Our Take: Net Neutrality, Virtual Care, and the Deregulation Demolition Derby

HTML Code: Photo by Markus Spiske on Unsplash

Photo by Markus Spiske on Unsplash

In a 3-2 vote December 14th, the FCC decided to overturn its rules around net neutrality. But, what does this deregulation mean for virtual care?

While no one can truly know the future, some very real concerns have been raised about the impact of internet deregulation on virtual care. As an industry, healthcare relies on the internet to support numerous technologies and services. Particularly when it comes to virtual care, maintaining a basic level of access is critical.

The intent of net neutrality regulations were to help ensure a level playing field for internet users (we call them patients) and businesses and other organizations by banning paid prioritization. That means internet service providers aren’t able to modulate speeds based on the destination. FCC Chair Ajit Pai has stated that eliminating this ban will enable the ability to prioritize healthcare services, though others responded that the regulations allowed for internet “fast lanes” for healthcare and other critical services.

Many thought leaders, however, believe that the repeal of net neutrality has a high likelihood of diminishing access to online care delivery and actively harming small practices. Hematology and oncology publication Healio noted specifically that individual providers and those in rural areas are vulnerable in a tiered pricing system. A pre-overturn piece in Modern Healthcare also noted that, “Prohibitively high Internet costs could exacerbate health disparities between high- and low-income people and between people in urban and rural areas.”

Deregulation’s Impact

I’m less concerned about the impact of deregulation on the internet service provider (ISP) industry than I am about the downstream effects. Healthcare has traditionally been local, with the patient-provider relationship at the heart of care delivery. The regulatory environment already poses challenges to health systems and providers, and healthcare systems throughout the U.S. are facing well-documented financial challenges. This deregulation adds a further layer of complexity and potentially cost for providers and health systems already facing unprecedented challenges.Photo by Deva Darshan on Unsplash

Eliminating the ban on paid prioritization and moving to a tiered pricing system has the potential to unleash a “demolition derby” effect. Smaller organizations like rural providers and critical access hospitals with fewer resources may find themselves crushed and pushed aside. Non-profit health systems which are on increasingly tight operating budgets and are facing a negative outlook for 2018 according to Moody’s, may need to route limited resources away from clinical services and into purchasing connection speeds. Industry monster trucks could end up with free reign to roll over the competition.

Managing Risk in the Demolition Derby

Where telemedicine stands to lose the most is in the modalities that truly require bandwidth like video-based care delivery. And this is important because, as much as I may have railed against the over-reliance on video in the past, it is an important modality for certain patients and use cases. It’s vital that video-based care be able to flourish, along with other bandwidth intensive telehealth needs such as diagnostic imaging.

While a knee-jerk reaction is never a good idea, as citizens and members of the digital health community, it’s important that we monitor how this repeal impacts patient access to care and the ability for all providers and healthcare organizations to deliver care online. Chairman Pai believes that eliminating net neutrality restrictions will improve access to online care for patients. While I’m not fully convinced, I am adopting a hopeful attitude. Organizations like the American Telemedicine Association are closely watching and ready to mobilize if patient access is threatened.

In the interim, providers and healthcare organizations can mitigate their exposure posed by the repeal of net neutrality regulations by leveraging technologies that require lower bandwidth to provide online care. Store-and-forward technology, like our online adaptive interview, provides access to care that doesn’t require the same bandwidth as face-to-face video visits, while maintaining a high standard of care. In fact, it was the use of mobile phones in rural Africa, over super thin bandwidth cell networks, that inspired me to start Zipnosis. One of my maxims is that constraints are where innovation occurs. With new regulation comes new constraints and also new innovations to maximize our potential for better access to healthcare.

What the Net Neutrality Repeal Won’t Do

We don’t have a clear picture of precisely what this deregulation will do, but the one thing it won’t do is slow the adoption of online care. Offering a virtual care solution, tiered bandwidth or no, is going to be critical to the success of health systems and providers going forward.  As such, we need to do our best to manage risk, support care delivery online, and work together as an industry to help ensure that providers and patients are in the driver’s seat.

Is a Medical Virtualist Specialty Necessary? Probably Not.

"We propose the concept of a new specialty representing the medical virtualist."A few days ago, an opinion piece in JAMA came to my attention. In it, Drs. Nochomovitz and Sharma called for a new medical specialty to be recognized: the medical virtualist.

As someone with a lot of experience in healthcare – years as a family physician, three terms on the MN State Board of Medical Practice, and my current role as Chief Medical Officer here at Zipnosis – I find this an interesting idea, but I’m unconvinced it’s necessary.

Why We Don’t Need “Virtualists”

First off, let’s talk about what virtual care (or telemedicine) is and is not. Virtual care isn’t a new type of healthcare, it’s a care delivery channel. This is an important distinction. The difference between healthcare services and technology that enables delivery of healthcare services is particularly vital when we look at tricky things like regulation. Typically, medical specialties are designated because of particular knowledge and skills needed for healthcare services, not the channel through which that care is delivered. We don’t have, for example, medical retailists who specialize in care delivery through retail clinics.

The biggest reason for steering clear of a “medical virtualist” specialty is simply that every care provider will need to have the skills and ability to provide healthcare services through online care delivery channels. The authors even recognize this, stating:

“Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care.”

I couldn’t agree more with this statement. Factors like healthcare consumerism, the shift to value-based care, and the need to address the quadruple aim will precipitate increased utilization and a growing need for healthcare providers to understand how to effectively deliver care online. It doesn’t, however, follow that a specialty is needed.

Further, their contention is that there will soon be a need for care providers to spend a majority of their time delivering care virtually. The trouble with this, though, is that there already are concierge medicine services, nurse lines, and telemedicine service companies that employ physicians, physician assistants, and nurse practitioners who work online full-time. Depending on the use case and mode of care, some hospitals and health systems may even have providers spending a good portion of their working week delivering care online or over the phone.

What We Do Need

Where Drs. Nochomovitz and Sharma really get things right is in their call for specific training – even certifications – for providers to support safe, effective online care delivery. The authors note:

“Physicians now spend variable amounts of time delivering care through a virtual medium without formal training. Training should include techniques in achieving good webside manner. Some components of a physical examination can be conducted virtually via patient or caregiver. Some commercial insurance carriers and institutional groups have developed training courses. [citation] These are neither associated with a medical specialty board or society consensus or oversight nor with an associated certification.”

Once again, I withhold support for a medical specialty board, but otherwise, I agree with the call for greater training and understanding of the specific skills needed to deliver care online. Up until recently, physicians and other care providers were trained exclusively on the medical and scientific elements of healthcare. Now, medical schools include courses on bedside manner and other “soft skills” that providers need to be effective in caring for patients. Many organizations, such as AAFP (of which I’m a member), offer and recommend training in areas like patient communication to support providers in their professional development.

Encouraging skill development in virtual care delivery would be a similar extension of the training medical professionals receive. The virtual care and telemedicine landscape currently has fewer options available, though that is changing with the AMA from last year stating its support for telemedicine training for medical students and residents. Most recently, the American Telemedicine Association partnered with the ClearHealth Quality Institute to develop and offer training and accreditation options in telemedicine.  

Moving care delivery forward through expanding virtual care is going to be increasingly critical for patients and providers. Drs. Nochomovitz and Sharma are clearly committed to forwarding the cause of virtual care. Their ideas for training and the core competencies that clinicians will need to effectively use virtual care to care for patients are well-thought out and comprehensive. However, for the reasons outlined above, I believe a medical specialty would be more of a distraction than a benefit to the healthcare landscape.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

What’s in a Name? Online Healthcare Terminology and Why it Matters

We are at a critical inflection point in healthcare delivery. This inflection point is front and center for online healthcare as traditional telemedicine evolves into virtual care. It is important that the industry adopts the right vernacular to define and capture the shift, just a biology has allowed us to classify species and their evolution. To that end, I propose we clarify and define the terms we use to describe the new online care delivery models. Specifically, “telemedicine” and “virtual care.”

Over the past couple months, I’ve shared some thoughts on how telemedicine and virtual care differ. To recap:

Telemedicine = Testing; Virtual Care = Viable

For nearly 70 years, we have been testing with telemedicine. They have been vital tests of technology, payment models, clinical quality, patient satisfaction and all the bits and pieces between each of those components.

Telemedicine = Analog; Virtual Care = Digital

Telemedicine was developed when cathode ray tubes were en vogue. Telemedicine providers are not technology companies, but service companies that use technology to assist with care delivery. It’s a model that fits the pants healthcare has worn for the past 70 years, but is woefully ill-fitting for the new models.

Virtual Care has digital DNA. These companies are technology providers who facilitate care delivery on their platforms. They assume healthcare is going to be dominated by data and devices.

Telemedicine = Transactions; Virtual Care = Value

Telemedicine is all about handling healthcare transactions for a fee. Each time the phone rings or the video conference queues up, a charge is initiated. Telemedicine is anchored in fee-for-service payment models.

Virtual Care is required for value-based care payment models. These companies push the transactional cost of care as close to $0.00 as possible while unlocking new value streams off their platforms and data.

What about other terms like mHealth, connected care, digital medicine or digital health? I won’t spend much time here digesting, but I throw out my gut reaction:

mHealth: The “m” already feels like shag carpet. It was cool for a moment but no body wants to live with it.

Connected Care: It sounds like horse without a hitching post. What are we connecting to – proprietary data sets companies may not want to share? Facebook? Instagram? The Apple Watch only the affluent can afford?

Digital Medicine: It sounds antiseptic; cold, clinical and focused on data not care.

Digital Health: I actually kind of like this one, but it feels a little too broad for our purposes. In my mind digital health encompasses all the electronic tools that patients and providers use to facilitate care and wellness.

So, there you have it. My 12 cents on how and why we need to segment the market between virtual care and telemedicine. It’s time turn our eyes to the next 20 years, thank the telemedicine times and venture towards virtual care.