Curbside Consult with Dr. Jayne 3/22/21

Both the virtual physician lounge and the informatics community were buzzing this week about the Amazon telemedicine announcement. For those that missed it, Amazon plans to expand its Amazon Care telehealth program nationally. The program will be available for all 50 states plus Washington, DC later this summer.

Amazon Care has been providing both telehealth and in-person primary care services to company employees and dependents in the Seattle area since September 2019 and expanded it throughout Washington state in September 2020. The first phase of the national expansion will cover other companies in Washington state, with the rest of the US following for in-person services in Washington, DC and Baltimore and virtual services in other locations. Planners note that the virtual clinic will offer both urgent care and primary care services as well as COVID-19 testing, flu testing, and vaccines. Patients also have the option of scheduling follow-up visits in their homes or offices. Patient can schedule them through the Amazon Care app, which also provides care summaries and follow up reminders.

Amazon has offered additional home services in the pilot program, including administering pediatric vaccines in patients’ homes as well as evaluation of the work-from-home arrangements of employees to help them avoid ergonomic issues. Employers will be able to access the service and offer it as a benefit to employees.

It will be interesting to see how it scales. In the current offering, patients are typically able to connect with healthcare providers in around a minute through the app, which offers live chat, messaging, and video. Unless they have a tremendous number of resources on standby, response times like that are typically only achieved when agents are managing multiple patient streams at a time. That’s what I’ve seen with some clinical call centers that add messaging to the mix. Maybe Amazon has some kind of secret sauce that will make things work differently.

The purported value as a workplace benefit is clear – employees would miss less time trying to seek care for minor illnesses or more straightforward services such as prescription refills. Those services are available through existing telehealth offerings. However, the Amazon name is likely to represent speed and efficiency, which are both attractive to employers. Amazon prescription delivery is also attractive.

Still, I wonder what their clinical quality data looks like in their pilots. How are they managing antibiotic stewardship? What are the metrics they are following to determine whether they are successful? Are they able to monitor downstream metrics, such as emergency department visits or hospital admissions? The availability of home visits is certainly a differentiator compared to other available offerings.

As a physician, I’m curious to understand what their compensation structure looks like for clinical resources. Are they using all employed physicians with enough licensure coverage to hit all 50 states? Are they using independent contractors? Most of the major telehealth organizations use independent contractors, who may have arrangements with multiple vendors and who practice on the different platforms depending on supply and demand factors. The Amazon press release notes that the service “allows employees and dependents to see the same dedicated teams of medical professionals, which creates long-term relationships that benefit overall health.” That would seem to describe employed physicians who would be focused on Amazon patients, but I would be interesting to understand how that kind of arrangement would compare to the salaries generated by brick-and-mortar physicians.

The Amazon press release also mentions same-day COVID-19 testing, so I’m curious to understand who they are partnering with to deliver the proverbial last mile of service for testing and vaccinations. That might not scale across the US in the same way it would in the Seattle area.

I’m concerned about the potential mismatch between patient expectations and reality, as well as how the extreme focus on convenience somewhat diminishes the value of the relationship with the physician. The release cites a patient who appreciates the convenience of Amazon Care and not having to wait at a doctor’s office. She states that using the services “makes me feel like I have more control over the healthcare system than the healthcare system has over me. It’s at my leisure. That’s power. I’m not waiting on someone else to show up on their schedule.”

I appreciate the need for patient convenience, but I think it’s important for patients to acknowledge that the vast majority of the time, physicians are not on schedule because they’re caring for other patients, whether in-person or asynchronously, because they are managing refills or completing paperwork. When my patients are frustrated because it’s taking 30 minutes for me to reach their exam room in my walk-in clinic, it’s usually because someone with a more acute need has arrived at the same time or before them. Although healthcare delays can be due to inefficiency or operational issues, they can also be due to me arranging a transfer to the emergency department or counseling a patient on a devastating diagnosis, such as a miscarriage.

In the case of Saturday night, the delay of care might have been due to the fact that our entire staff was busy performing cardiopulmonary resuscitation on a patient, trying to bring him back from the dead in the interval before the ambulance arrived. If you’re the patient in distress, you certainly don’t want me cutting you short because I have someone else who is waiting.

I struggle with understanding how they plan to balance the promised levels of convenience with the offered continuity, because they’re often in conflict. Team-based care can certainly help with this, but patients have to understand what that really means. As healthcare has become more transactional, I find that many patients don’t care who they see. While a brick-and-mortar practice can’t staff an unlimited number of physicians, online practices can certainly have a deeper bench. But we can only deliver face-to-face care (whether virtual or in person) to one person at a time, even if we’re running back and forth between exam rooms. The demand for instantaneous care has definitely impacted the relationships that we are trying to build with our patients, and at least anecdotally among my local peers, is one of the reasons some of them have changed jobs.

The devil will be in the details, but I can’t wait to see how this unfolds. Get your popcorn, folks. How do you think Amazon Care will play out nationwide? Leave a comment or email me.

Email Dr. Jayne.