Q&A: Why Direct-to-Consumer Telehealth Isn't the Right Fit for Everyone

Direct-to-consumer telehealth aims to give consumers a quick and easy path to healthcare services, but critics say it bypasses a critical element in healthcare delivery: The health system.

As the HLTH conference convenes this week amid the glitz and glamor of Las Vegas, the healthcare industry is facing a conundrum. Direct-to-consumer (DTC) care is blurring the line between provider and vendor and forcing everyone to rethink the concept of healthcare delivery.

And while DTC telehealth might help boost access to care for consumers who can't easily make a doctor's appointment or go to a clinic or hospital, it does have its drawbacks. Some see the platform as way of bypassing the traditional healthcare provider and selling a product—namely, healthcare—directly to the consumer. This, in turn, leads to questions around where the traditional provider fits into the new ecosystem.

As the technology improves and payers begin to support virtual care, hospitals and health systems are debating whether to outsource some services to DTC telehealth providers or launch their own platforms in-house.

HealthLeaders recently sat down for a virtual Q&A with Sachin Agrawal and Miles Romney, president and chief technology officer, respectively, of eVisit, a telemedicine company that partners with providers to offer a branded virtual care service.

Q: How might a direct-to-consumer telehealth program negatively impact healthcare?

Agrawal: Healthcare should have a strong focus on patient safety and quality. When you look outside the health system, you lose years of quality initiatives, patient safety measures, and evidence-based protocols. You also fragment the data. One of our customers reminded me recently that roughly 80% of diagnoses live within the patient's health history. I think technology has changed that statistic a bit, but there’s no doubt that patient history is a primary component of clinical practice. Unfortunately, direct-to-consumer telehealth programs cannot access health history and that all-important and comprehensive patient picture that supports clinical decision-making.

Romney: Direct-to-consumer care offers an episodic approach that tends to keep healthcare fragmented; it works directly against the holistic, integrated approach that physicians have practiced for decades—and which is becoming increasingly relevant, and increasingly possible. Direct-to-consumer programs tend to prioritize cost optimization over patient outcomes. These models have taken some general principles of business scaling and recommended that they somehow guide healthcare delivery. This kind of thinking makes a strong case for 'disrupting the disruption in healthcare.' When people's health and lives are on the line, disruption for disruption's sake is an ethical violation.

Agrawal: Beyond quality and patient safety, direct-to-consumer telehealth programs that partner with health systems to augment their staff are eroding market share. Our health systems need to focus on building an in-house program and shift higher complexity care to virtual where appropriate and substantiate more procedural conversions by closing the referral loop. Provider adoption is often cited as an issue for this model. Still, [healthcare providers can] drive in more revenue and manage provider adoption with the right incentives around virtual care. This is a better strategy than paying a third-party staffing platform with fragmented data and uncontrolled quality.

Q: How should one measure the impact of a DTC platform to show these negative results?

Agrawal: I think we can all agree that virtual care is here to stay and is an expected service for most consumers that will continue to grow in markets served by health systems that have opted to implement it as a distinct service line. One way to look at how outsourcing can negatively impact the health system and care in the long term is the total market share of virtual care. It can be a predictor of patient erosion. Encouraging more specialty care and higher complex care to shift to virtual care throughout the organization can increase access and capacity, capture more market share, and prevent erosion of physical care. It can also help prevent and lower hospital readmissions, ED usage, and waste.

Romney: Beyond comparing quality standards, fragmented data, and lifetime patient value, there’s a fair amount of downstream revenue potential that slips away when a health system partners with a direct-to-consumer program to serve as its digital front door. When that's the top of your funnel, it's like saying, 'I'll save money by outsourcing my sales leads to a competitor.' Organizations can quantify the impact by looking at their average virtual care visit volume outsourced today and the opportunity cost they are giving up by not growing that volume and referring those patients throughout the system. By evolving virtual care workflows to support more comprehensive care, health systems can build a greater volume of higher-complexity visit types and see more patients than they’re able to turn over in the office.

Q: What are the positive attributes of a DTC telehealth platform?

Agrawal: A direct-to-consumer third-party vendor offering staffing augmentation can be beneficial during surges, as long as they are not competitive with the health system and can facilitate comprehensive data exchange between the system and external providers. Still, it should be a backup, and once the health system's capacity returns, staffing services should switch off.

Q: Why are health systems drawn to a DTC telehealth platform?

Romney: Because of the pandemic, many health systems had to implement virtual care strategies quickly and then wait to see what virtual care's future would look like for their organization. Many chose to partner with third-party solutions that offered the technology and the staff because they could quantify cost savings attributed mainly to labor and operational expenses in the short term. Today, virtual care has become a mainstay that can provide access and simplify care delivery, and I’ve already seen a shift in that mindset from the early days of the pandemic. 

Q: Do health systems understand the challenges or negative effects of a DTC telehealth service?

Agrawal: Yes, most do, and they are starting to evaluate options as their contracts with the DTC vendors come up for renewal. We are active in those conversations, and they understand the revenue potential that comes from having the right virtual care strategy and partnerships in place.

Q: Do consumers understand this issue?

Romney: Consumers want convenience, access, and a quality of experience equal to their other favorite phone apps. We like to say that healthcare apps have to 'look at home on an iPhone between Facebook and Fortnite.' The DTC companies have been able to focus on that kind of innovation, yes, but at the cost of care quality; while health systems focus on care quality and less on consumer experience in the areas of telehealth and care orchestration. That’s why healthcare organizations need the right virtual care tools—that don't compete with them—while supporting their providers with workflows, facilitating streamlined reimbursements, and meeting their patients where they are.

Q: Can a DTC telehealth platform be designed to overcome these issues?

Romney: Today, there is not a D2C solution that can partner with the health system without competing against them, disrupting their integrated care, and interrupting their revenue funnel, while accurately exchanging patient data, and building the kind of quality and evidence-based care that patients receive from their health system.

Q: How will DTC telehealth evolve?

Romney: The 'how will it' and 'how should it' are blessedly aligned, thanks to the efforts of many in the industry (and certainly not without obstacles) Telehealth will evolve by disappearing. We’re already seeing lines blur between on-site care and remote care. It will all simply become 'hybrid care,' and then simply 'care.' We won’t even think about the difference in modality when some aspects of a treatment course are administered on-site, and some from home—and some continually, invisibly, from wherever we are.