Like many other physicians, Dr. Sandra Esparza and her husband Ramon closed their 17-year old primary care practice in December. It had always been a strain to both run the business and be the practice’s lead physicians, but the pressures of the pandemic made operating their company unsustainable. After closing their practice, Ramon, who is a pediatrician, started working full-time at a local clinic in Austin. Esparza started working for Doctor On Demand. She’s now licensed in 10 states caring for a stream of patients she’s never seen before and probably won’t see again.
The Esparzas aren’t alone. COVID-19 has put unprecedented stress on doctors’ offices across the United States. In December, the nonprofit Physicians Foundation reported that roughly 8% of physician practices were forced to close because of the pandemic. Another 4% of physician practices are expected to shut down their offices within the next year. Even doctors that are still in business are burning out.
Meanwhile, online healthcare has exploded, providing extraordinary support to a medical system under fire. Doctors are already incorporating telehealth into their practices and shifting elements of care out of the office and into the home. There is also a wave of online-only national health care providers that have been waiting in the wings for a moment just like this. These companies—Teladoc, Hims & Hers, Doctor On Demand—have been invaluable in taking care of Americans whose typical primary care practice has closed or who are too afraid to go into the doctor’s office (and maybe aren’t aware their doctors are online).
While many of the changes are good, the reduction in doctor’s offices stands to have profound repercussions for how, where, and from who patients get care. The branded telehealth services that people have come to rely on under COVID-19 are not designed for the kind of long-term care that primary care offers. They’re based on an urgent care model, where you see the next available doctor regardless of who they are. This has huge benefits—it means you can get a hold of a doctor 24/7 and it takes pressure off of emergency rooms and potentially general practitioner offices. But it’s meant to be supplemental care, not a person’s main health provider. Long-term, continuous relationships between an individual and a doctor are linked to better health outcomes. A confluence of events has now opened the door for these national telehealth brands to take over as Americans’ main healthcare providers. The question is: Can these telemedicine companies truly stand in for the most foundational piece of our healthcare system?
The sudden shift to telehealth
It’s important to understand that telehealth is not a monolithic service—it’s a technology. It can be as simple as a doctor in a traditional primary care office connecting with their patient over Zoom. Telehealth also comprises a cadre of apps and platforms that focus on everything from urgent care to psychiatric evaluations and chronic care monitoring.
When the pandemic began, an entire network of physicians, nurses, and whole health systems rocketed into cyberspace overnight. As doctors moved online during the pandemic, they did so in a variety of ways. Some doctors joined branded online platforms where patients could receive on-demand urgent care. Others moved their whole clinics online, though that was not without challenges.
In March, People’s Community Clinic, a Federally Qualified Health Center in East Austin, rallied to put their practice online. Federally Qualified Health Centers provide primary care to Americans on Medicare and Medicaid. Most of the clinic’s 22,000 patients have layers of chronic health issues, which made telemedicine vital to keeping patients safe. Diabetes, hypertension, and obesity are common diagnoses. All of these diseases put patients at higher risk of having a severe reaction to COVID-19.
To go digital, the clinic’s staff had to individually walk patients, many of whom only speak Spanish, through the process.
An entire network of physicians, nurses, and whole health systems rocketed into cyberspace overnight.
“Front desk staff did a lot of step by step, this is what this says,” says Dr. Mariela Lane, a physician at the clinic. “[It] is so different from what I experience for myself or my family, which is just, ‘Here’s a link, we’ll see you at 10:15.'”
Federally Qualified Health Centers like People’s have a reputation for being slow moving or mired in red tape. But People’s got online fast. It wasn’t alone. The National Association of Community Health Centers found that weeks after COVID-19 arrived, 98% of community health centers made the shift to telehealth. Part of what made this possible is that the Center for Medicaid and Medicare Services agreed to reimburse telehealth services, including phone appointments, as they would in-person care during the pandemic. Whether or not that continues to be the case will have profound implications for how doctors’ offices continue to use telehealth.
Lane says embracing telehealth has had startling effects. It reduced no-show rates, because patients often struggle with transportation. Many patients don’t have internet, so physicians did telephone visits—an important and underestimated piece of telehealth. The health center also sent out blood pressure cuffs, pulse oximeters, and glucometers so that doctors could monitor their health conditions remotely. All these tools have helped traditional doctors meet patients where they are.
The switch to telehealth also meant that doctors, nurses, and physician’s assistants who had their own underlying health conditions could opt out of seeing patients in person. “We decided, yes we’re going to do the best we can with our resources, but we’re not going to force anyone to put themselves in what they feel like is a dangerous position,” says Lane.
The vacuum left by closing clinics
The massive adoption of telehealth by doctor’s offices will have profound repercussions for how doctors interact with patients of all income brackets. You may finally be able to text with your doctor, if you don’t already. The great promise of telehealth is to be engaged in an on-going conversation with your doctor in the same way you communicate with everyone else in your life in 2021. But a sizable number of clinics will not make the transition online. The decline in primary care practices may leave a lot of patients stranded.
A May 2020 survey from the Larry A. Green Center, done in partnership with Primary Care Collaborative, found that 19% of primary care practices surveyed had temporarily closed. When Dr. Esparza started working for Doctor On Demand she saw a lot of patients that had been displaced by closed practices.
“I had a gentleman call me just recently because he’s been trying to get a referral from his primary care doctor for weeks and nobody answers,” she says. “I think there are a lot of clinics that are struggling and there are a lot of people who can’t see patients in the office and these patients are left high and dry.” Oftentimes, she says, patients are looking to get labs done or find a way to continue a diabetes medication regimen.
He’s been trying to get a referral from his primary care doctor for weeks and nobody answers.”
In November, research and advocacy organization Primary Care Collaborative found in a survey of primary care physicians that 2% of practices were closing. Not quite half of respondents said they had reduced or skipped out on salaries all together. This constrained supply may send people to virtual platforms like Doctor On Demand rather than trying to find a new local office.
On top of that, the number of primary care physicians is shrinking. A pre-pandemic analysis from the Association of American Medical Colleges estimated that by 2032 the U.S. will be short anywhere from 21,400 to 55,200 primary care physicians. Some experts think that’s because the health system doesn’t value primary care doctors as much as specialists. Despite their importance in the health system, primary care physicians have relatively lower salaries than specialty doctors.
They’re also increasingly being replaced by nurse practitioners. Nurse practitioners are cheaper than doctors and states have been increasing their scope of practice for years. The American Medical Association has raised concern that nurse practitioner’s growing responsibilities are eroding the standard of care for patients. Notably, branded telehealth services lean heavily on nurse practitioners for patient care. For example, over half of the clinicians on Wheel, a nurse and doctor staffing service for other telehealth platforms, are nurse practitioners.
More and more health care workers may be turning to branded telehealth companies, which can provide a better working environment than what doctors and nurses face in person. Not only are clinics closing, but doctors are burning out. Roughly a third of nurses were overwhelmed and exhausted before the pandemic. The same was true for half of doctors. But COVID-19 has intensified the stress and daily pressure in the practice of modern medicine. Some practitioners are cashing out entirely and retiring early. Others are moving to platforms where they can clock in and clock out without ever having to leave home.
“COVID pushed me over the edge,” says Carey Ledee Krause, a family nurse practitioner in urgent care. The urgent care clinic she works at only has registered nurses and medical assistants on staff, and there is no doctor on premise. Krause, who has the highest level of training, has to see every patient that walks in the door. If there is an issue outside of what she’s certified to handle, she’s supposed to contact an on-call doctor. “[The nurse-only clinic] was supposed to be this shot of independence, but instead it was like, ‘You’re more efficient than a doctor and we can pay you less,'” she says.
We have to re-use our masks basically until they break, and it broke.”
Before the pandemic, she would see anywhere from 40 to 70 patients during a 12-hour shift. Since the COVID-19 outbreak, Krause estimates that this number has grown to as many as 100 patients in a single shift. Where at the beginning of the pandemic everyone was nice, now she finds patients are frequently angry about having to wait in line for care. Her urgent care center, like many others, also has a critical lack of personal protective gear. “We have to re-use our masks basically until they break, and it broke,” she says.
Days before Christmas, Carey Krause’s mask broke while she was in the room with a maskless patient who had tested positive for COVID-19. She was forced to spend the holiday alone, quarantined away from her kids for two weeks. In this isolation, she realized she was done with working like this.
“My goal is to slowly drop off in-person care,” says Krause. Prior to COVID-19, she started dabbling in telemedicine on Wheel for extra cash. She didn’t expect the lifestyle of working online to be so much less stressful than her in-clinic work. Now, she wants to go online only.
A technology in transition
The pandemic has created both an opportunity and a challenge for telehealth brands. Closing clinics and doctor burnout is already making it harder for patients to find local doctors. With a growing portion of Americans giving up on primary care altogether, more Americans may be turning to big telehealth brands for their medical needs. But many of these telehealth platforms weren’t designed for primary care.
Online on-demand doctors were originally focused on providing urgent care: a quick interaction with a licensed doctor to address an immediate need. Teladoc, one of the earliest telemedicine services which launched in 2002, was designed as an employer benefit. It later launched a personal pay option, which has become popular with newer branded telehealth options like Hims & Hers. The option to pay on the spot widens access. Patients don’t need to be employed or have health insurance to be seen by a doctor online.
As these telehealth companies have aged, they’ve increasingly tried to build their relationship with patients around more than just an urgent care visit. Hims & Hers, for example, sells prescription health and wellness products. Rather than give a patient the same doctor every time (which would be impossible to provide on a 24/7 basis) these platforms have developed proprietary health record systems that make it easy for any doctor to get up to speed on a patient instantly. But these innovations failed to gain major traction.
Then COVID-19 hit. Where online urgent care was once an underused novelty, it suddenly became a hugely important mode of healthcare. Paranoid Americans who wanted a virtual healthcare option along with people with COVID-19 symptoms seeking care drove an incredible rise in use. Doctor On Demand saw a 140% increase in usage between March and July 2020. Hims & Hers, a branded telehealth service, grew revenues 91% year over year. In the first half of 2020, appointment bookings on MDLive soared 300%.
“There’s no question that during the darkest days of the epidemic, the biggest growth of telehealth was in urgent care,” says Roy Schoenberg, CEO of Amwell, a telehealth service that offers its own on-demand urgent care and serves as the underlying telehealth technology for health systems like Cleveland Clinic. His company went public amid the spread of COVID-19 and the stock went up 28% on the first day of trading. “People were very, very scared, and on the other hand the availability of services diminished fast.”
A new kind of relationship
While branded telehealth companies have been able to capitalize on this moment, the wide adoption of telehealth has made these brands less distinguishable from traditional primary care than they used to be. Where once they could differentiate themselves from regular doctor’s offices by promoting their digital savvy, now much of the healthcare system is online. Instead of tech gimmicks, they’ll have to compete on their ability to deliver quality healthcare.
There’s no question that during the darkest days of the epidemic, the biggest growth of telehealth was in urgent care.”
Quality of service will differ per brand and per business model. How telehealth brands pay their bills will influence how they care for patients, just as the fee-for-service model influences how doctors are able to deliver care at physical clinics. Branded telehealth-first platforms already have some funky incentives at play. Hims, which makes its money through healthcare subscriptions and recurring prescriptions, has been accused of pushing pills on its platform. United Healthcare, which has been building out its own system of care providers for years, is now in the position to control more elements of a patient’s journey through the healthcare system and its associated costs. That may give the insurer more room to nudge patients towards certain practitioners based on price rather than quality.
It is telling that telehealth brands that have made their bread and butter on urgent care are shifting to support an online version of more traditional primary care. In 2020, Teladoc, regarded as the granddaddy of telehealth, merged with Livongo, a chronic care system—an important development because it signaled that Teladoc was putting its money on long-term disease management and care, as opposed to quick health fixes. Since that deal, Hims, Teladoc, and United Healthcare (via Amwell) have all launched virtual primary care services with the option to maintain a relationship with the same central physician. Rather than trying to reinvent what care should look like, they’re adapting their systems to the traditional models that people have come to expect.
The adoption of telehealth during the pandemic is sure to upend the way we receive care from our doctors, says Roy, whether we stay with our standard primary care physicians or embrace online-only telehealth systems. “It changes the fabric of how health relationships are actually being maintained.”