Telehealth isn’t living up to any sort of hype.

I’ve been having lots of conversations lately with brokers, employers & health plans who finally realize that 10 min telehealth visits aren’t living up to the hype. Also, word is Teladoc is pressuring plans & brokers to increase their monthly fees paid by the group on top of the per use fees.

Instead of a solution like Teladoc and the clones who can only diagnose ~30 simple things like pink eye, I think folks are realizing that the combination of Virtual Primary Care and Direct Primary Care is the most effective way forward. VPC for the 70% of daily health issues (~1,500 conditions) that don’t need an in-person visit and DPC for the more complicated folks who would get value from an ongoing in-person relationship with a PCP.

The tyranny of the appointment

Forcing doctors and patients to communicate and problem solve within defined time slots forces a series of bad practices. A health issue is like anything in life. They have a beginning, a middle, and, ideally, a resolution. People need support, feedback given, and questions answered in all phases. Sometimes it’s a quick question, comment, or clarification around something weird or how to take their medication properly. But an appointment, whether that happens in a costly office visit or a real-time video visit, is just one 10 minute snippet in time. If we had the opportunity to blow up the concept of an appointment, and allow doctors and patients to communicate normally like we all do nowadays, diseases would be managed markedly differently. Doctors wouldn’t be forced to make split-second decisions (even guesses) around a diagnosis and how to manage it, and management could be far more conservative and less invasive. If, when I’m working with a patient and I’m on the fence about whether or not this is bacterial or viral and therefore may or may not need antibiotics, if I could just check-in quickly and easily with a patient over the next hours or days, I could choose a far more conservative route. This is just one example of many more.

Why most health issues can be treated online, without doctor office visits

The best doctors are exceptional detectives and masters of all the tools they have to figure out what’s wrong with you. How do they do that and what do they use to diagnose you? Here are the six main ways:

  • They ask you questions about your symptoms (how long, what kind of pain, etc.)
  • A physical examination of your body with a good old-fashioned poke here and a listen there.
  • Lab tests (blood work, etc.)
  • Imaging (x-rays, ultrasounds, MRIs, etc.)
  • Experiments (if I prescribe you this anti-histamine and your rash goes away, it must have been an allergy)
  • Time (if you have bad belly pain and your doc thinks it’s just gas but it might be appendicitis, she’ll watch you in the ER to see if your pain goes away)

Of these six tools, what needs to be done in-person in a doctor’s office and what can be done online with your doctor?

Asking you questions

Does not need to be done in-person and would likely be more efficient and higher quality if not done in-person. This can be done online with a back and forth between you and your doctor. And most any doctor will say that 80-90% of diagnosis stems from asking detailed, targeted, thoughtful questions. It’s also important to ask questions in a structured, checklist-driven way— something that can’t easily be done in-person. And secondly, it’s important to give patients time to thoughtfully contemplate questions and respond to them— something they can’t do during time-sensitive oral conversations during an office visit. And, finally, looking a doctor in the eyes when talking about something embarrassing is hard and I believe it’s easier to write about embarrassing things than talk about them.

A physical exam

Needs to be done in person: Sometimes. Honestly, in many situations, the old-fashioned physical exam is a blunt tool. It’s often used to support what you already suspect from the questions you ask and occasionally to direct the test you order to confirm your suspicions.

Many of the clues you’d get from a physical exam can often be done by-proxy. If it’s a rash, a high quality photo is much better than a doctor seeing it in their office and not taking a photo of it. If you injured your leg and you’re worried it’s broken, there are questions your doctor can ask to determine whether or not it’s broken. For example, via a phone call, your doctor can ask you “can you jump up and down?” If you can, your leg is not broken. If you’re monitoring your blood pressure, for $130 you can purchase an iPhone-connected blood pressure monitor and share the results with your Sherpaa doctor. If we suspect strep throat, having a friend use your iPhone to take a photo of the back of your throat is just as good as a doctor shining a light in your throat. If we need to know your temperature, a simple thermometer is a few dollars at Walgreens. If you need an updated eye exam to get new contacts, you can use Simple Contacts to do your eye exam on your iPhone.

An old-fashioned in-person physical exam is very, very rarely the missing piece of a puzzling diagnosis.

Lab tests

Needs to be done in person: Sometimes. If you need STD testing or your cholesterol checked, you can purchase tests from Everlywell and do everything from the comfort of your home. If you need your cholesterol checked, you can purchase a kit at Walgreens. However, if you need a good old-fashioned blood test, your doctor can order them at Quest or LabCorp in your neighborhood and you simply show up and get your blood drawn and the results are sent back to your online doctor who ordered the tests.


Needs to be done in-person: Yes, at an imaging center. To look inside your body with an x-ray, you need to go to a local imaging center. Your online doctor can order these tests and you visit the imaging center and the results are sent back to the doctor who ordered the test.


Needs to be done in person: Sometimes. If the experiment involves trying a medication for a short period of time and then checking back in with results, it’s best to not do this in-person because you’ll have to pay for two doctor office visits. If you could just send off a message with an update so your doctor could use this information to determine your next steps, that’d be inexpensive and ideal.


Needs to be done in person: Rarely. Almost every health condition follows an expected timeline. If you have a UTI and start antibiotics, if the antibiotics are working you’ll start feeling better in a few hours. If you have appendicitis, you can expect that appendicitis to worsen over the course of hours if it’s not being treated. If your pain is just gas, you’ll probably feel a lot better in a few hours. Reporting updates about how you’re feeling surely does not require an office visit. If expensive office visits are the only ways to update your doctor so your doctor can make a decision about what she thinks you have, that’s going to be expensive and inconvenient.

After 7 years of operating, our data shows 70% of the issues for which you’d traditionally use an urgent care or primary care doctor office visit can be diagnosed and treated from beginning to end exclusively online.

Maintaining complexity, without adding value.

One day, you wake up and look around and see that 90% of everything around you is there to maintain complexity, and not add value. That’s my definition of medicalcare in America. A new study published today in JAMA looks at healthcare spending in America and concludes:

Prices of labor and goods, including pharmaceuticals and devices, and administrative costs appeared to be the main drivers of the differences in spending.

Meanwhile, the medicalcare industry led all other industries in new employment and added 300,000 new jobs in 2017. As an industry, we need to focus on adding value, not adding jobs. I’m afraid, with today’s mandated health insurance complexities, this isn’t possible. That’s why incumbents won’t and can’t save us. Any new innovation will come from left field. And those innovations will strictly focus on 21st Century efficiencies that increase value and destroy complexity. But, in order to get there, it’s going to take a coalition of small and medium-sized players willing to think differently and invest their healthcare dollars in the future, not propping up the past.

Can innovation in healthcare do more harm than good?

Sure, here’s how. Say there’s a new thing called “video visit for 10 minutes with a random doctor.” A 10-minute random doctor conversation (without the ability to follow-up or order tests to confirm suspicions) is, by design, a tool to solve an extremely simple problem, like pink eye. This innovation depends on users understanding how and why they can use the tool. If the user believes this tool is far more capable than it is, they’ll pay for a tool that can’t help them. And then they’ll pay again for the more traditional tool (like an urgent care visit) that can finally help them. The “innovative tool” is just part of the equation. By far, the most important part of an innovation is educating people how to use the tool. Unfortunately, many of these video visit companies market to users “talk with a doctor now” vs. “talk with a doctor for super simple things like pink eye now.” They make money from users misunderstanding and misusing the service and can ultimately increase the cost of care when not used appropriately. Talking with a doctor for 10 minutes via video is kinda cool, but it’s a rock to use in a pinch, not a Swiss Army knife.

Magic doesn’t make health happen.

Last week, I wrote about the difference between “health” and “medical.” Basically, “health” is a series of everyday choices and “medical” is pills and scalpels. The concepts are wildly different. But I get it, the medical world wants to prolong and/or return you to a state where you can make the same everyday choices. Helping you make different/better everyday choices really isn’t medical’s expertise. Here’s what I think is even crazier. The health world makes more money by raising your awareness of those everyday choices. The medical world makes more money from people who ignore everyday choices. They are diametrically opposed. The healthier the population, the less medical makes. Don’t get me wrong, I don’t think there’s some grand conspiracy amongst doctors and hospitals to keep us suffering. But if there’s any way forward out of this mess (and I mean 20-30 years from now), the health and medical worlds must collide and figure out a sustainable, national business model that leverages one another’s skills and profits off health, not sickness. That has to start with today’s medical educators preparing today’s medical students for a brand new business model of the future. That’s exciting to think about, but magic doesn’t make things happen.

What happens when you do the obvious/logical thing in healthcare?

If today’s flavor of telehealth is 10 minute video/phone conversations with pink eye doctors, and those doctors can’t manage your issues for the long term, well, you can’t take advantage of new ways to manage expensive chronic issues like this one. This is wonderful. And obvious. That’s why Sherpaa has been managing high blood pressure completely virtually with our patients for the last 7 years.

“People who monitor their own blood pressure and share the readings with their physician get better control,” said the lead author, Dr. Richard J. McManus, a professor of primary care at the University of Oxford. “Seventy-five million Americans have hypertension. If a good proportion of those self-monitored, it would lead to a big reduction in stroke.”

Via the New York Times, “The Best Way to Monitor Your Blood Pressure? Do It Yourself