Digital Access and Consumer-Directed Payments Are Remaking Healthcare

Telemedicine’s rise is igniting demand for digit-first healthcare delivery and consumer-directed healthcare payment models, both inside and outside traditional healthcare billing and payments confines, by blazing new trails in how patients access care, and how payments flow.

In a discussion for the “Visa B2B Series: What CFOs and Treasurers Can Teach Payments About Going Digital,” PYMNTS’ Karen Webster was joined by David Goldhill, founder and CEO at Sesame, and Mansoor Khan, CEO of OneClinic and parent AMK Technologies, where the inefficiencies of healthcare reimbursements — and the workarounds — were highlighted.

The two businesses have key structural differences — Sesame is a straight-up telehealth offering, while OneClinic relies on physical locations with on-site telehealth facilities physicians can use — but both struggle with outdated insurance reimbursement models.

Noting that whether insured or uninsured, patients are increasingly forced to absorb more out-of-pocket costs for their care, Goldhill said more doctors and providers “have patients who pay directly for services. And yet they tend to be encumbered by the same sort of administrative and payment complexity that the insurance system puts on them.”

For that reason, among others, Sesame operates much like “a traditional online marketplace, but for healthcare services that are paid for directly by the patient, charged directly by the doctor,” he said. “Unlike the insurance market, doctors are free to compete on price and on the packaging of care and definitions of what they provide.”

Goldhill said, “We regularly criticize innovation for not working for all 325 million people 100% of the time. That’s one of the reasons we have so little consumer-directed innovation in healthcare. The reality is that video medicine creates broader access for a lot of people for a lot of conditions a lot of the time in a way that didn’t happen before.”

See also: 46% of Americans Mixing Telehealth, In-Person Care

Unlocking Healthcare’s Potential With Digital Access

Much of the debate comes down to access and cost. Set in rural Ohio and serving mostly rural users, OneClinic doesn’t operate as a marketplace of video doctors, but rather “works with providers and helps them expand their practice,” Khan said.

Both are on a mission to match more patients with more doctors with previously unheard-of efficiencies in when they can be seen, taking the inconvenience out of office visits.

“The problem with video medicine wasn’t that we couldn’t figure out the technology [or] we couldn’t figure out the value, or doctors couldn’t figure out how to do it. The problem was no [payer] would reimburse for it. Period,” Goldhill said.

By using an online marketplace approach, it opens 24/7/365 access to legions of doctors who would be available during off-hours but couldn’t until video made it possible.

To make the point, he joked that, “There are no pediatricians at 9 at night, and if you have young kids, as I do, there are no pediatric problems for some reason that exist during the day. 100% of them exist at night for evolutionary biological reasons none of us understand.”

That’s a tongue-in-cheek way of saying a doctor sitting at home at night who feels like working can see a senior or a child via video, creating enormous value from “one of the terrible assumptions that our payment system has imposed on us,” — the idea of on-site office hours.

For his part, Khan said video visits without legacy restrictions keep people out of emergency rooms and offer “a level of assurance that you can wait until morning” when appropriate.

See also: Telehealth Tech at Crossroads as In-Office Visits Resume

Act Like a Consumer-Facing Business

Telemedicine’s upward trajectory is a function of the fact that, “The number of people who use the healthcare system in a transactional way is increasing,” Goldhill said, adding, “There are things we’re very comfortable doing that with, and things we’re not. One of the intellectual handcuffs in … our healthcare system and in reforming it has been this one-size-fits-all thing.

“We fail to understand that healthcare is fundamentally a consumer-facing business. Unlike other consumer-facing businesses, 100% of the population uses it, but uses it in very different ways and often in reactive ways. But the right way to serve 100% of the population at different stages in their life and different types of needs and different types of preferences is variety.”

Injecting this level of choice into a legacy system creates a time management conundrum for many providers, but Goldhill and Khan see solutions like theirs and others solving for this.

Other issues remain. For example, Goldhill said, “healthcare is the only industry where the customer determines what the seller can sell. We don’t think of it that way because we think we’re the customer, but of course, we’re not, the insurers are. If the insurer doesn’t give you a code and say I’ll reimburse against it, you can’t sell.” In a direct pay arrangement, the doctor and patient agree on a different way of packaging care, from appointment frequency to treatments.

His bottom line is that, like it or not, insurers are now part of a hybrid system. “They’ve got to start integrating what we are doing into their model. Otherwise, they’re just imposing massive and unnecessary cost and complexity on the therapeutic experience.”

Khan agreed, saying, “From a technology perspective, where can we reduce friction? Can we automatically verify that a card is valid? That reduces friction. Can we help the providers do data entry or help patients do data entry into the EMR by using artificial intelligence tools? That reduces additional work that’s required for insurance requirements.”

Saying that Sesame charges as little as $20 for a video doctor visit, Goldhill called that “real access. In healthcare … we have this sort of language which reflects some economic island. We have failed to create competition in the healthcare space. We’ve failed to give providers the opportunity to market their services, including innovation around their services outside of these very constricted, very concentrated payer models.”