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Urban Telemedicine Remarks Delivered before HII99 April 27, 1999 Jonathan D. Linkous, Executive Director American Telemedicine Association Telemedicine has been traditionally described as benefiting populations in remote, rural areas. Almost all of the government-funded demonstration programs have supported hub and spoke systems with an academic medical center at the hub with rural primary care clinics as the spokes. Government demonstration programs have been beneficial in proving the efficacy and effectiveness of telemedicine but will have little effect on the overall growth of telemedicine in the future and its potential effect on the delivery of health care for the majority of the population. Telemedicine growth over the past 12 months and over the next five to ten years is very different. I assume that the largest area of growth for telemedicine in the future will be in populations living in urban areas. This will have a profound effect on the delivery of health care. It may also be very beneficial to under-served urban populations but this is still unclear. There are two primary market drivers for telemedicine today: 1. Cost savings 2. Market share The cold hard fact is that cost is a driving force in health care reform and the design of health care delivery systems of the future, not extending care to currently under-served populations Telemedicine can play a role in reducing cost, particularly in certain specialty and subspecialty areas. The most common example of this today is in radiology. For urban inner-city populations this drive has the potential of lowering the cost of accessing specialty care services and extend available benefits covered under existing health insurance plans. For example, if the cost of pediatric dermatology consults are reduced and made available on-line there is a larger chance that a low-income resident in the inner-city can access this service under existing health benefit plans. It is, however, the growing push to gain market share that will foster the greatest change in health care delivery in our lifetime, perhaps in the history of medicine. It will be developed not through new stand-alone systems but build on the existing economic network being built in the delivery of health care and in the existing network in delivery of telecommunications services. Currently profit and non-profit health care organizations are keenly interested in locking up referrals from primary care physicians (entry-points) into their own institution. This has led to the development of horizontal monopolies within a defined region or market area, where a single organization owns and controls primary-care physician offices, regional clinics, hospitals, outpatient centers, home care companies, nursing homes, and, finally, hospice centers. Cradle to grave market control. This has concentrated investments in the areas of largest potential revenue for health care and has had the effect of creating health care redline zones – avoiding lower income urban areas. Telemedicine is going to have an interesting effect on this trend. On the one-hand it will be able to help tertiary care centers extend their reach into outlying areas and deliver care to people in their own neighborhood doctor’s office, making it more likely that they will go to the tertiary care facility if and when there is a need for hospitalization. On the other hand it provides the ability for other competing institutions to reach their hands into the formerly locked up market area of an existing institution. For example, where I live Inova Health Services serves northern Virginia and has a large presence and growing share of health services within this region. However, the use of telemedicine allows Johns Hopkins or even Mayo to establish their own high profile clinics at relatively little cost as a new entrant and new competitor into the northern Virginia area. Telemedicine will also allow these same institutions to establish a presence in lower income inner city communities with relatively lower up-front investments. This may lead to an extension of health services in these areas. The next logical step is the use of the Internet as a vehicle for the delivery of medical care. In fact this is happening in small steps today but we are poised to have it become a major factor over the next five years. There are several companies that are quietly investing in telecommunications delivery services and health care systems in an effort to emerge as a major player in providing consultations, diagnoses, treatment and delivery of prescription medications all on-line all by paying for the services by credit card. This creates a new territory for horizontal monopolies for health care – the virtual on-line region. These services will be primarily in general medical treatment but will, in time include specialty care services as well. What is the effect of this on urban populations? It will undoubtedly help eliminate the problem of mal-distribution of medical specialty physicians it will help extend the availability of medical care into the communities and homes of under-served populations and it can increase the ability of low-income inner-city residents to gain access to care at lower costs. The future of telemedicine and the future of health care delivery will be change, rapid change. I believe the effect of this on central urban populations will be positive and profound. What we see in five to ten years in the delivery of health care may be very different than what we see today.
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