Eren Bali, Co-founder & CEO, Carbon Health

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Telemedicine adoption rates are low — in some cases, 

0.52 percent in rural populations and 0.41 percent in urban populations

 for large employer health plans. Clearly, the promise of telemedicine has yet to materialize. As a result, many in the healthcare industry are discussing how telemedicine has failed to receive strong adoption among consumers despite the generous amount of funding that goes into the market. Analysts, providers and doctors alike are quite puzzled by the situation.

All the factors in the market seem to be there. Patients don’t like the experience of going to the doctor’s office — in fact, 

 avoid doctors visits. But doctors believe a significant portion of their visits could be done virtually, and many physicians prefer the flexibility of working remotely. Meanwhile, telemedicine companies cite limited insurance coverage, lack of consumer awareness and regulatory hurdles as reasons behind these low adoption rates, but I believe there’s a more fundamental product-market-fit problem.

In my previous life, I started a very successful online education company where we made a deliberate bet on purely digital education. The industry was going through a similar rough patch. The previous generation of companies had sunk millions of investment dollars with nothing to show for it. In fact, the only success it achieved was pretty uninspiring: While many corporations opted into online education platforms, these platforms floundered, with low utilization among employers, and it created a ticking time bomb.

READ: Health Systems Must Beware of Retail Telemedicine

What follows after a period of inflated investor expectations is a shuttering decline where you can’t even discuss the subject with VCs or investors. But where the earlier attempts had failed by trying to copy-paste physical classrooms into the internet, a new generation of companies became successful by simply wondering how consumers wanted to learn online.

When we built a team to reimagine primary care from the ground up, my instinct should have been to go 100 percent virtual. But neither I nor any of my friends had ever used telemedicine. We decided to hear more perspectives and surveyed about a thousand people in our target demographic: mostly woman, in their 30s, and living in major metropolitan areas. The results weren’t optimistic. Almost everybody knew about the concept of telemedicine. More than 70 percent of them could even name two or three companies providing the service, but only 2 percent of them had ever used a telemedicine service, and a mere 5 percent said they would consider it. The research funded by telemedicine companies cite 

 for that number, but even that isn’t very high.

One interesting pattern we caught in the research process was that people who have a doctor in their family called them often for medical care. In fact, calling the doctor in the family was the starting point of almost all of their healthcare interactions.

We decided to keep an open mind and launched the service by providing a hybrid of in-clinic and video visits. We put the two options side by side so that the patients would consider video before every clinic appointment, but the usage was still very low, as only 5 percent selected a video visit. Wondering why more people weren’t using it, we started surveying our patients one by one.

The fundamental issue is that patients perceive going to a clinic as a reliable solution to their problem, but doing a virtual visit feels like a risky bet. They don’t know whether their specific problem will require an in-person examination, testing or a simple procedure. If the telemedicine visit doesn’t require a follow-up, in-person visit, the patient saves roughly two times their commute time. If it does, their loss is the time of the virtual visit, the cost of that appointment and the hassle of explaining their situation to a brand new doctor, plus their commute time. That sucks! And a part of them wonders whether the telemedicine clinician will overlook their situation during a video visit to avoid sending patients to a physical clinic. Therefore, a virtual-only synchronous video visit doesn’t seem to be a great product for consumers.

One win for telemedicine in 2018 was the rapid revenue growth of companies like Hims, The Pill Club and Nurx, which allow people to quickly obtain medications for birth control, erectile dysfunction and hair loss after a quick online survey. These companies make money from the lucrative medications they are selling, so they can subsidize the cost of the asynchronous virtual interaction. But more importantly, patients know what they want to get and see the doctor’s prescription requirement as a nuisance, or simply a formality.

But as most doctors would say, ordering medication is much more complicated than ordering lunch. Medications can cause harm, and doctors have a duty to make sure that their patients get the right diagnosis and the right treatment. How do we balance the competing needs of patients with the need for safe and accurate diagnoses and treatment? How can we use technology to reduce the overall cost of care?

I believe this is the direction telehealth will evolve toward in 2019. Instead of completely bypassing the existing healthcare delivery system, telehealth will supplement the existing offerings to make the process of finding the right care at the right price point, safely, effectively and conveniently. Telehealth will be the starting point for nearly all patients who seek care, seamlessly guiding patients from the problem they are experiencing to the most appropriate solution, based on their individual needs and medical conditions. This is where telehealth can be influenced by machine learning or artificial intelligence (AI). These technologies will significantly reduce the cost to triage patients and in many cases will allow doctors to treat patients in a more cost-effective manner.

In an industry where doing simple things like making an appointment is mostly handled by telephone today, layering the benefits of telehealth on the existing infrastructure to take care not only more efficient and convenient but also safer due to machine learning and AI, will be a welcome change for patients. In this setting, providers benefit as well. Patients will no longer need to figure out where to go for care, only to be bounced around to other providers, further delaying their care. Telehealth as the starting point of care solves the problem of access and makes people feel like there is a doctor in the family guiding them through the confusing maze that is today’s health system.  

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