At the World Health Care Congress in Washington, D.C., Steven J. Corwin, M.D., president and CEO of NewYork-Presbyterian (NYP), said that telemedicine is the single healthcare innovation that he thinks has the best chance to turn around the troubling trends of rising costs and poor access.
Dr. Corwin, speaking to Susan Dentzer, president and CEO for the Network for Excellence in Health Innovation (NEHI), who asked him a series of questions in an informal chat session on April 30, explained how there are only some 7,000 child and adolescent psychiatrists in the country for the entire U.S. population. What Corwin and his NYP senior executive colleagues found out, as it relates to telehealth, is that child psychiatry can be done in school-based clinics with one remote psychiatrist as opposed to the patient going from place to place.
“When we first did telemedicine, I wondered if people would really accept it. But the reality is that the net promoter score of these interventions has been quite high. We have ER kiosks where the net promoter score is 95, and we have a [net promoter] score of 92 for [virtual] adolescent psychiatric services. So there has been wide acceptance, regardless of age,” Corwin said.
He noted that NYP has put OnDemand kiosks in some Walgreens’ locations to make sure that people who do not have broadband access could still get access to the telemedicine services. “And [similar] to rural America, in inner cities, there are connectivity problems as well. We wanted to narrow health disparities, not exasperate them,” he said.
Corwin recalled a recent story when a 35-year-old male, who never saw a doctor before and was afraid of going to one, was short of breath one day recently and assumed that it was from asthma or a cold, so he went to the drugstore to get cold medicine. The man saw an OnDemand kiosk in the store, decided to go into it, and ended up getting treated by an NYP ER doctor. As it turned out, the new patient had an elevated blood pressure of 220/120 as it became clear that he had congestive heart failure (CHF). After being treated by the ER physician, he started on the path to recovery. “He never would have gotten that care had he not gone to Walgreens. It was a telling story in how people access the healthcare system,” Corwin asserted.
Corwin noted that NYP made the decision to do telehealth regardless of physician reimbursement, feeling that reimbursement would eventually catch up to it. “Any system can be gamed. You can always say that the telehealth visit is the bait-and-switch and gets you into the system. My view is that telehealth will reduce the cost of care to the patient longitudinally, and reduce the cost to hospitals. But we don’t know the answer now [for sure]. We still need to demonstrate it.”
So far, Corwin said that NYP doctors have embraced telemedicine, offering the example that using virtual care, a patient with CHF can complete a physician visit in five or six minutes. “And if you scale the visit appropriately, in terms of your associated personal, the physician doesn’t have to do medication reconciliation since it can be done by the pharmacist. There are social work issues that can be dealt with as well for patients with CHF. So for those issues, telemedicine is embraced here,” he said.
Corwin was also asked by Dentzer about other leading-edge innovations such as artificial intelligence (AI) and machine learning, to which he noted that 60 percent of NYP’s hospital expenses are labor costs, meaning there is an opportunity to use AI and machine learning to bring those costs down. But, Corwin asked, “What are the values we are placing into AI and machine learning? Will it aid humans or replace them? Are we dehumanizing or re-humanizing care?” “But,” he admitted, “If you don’t reduce labor expenses, you can’t get hospital costs down.”
Corwin was asked about machines already being able to read radiologist scans better than the average radiologist, to which he admitted that there will be less of a need for radiologists over time. For medical image transfers, for example, “we need less neuroradiologists because we can cover stroke in seven or eight different places. There is less of a need for pathologists, too. The physician need in this country will go down in that sense, but may go up in other areas like primary care,” he said.
In the hospital system, Corwin continued, a very productive person doing insurance clearances can do about 70 clearances per day. But NYP is working with a bot that can do one clearance every 90 seconds, 24/7, 365 days a year, with no sick or vacation time. “Where do those jobs go?” he asked. “We are having that discussion with 40,000 of our employees. And we have to have [those discussions]. If everyone thinks that [AI and machine learning] will take away from the work they do, it will be resisted. So we need to figure out a way in which jobs are persevered and new jobs created. That’s a responsibility for me.” To this point, Corwin mentioned that NYP has a cybersecurity academy in which it takes people who have been displaced from jobs in finance, and then trains them in cybersecurity.
On the policy front, Corwin believes that the country took a big step back with the ACA repeal/replace debate last year. He stated, “This debate over Medicaid was unfortunate and insensitive in the extreme. We have 75 million Americans on Medicaid. It is shameful that states have not expanded Medicaid, which is the face of many families. Four of every 10 children in the U.S. are on Medicaid. And I think we could have rejiggered the ACA to make it more affordable for people, as opposed to dismantling it. We must have universal coverage to get costs down. And I believe we can get there with employer-based healthcare, with the insurance exchanges, and with Medicare and Medicaid. We don’t need to go to a single payer system, nor should we. But we have to get everyone covered,” Corwin asserted.
And coming full circle, when asked what he would do if he could wave a magic wand that would result in one innovation meeting healthcare’s Triple Aim, NYP’s chief executive said that telemedicine would be his choice. “I really believe that it has the promise to dramatically improve access, quality and reduce costs. We are committed to making that happen [at NYP],” adding that the industry is moving in the direction toward ambulatory care and home care. “That gets juxtaposed with hospitals being the largest employer in many communities, and being the sole access provider in rural communities. What do you with the jobs? If the hospital goes away, what happens? We will wrestle with that as a country,” Corwin predicted.
