Just about everyone agrees in the basic vision for telemedicine: When a person gets sick, instead of jumping in the car to drive to a doctor’s office or urgent care center, they can pick up a phone or tablet instead, and get in touch right away with a doctor.

But when it comes to which doctor should be on the end of that call — and who should be facilitating that connection — healthcare stakeholders start to disagree. The incumbent model that initially catapulted companies like Teladoc or Doctor on Demand to success is one where insurers or self-insured employers broker deals with telehealth vendors, giving their members access to 24-7 virtual care. But over the past few years, at an accelerating pace, hospitals and health systems have started to get into the game, on the theory that consumers would rather get virtual care from the same doctor they see for in-person care.

“I think that while the early incumbents in telemedicine have certainly laid the foundation for the acceptance of telemedicine and that was done largely by aligning with payers and self-insured corporations, there is a swinging of the pendulum … in that the major health systems have come to realize telemedicine is not a medical carve-out service. And, in fact, it is probably a mistake to carve it out,” Dave Skibinski, CEO of SnapMD, told MobiHealthNews.

SnapMD and Zipnosis are two telemedicine companies that have focused primarily on the provider market. Others, like Doctor on Demand or MDLive, continue to focus mainly where they’ve had success thus far — on payers. And some of the biggest players, Teladoc and American Well, are hedging their bets with customers in both markets. All agree the provider segment is growing, though interpretations vary about the extent of that growth, and whether it comes at the expense of the payer model.

“There’s no question that providers are embracing virtual care more than ever before,” Teladoc CEO Jason Gorevic told MobiHealthNews. “However, I would say that this is a case of ‘and’ not ‘or’. From my perspective, this is additive, because health plan, employer, and consumer adoption is also rapidly increasing, as has been evidenced by Teladoc’s growth rate.”

“I think it’s a hot new area for software sales but the actual uptake of it is at the starting gun at best,” Doctor on Demand CEO Hill Ferguson told MobiHealthNews.

A Doctor or Your Doctor?

In the early days of telemedicine, payer, provider, and even direct-to-consumer were all explored as business models. Payer-based models took an early lead because, appropriately, that was the area where vendors were most easily able to get paid. Reimbursement for telemedicine is only now starting to come along, so, under fee for service, even enthusiastic providers were hamstrung by an inability to pay providers for virtual care.

“The cost pressures and access to care pressures hit the health plans harder and earlier than the providers,” Gorevic said. “So they were motivated to move faster. The second issue is that the Affordable Care Act, ACOs, shared savings, and value-based care had the providers pretty preoccupied until recently — just trying to figure out what their strategies were, what core capabilities they needed, things like that. It’s only more recently that they were able to pick their heads up a little bit.”

Skibinski added that it’s not unusual for hospitals to be slow to innovate new technologies.

“In the typical adoption cycle of new technologies and therapeutics, [hospitals] look to see market leaders initiate these types of new innovations and then learn from those," Skibinski said. "So as you look to move from the early innovators to early adopters to early followers, there is a natural sequence of things that happen. And in healthcare, that sequence is slower than perhaps consumer products. But it is a very natural progression that is well documented.”

But now that provider-sourced telemedicine is starting to arrive, the question is whether it has a strong enough advantage that it will drive patients, even those who are already using telemedicine via their insurer, through the door.

Folks like Skibinski and John Pearce, CEO of Zipnosis, think it does, because the two products are actually very different. Employer-based services can offer access to a doctor, but providers can offer a patient access to their doctor.

“You’ve seen these external networks … kind of come up and meet a market need," Pearce said. "But now we’re seeing the providers get into that game and a lot of our growth in the future is about helping them connect their services, their local brand, back into the market. And we know the economics are going to be way more favorable for them than anything the external people can do. And you’d rather interact with a local Baylor-White physician than a random Teladoc physician, we know that at our core. We’re all about that provider enablement, it’s a clean business model, and it’s giving us some really good success in that side of the market.”

Dr. Joseph Polizzi, regional ambulatory chief medical information officer at Mercy Health, echoed those sentiments. He hopes and believes that his patients will flock to his hospital once its virtual care program is up and running at full strength.

“Patients want convenience, so they have leveraged some of these opportunities just because they were available and we didn’t have it,” he said. “But as we are ramping it up, I would expect our patients to be using our services. They know they’ll be getting the same care they get when they see us in person.”

Gorevic, on the other hand, thinks this argument doesn’t hold up to real-world experience in the 21st century.

“Half of the consumers across the country don’t have a primary care relationship that they can cite,” he said. “When you ask them ‘Who’s your doctor?’, they don’t actually say, 'I’m a patient of Dr. Smith.' And I think that the evidence of that is in the proliferation and success of MinuteClinics and urgent care centers and things like that.”

In fact, Ferguson says, when the decision comes down to familiarity versus convenience, the equation is less cut and dry.

“If you ask a typical consumer who would they rather see, their primary care doctor that they’ve seen for five years or some doctor they’ve never met before, I’m guessing 99 percent would say they’d rather see the doctor they’ve been seeing for five years,” he said. “But then you actually put it to the test in reality and you say ‘Oh you’re going to have to wait a few days to see your doctor, but you can see a doctor right now at midnight on a Sunday night, now what do you want to do?’, that answer’s probably going to be different. So I think the context is really important.”

And Ferguson and Gorevic reject the ideas that familiarity necessarily equates to quality, or that quality need come at the expense of convenience.

“Underpinning all of our offerings is the Teladoc clinical quality, which we believe inspires trust and delivers better or at least as good outcomes as the traditional delivery system,” Gorevic said.

Ferguson adds that telemedicine is a skill in and of itself, and that there’s a benefit to offering visits with doctors who are trained on virtual care.

“It’s almost a subspecialty in a way,” he said. “It provides a different level of training, a different level of support, perhaps a different kind of doctor who thrives in a virtual setting.”

American Well CEO Ido Schoenberg pointed out that the ‘a doctor versus your doctor’ debate isn’t just about familiarity — it’s also about what level of care a doctor is equipped to offer.

“When you look at primary care, urgent care, there’s tons of evidence that this is important. That’s why most of the payers in America are financing it,” he said. “Ironically, that’s one of the areas that creates the least amount of value because if you compare quick access to CPAC to a multi-chronic patient care in their home, there’s no competition. But doing that is infinitely harder. You cannot possibly treat the multi-chronic without having deep knowledge of all their issues. So you have to have connectivity to all the records and the data sources. You cannot assume that a random doctor will do that.”

Can payer-based telemedicine address chronic care?

Schoenberg says that the kind of telemedicine his company and others started out doing was focused on coughs and colds — the bread and butter of family physicians, but not the most complicated cases.

“Most of telehealth today is focused on employers to create a valid pathway for care,” he told MobiHealthNews. “To say it differently, these are companies that help people find quick access to a doctor. And of course if you’re stuck at night or you have a problem and you really can’t get to your doctor, and we know that people sometimes wait two weeks to see a doctor, it’s a very variable thing. You have a sore throat you need to talk to someone, you get the script, take a Z-Pak, get better, everybody wins. The patient wins, the employer wins, you save time, you save money.”

But while that aspect of care is easily addressed by telemedicine, it doesn’t have nearly the impact on healthcare costs as chronic care does.

“So what we see [working out longterm] is not a solution that replaces the doctor that we trust,” he said. “We think that will not scale. It could work for your sore throat; it will never do for cancer or congestive heart failure. So the only solution that would work is a hybrid model where I can connect electronically to the trusted system and when I need to I can see a person, and really leverage everything technology has to offer without compromising the basic trust.”

American Well’s strategy is to fade into the background and become a connector that links up both payers and providers — as well as consumer vendors like Samsung — to patients, and also connects those stakeholders to each other.

Gorevic also believes chronic care is important to the future of telemedicine, but his approach is a little different. Teladoc is tackling that market through things like its partnership with IBM Watson around oncology and the second opinion services it obtained through the acquisition of Best Doctors.

“Teladoc believes there should be a comprehensive virtual care solution ranging from one end of the clinical spectrum to the other, from episodic all the way to complex and critical, and obviously we bring a significant set of expertise with our global network of experts who can do expert second opinion and critical care support for a consumer who winds up in the ICU,” he said. “And those are capabilities that are complementary to the existing delivery system, not in conflict with them.”

But Skibinski believes care for complex conditions requires too much coordination and too much of an integrated approach to be carved out to different stakeholders.

“Who needs to own telemedicine as the primary stakeholder?” he said. “It is those who can deliver the full continuum of care for all populations that need to be served.”

SnapMD actually avoids the terms telehealth and telemedicine in favor of “virtual care,” a moniker which encompasses not only episodic virtual visits, but also remote monitoring and population health initiatives.

“In many minds telemedicine has become single episodic low-acuity care, high-volume low-acuity interactions for coughs and colds, and things like that,” he said. “But for value-based care, and to affect the cost curve in healthcare, while you have to meet the needs of the consumer there, the greater need for the health system is to focus on how can we better deliver care, and better outcomes at lower costs, for the 20 percent of Americans that consume 80 percent of the healthcare dollars. And a virtual care approach can do that.”

Ferguson thinks that the advancement of technology will call into doubt the assertion that hospitals are inherently better equipped to deal with chronic care than telemedicine groups like Doctor on Demand.

“I think there’s a whole lot of exciting innovation going on in the hardware and sensor market that’s making remote care monitoring more and more a reality,” he said. “I definitely envision a future where households have a kit of devices at their disposal, perhaps paid for by their health insurance companies, that enable them to take a number of vital readings, measurements, images, etc, that can be uploaded into that patient’s medical home in the cloud and then a doctor can consult on that information. I don’t think virtual care is limited. Perhaps in the immediate term that’s true, but certainly not over the medium to long term.”

An ‘And’ or an ‘Or’?

Maybe, as Gorevic says, payer- and provider-driven telemedicine can continue to be an ‘and’, not an ‘or’.

Ferguson believes that the availability of telemedicine through different vectors will have a free market effect, as consumer choice pushes everyone to offer the best possible care.

“If we’re to make the progress in this industry that all of us want to have, it’s to move towards more of a consumer-driven marketplace where the customer has more choices and can choose for themselves what works best for them,” he said. “Generally in free markets, that’s what happens. The customer gets what they want through more choice. And I think that’s the part of the story that we’ll figure out.”

And different modalities are going to work better for different patients.

“I don’t think this is a winner-take-all market. I think it’s going to depend on the person,” Ferguson said. “You have some people who have the same job and the same insurance company and never move their house. That’s becoming less and less common as we move through time. But you have other people, maybe on the younger side, who are looking at six job changes in the next 15 years, five different health insurers, and maybe they’ll live in three or four different zip codes in that time frame too. So having a portable primary care is really valuable for that latter category, whereas the former might be better suited to having a local provider for their healthcare.”

SnapMD’s Skibinski, on the other hand, believes that continuing to parcel out care is harmful to the goal of patients getting the best care possible.

“Why would you carve out telemedicine for this low-acuity stuff and have a different platform for that,” he said, “but now your in-network providers are on another platform to do continuity of care and chronic patient management? And by the way, as part of the health plan’s population health approach, the case managers may be in on the plans, but the people treating the patient are at the health system.”

Nonetheless, even in the current status quo, those stakeholders are working together in many ways around telemedicine.

Sometimes that’s by offering that elusive reimbursement — UnitedHealthcare, for instance, reimburses telemedicine visits at the same rate as in-person care at places like Weill-Cornell Medical Center in New York. At the very least, telemedicine providers are working on ways to make sure that when a patient needs to be referred to an in-person provider, they can easily find an in-network doctor, and transfer records from their virtual visits to that physician.

But for provider- and payer-based telemedicine offerings to continue to exist side by side in the long term, Gorevic said, a deeper level of collaboration will need to emerge.

“Some of our most exciting and progressive discussions are with health plans who are coming to Teladoc for an enterprise-wide virtual care solution. In many of those cases the discussion includes bringing their network providers into the fold to provide care through the Teladoc platform. So I think it’s more convergence and cooperation than competition,” he said.

Of course there’s no way to know whose vision of the future will play out. Sooner or later an equilibrium will emerge, and different groups of consumers will fall into a pattern of seeking care via payers, providers, or even new emerging groups like retail clinics and pharmacies.

“Our job and the reason we play in all market segments is to be able to create that as a seamless experience across all the different entry points into the healthcare system,” Gorevic said. “The concept of a single entry point into the healthcare system is a fallacy. There are very, very few people who have a single relationship with a single hospital and a single doctor and that’s their only entry point and touchpoint in the healthcare system.”