To achieve parity on virtual health, demonstrate its value, says North Dakota endocrinologist who uses a variety of methods to reach patients hundreds of miles away.
For endocrinologist David Newman, MD, virtual technology has been a lifesaver in treating the unique patient population he serves in North Dakota and other areas.
Many of his patients live hundreds of miles away and can’t afford to travel for an office appointment every three months. Telehealth visits have meant patients can save two tanks of gas and don’t have to miss a full day from work.
Getting necessary care to patients with specific endocrine problems has also gotten easier.
For example, seeing patients from the North Dakota State Penitentiary was a challenge before the big telehealth boom. Law-enforcement officers would have to accompany the patients to his office.
Now, he’s able to see these patients virtually, which is a better and more effective way of delivering the care they need.
Physicians often like to guide the discussion to what they want to do. And many doctors do prefer in-person care, said Dr. Newman, a diabetes and metabolism specialist with Sanford Health in Fargo. But he advises that “we should partner with patients to do what they want to do,” which is likely going to be virtual care for many of them, he said.
Dr. Newman, who has discussed the ways in which we can learn from health care disruptors such as Amazon and Google, offered more candid observations in this exclusive Q&A with the AMA. Diabetes care has become so much easier with telehealth. What needs to happen next is better payment so that physicians can maintain virtual platforms, he said.
Sanford Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
The AMA, in collaboration with Manatt Health, has developed a Return on Health framework to articulate the value of digitally enabled care that accounts for ways in which a wide range of virtual care programs can increase the overall health and generate positive impact for patients, clinicians, payers and society.
AMA: Tell our readers about the telehealth and other digitally enabled care innovations you have been undertaking in endocrinology for Sanford Health?
Dr. Newman: I am an endocrinologist, so I treat a variety of hormonal conditions such as diabetes. And I'm based in Fargo, an urban center in North Dakota. I serve lots of patients all over the state, as well as rural western Minnesota and some patients in South Dakota and even Montana, which is a 400-mile drive from Fargo.
I would say roughly 70% of my patients live in rural areas, and probably 30% live in urban areas like Fargo. As far as my practice goes, I do both clinic and hospital work.
In the summertime, about one in five of my patient clinic visits are virtual. In the winter, at least 40% of my visits are virtual. We’ve had a very long and rough six months of harsh winter weather in Fargo and our surrounding region. When it’s been too dangerous for travel and the interstate has closed, I’ve been able to move in-person appointments to virtual visits so that my patients can still receive the care they need without delaying, or worse, canceling their appointment.
That can be either a visit where the patient is in their home using their cellphone or their computer to talk with me. Or it could be a telemedicine visit where the patient who doesn't have access to broadband goes to a clinic in rural North Dakota and talks to me from the clinic while I'm still at my office.
The other things that I've done from a technology standpoint relate to dramatic changes in diabetes care. Ten years ago, insulin pumps and glucose sensors were in their infancy. Now, it's almost standard for lots of my patients to have these things. Whereas somebody used to have to come to my office so that we could download how often they're taking insulin or what their glucose trends look like, we can do that all remotely now. We can offer comprehensive diabetes care for somebody who is across the state or even across the world.
AMA: Why is it important to connect with patients digitally—for endocrinology care, specifically?
Dr. Newman: One of the things about endocrinology, which is a bit different from some other specialties, is we don't rely super heavily on a physical exam—where I can see somebody once in clinic and earn their trust right there. Also, I have a primary care model where I've been following some patients for 15 years now. One of the things that's very enjoyable is having that relationship with the patient where they know that they're going to get the same level of care, whether it's virtually or in person.
AMA: How does delivering this care remotely help patients?
Dr. Newman: Certain insurer rules say that if somebody has an expensive piece of diabetes technology, they need to be seen every three months. I've got patients that live several hundred miles away that can't afford to come to an office appointment every three months. We can meet virtually, and they don't have to purchase two tanks of gas. They don't have to miss work. They can do their appointment from their home. They can do it from work. I've had patients do their appointment in the car.
They’ve come to expect these things. If we can do the same thing virtually that we can do in person, it doesn't make a lot of sense to have the patient experience something that matches what I want. We need to do what the patient wants.
AMA: What is the importance of this, given the wide scope of your service area? What kind of access to specialty care are you able to expand through this work?
Dr. Newman: That's a phenomenal question and one of the reasons I think we're very passionate about this at Sanford. There aren't a lot of specialists in the state. Most of the specialists are limited to the urban population centers. As an endocrinologist, I’m one of the few people in the state that treats gender dysphoria. The No. 1 barrier to treating patients for gender dysphoria is getting access to a provider that is willing to provide gender-affirming hormonal therapy.
I can do these things remotely. I have several patients that I've never met in person, but I can provide this care based upon the several hours that I've spent with them virtually.
AMA: What about lack of reliable internet access on the patient side? How big of a barrier has that been to advance how many patients you're able to reach? How are you able to help patients with that?
Dr. Newman: It honestly hasn't been as big of an issue as I thought it would be. I'm committed to meeting patients where they're at. If they don't have broadband, I can make phone calls. We can get them to an area that does have broadband so we can do virtual care.
Sanford is committed to digital equity. We have several initiatives that are trying to solve this problem. We are building a new $350 million virtual care center that is helping to lead the charge for virtual care.
One of the biggest things is asking the patient what their preference is. My spiel at the end of every appointment is: "Hey, I want to see you back in three months. I want to meet you on your terms. It can be an in-person visit, it can be a virtual visit, but it's really going to be what works best for the both of us."
AMA: What kind of payment challenges are you encountering, and how are you navigating those? We're hearing about more payers refusing to pay for telehealth, for example, or only pay a smaller percentage of in-person care.
Dr. Newman: We don't know exactly where reimbursement's going to be over the next several years. That is the one thing that I'm certain of—that it's going to be a moving target. What we must do is demonstrate the value. The patients know the value. As health care systems and providers, we need to demonstrate that it probably should be compensated at the same rate as in-person care.
Virtual care is reimbursed at a lower rate because some of the ancillary services aren't there. It takes less nursing staff. But there are other costs. There are upfront costs for infrastructure. We must increase our internet access. We need platforms for talking with the patient. It’s our responsibility to do those things. In our viewpoint, these things should be reimbursed at the same level as an in-person visit.
AMA: Anything else you want to add that you think our physician readers, or endocrinologists, should know?
Dr. Newman: I firmly believe this is the future of medicine. What we as providers need to do is partner with technology and partner with patients to meet everybody where they're at, to serve them best.
