lawrence, Oded Nov, Devin Mann, Soumik Mandal, Eduardo Iturrate, and Batia Wiesenfeld (JMIR Medical Informatics, 2022).
- “Medical Documentation Burden Among U.S. Office-Based Physicians in 2019,” by Adam Gaffney, Stephanie Woolhandler, Christopher Cai, David Bor, Jessica Himmelstein, Danny McCormick, and David U. Himmelstein (JAMA Internal Medicine, 2022).
- “Physician Burnout & Depression Report 2022: Stress, Anxiety, and Anger,” by Leslie Kane (Medscape, 2022).
- “Paying for Telemedicine After the Pandemic,” by Ateev Mehrotra, Sacha Bhatia, and Centaine Snoswell (JAMA, 2021).
- “Are More Expensive Hospitals Better?” by Freakonomics, M.D. (2022).