Elastic CC comment re: telehealth

So I started reading the Elastic conf call transcript from the just released quarter (seems they did pretty well, but this isn’t about ESTC’s performance),

https://seekingalpha.com/article/4370985-elastic-n-v-estc-ce…

And right at the beginning of his comments Shay Banon (ESTC founder and CEO) states the following:

The U.S. healthcare industry has seen an over 30 times increase in Telehealth appointments compared to pre-COVID appointments. As such, one of our customers, a leading managed healthcare customer has seen video appointment volume growth from an average of 700 to 20,000 per day.

That’s the same staggering increase (30X) that we heard about from Zoom regarding meeting participants (from 10M to 200M, then upped to 300M) at the start of COVID. He didn’t name the customer, and I’m not saying that it’s Teladoc, but they have to be getting their fair share when there are major disruptive increases like that going on in the industry.

I realize that after COVID, the number of telehealth appointments will probably reduce…but I’m guessing not to the level they were pre-COVID, there will be a huge increase of usage that they will keep. That’s why even though I have LVGO as my largest holding (by far), I’ve also started a separate TDOC position.

Long TDOC/LVGO

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I am not sure that the levels of telemedicine visits are sustainable.

From a phsician point of view you are fighting:

  1. Regulatory compliance: will Medicare rescind the telemedicine restrictions previously in place?
  2. Having to wait to wait until the patient gets onto the call. It maybsiund simple but going from room to room, and then stopping to check your virtual waiting room in your office is a hassle. Physicians are not paragon of efficiency.
  3. Inertia: doctors are very slow adaptors and rarely do something unless forced. These visits may have gone up while the pandemic was at its peak because there was no other choice. The alternative was not getting paid.
  4. Documentation: sounds relatively simple but doctors are not sure how to document visits. This is important for payments and medical medicolegal justification.
  5. Reimbursement is lower than face to face. Usually by 10-20%. Why would a physician accept that?
  6. Medicolegal: will juries remember why we were doing telemedicine to begin with and why face to face visits werent offered. Because patients will.say they requested in person visit and doctor refused if something goes wrong.
  7. Physical exams: how are you going to do a gynecological or colorectal exams? Or listen to heart and breath sounds. Will patients forego face visits for convenience and clicial signs are missed?

I see numbers going down for the rest of the year. Telemedicine will be used in a niche fashion (discussion of labs and to answer quick questions).

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I am NOT a shareholder (yet) but still want to address some of these:


1. Regulatory compliance: will Medicare rescind the telemedicine restrictions previously in place?

I assume you mean reinstate, not rescind (which means to take away, but you can’t take something away if it was previously in place, because it is no longer in place). This doesn’t seem like an argument to skip investing. Just one to watch. The landscape today is what we know and what is real. I wouldn’t invest hoping for regulation changes and this is the other side of that coin. I wouldn’t NOT invest because a regulation may come later when we have no evidence to support that it will.

Regardless, all anyone has to argue is that there WILL be another pandemic and regulators will be hard pressed to ignore it.


2. Having to wait to wait until the patient gets onto the call. It maybsiund simple but going from room to room, and then stopping to check your virtual waiting room in your office is a hassle. Physicians are not paragon of efficiency.

I’ve seen this argument a couple of times and it doesn’t make sense. You have virtual waiting rooms (Zoom has them). If there is no one in the waiting room you skip the call, just like real waiting rooms.


3. Inertia: doctors are very slow adaptors and rarely do something unless forced. These visits may have gone up while the pandemic was at its peak because there was no other choice. The alternative was not getting paid.

You can’t have it both ways. If they were already forced to do it due to the pandemic, then they have already adopted the tools. Slow adopters simply didn’t have visits. This is in the past, not the future.


4. Documentation: sounds relatively simple but doctors are not sure how to document visits. This is important for payments and medical medicolegal justification.

Sounds like an integration or product expansion opportunity. If there is a need I’m sure it will be addressed. SaaS is great at this sort of thing.


5. Reimbursement is lower than face to face. Usually by 10-20%. Why would a physician accept that?

I believe the assumption is that cost savings and/or patient acquisitions make up the difference. If these visits are more efficient you can do more of them. If you offer this and others do not you may win more patients and multiply the effect of efficiency. I know I would pick a doctor offering this over another. Regardless I would be shocked if a doctor couldn’t do 10% more visits in the same amount of time. Just guessing here but seems logical to me.


6. Medicolegal: will juries remember why we were doing telemedicine to begin with and why face to face visits werent offered. Because patients will.say they requested in person visit and doctor refused if something goes wrong.

I don’t get this one. Seems flimsy.


7. Physical exams: how are you going to do a gynecological or colorectal exams? Or listen to heart and breath sounds. Will patients forego face visits for convenience and clicial signs are missed?

I don’t see how this is different before, during, or after the pandemic.


The biggest reason this won’t go back to the volume from before is that PATIENTS WANT IT and doctors who adopted it are more attractive now and know how to do it. I’m sure volume will subside a bit but how much is anyone’s guess. My guess is it won’t be all the way back. I can tell you I will definitely be seeking out a doctor with remote capabilities. I always hated the idea of giving up rest when I am most sick to travel to a waiting room where I sit with other sick people, suffering sitting up, just to be told there is nothing to be done; or given an prescription which then requires another trip. I’d rather stay home in bed and have a prescription delivered to me, if possible. I assume there are services that do this.

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I think a lot of the medico-legal (Is that really a word? If so, I’ve just learned a new word) issues are solved by sound recordings and automated transcription services. See Dragon Naturally for Medicine, by Nuance (NUAN) [this is growing and shifting towards a subscription model, and bears watching, but I don’t think it is anywhere close to a DDOG as far as this board is concerned.)

Personally, I think lack of documentation will be the least of the problems associated with telehealth.

I’ll be very surprised if this field does not start discussing how many more people will be seen outside a “reimbursement framework”. Doctors’ practices (offices) are, by-and-large, very invested in how to get along in/with the system, they have to be. Their ability to scope the issues beyond the patients they have, the practices they run, and how they currently get paid is a huge reason to downplay doctors’ opinions about the trend. (Focus on the business numbers that actually happen, that’s what you/we do here, not speculate about what might happen. I cannot let Splunk and Accenture tell me whether DataDog or Elastic has ‘traction’, either.)

Lastly, “Über for Doctors” is going to find a lot of doctors willing to work in ways that accomodate a lifestyle of their choosing, whether that is WFH, immediate-family elder care, parenting, or driven by personal disabilities. That’s going to drive a ‘retail’ price for these services down. Personally, I have always said that most Über drivers would be better off just being Über customers, and I do not see a similar corollary here.

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I’ve seen this argument a couple of times and it doesn’t make sense. You have virtual waiting rooms (Zoom has them). If there is no one in the waiting room you skip the call, just like real waiting rooms.

Not to mention that it is common in many medical practices for a nurse or technician to handle the initial contact, get basic update information, and the like and there is no reason that can’t also be done with telemedicine so that the doctor knows not only that the patient is there, but some basics about the history and purpose of the visit.

I believe the assumption is that cost savings and/or patient acquisitions make up the difference.

I don’t know how common it is, but the local major provider bills separately for the physician and the use of facilities. In a telemedicine call, the facilities are either going to be minimal or non-existent.

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The last time I looked, Teladoc asked for doctors to be “working” at various hours so that they have doctors available quickly, rather than the doctors scheduling patients to have a busy clinic and having their ancillary staff do prep work so that the patients are waiting in the rooms ready. If it’s a busy time and the patients are abundant, maybe Teladoc physicians will just be able to jump from patient to patient. But if they’re just obligated to be available and may or may not have patients, it might be irritating. Frankly, it seems like most of what Teladoc physicians offer could basically be done by a rudimentary AI. There’s only so much you can diagnose based on history and visual inspection, and even then the accuracy will be limited.

  1. Regulatory compliance: will Medicare rescind the telemedicine restrictions previously in place?

I assume you mean reinstate, not rescind (which means to take away, but you can’t take something away if it was previously in place, because it is no longer in place). This doesn’t seem like an argument to skip investing. Just one to watch. The landscape today is what we know and what is real. I wouldn’t invest hoping for regulation changes and this is the other side of that coin. I wouldn’t NOT invest because a regulation may come later when we have no evidence to support that it will.

Medicare preciously did not cover telemedicine calls. They stated they would pay on an emergency basis at the same rate of face to face office visits. Once the emergency is over, the lack of reimbursement will be resumed.

  1. Having to wait to wait until the patient gets onto the call. It maybsiund simple but going from room to room, and then stopping to check your virtual waiting room in your office is a hassle. Physicians are not paragon of efficincy.

I’ve seen this argument a couple of times and it doesn’t make sense. You have virtual waiting rooms (Zoom has them). If there is no one in the waiting room you skip the call, just like real waiting rooms.

Physicians usually have 3 exam rooms and an office with their computer in it. Some will have computers in each room that do not have internet capability (just intranet using thin clients). The exam rooms get filled and the doctor goes from room to room. Walking back to your office to check in on a patient will disrupt flow.

A lot of physicians have been using whatsapp to do face to face. Some are using doxy. These are fairly easy to use but don’t integrate well with many EMS. Doxy does have a premium feature that does integrate with some of the larger EMRs. So now you are asking physicians to pay to be able to see some patients at lower reimbursements.

  1. Inertia: doctors are very slow adaptors and rarely do something unless forced. These visits may have gone up while the pandemic was at its peak because there was no other choice. The alternative was not getting paid.

You can’t have it both ways. If they were already forced to do it due to the pandemic, then they have already adopted the tools. Slow adopters simply didn’t have visits. This is in the past, not the future.

Doctors were forced to pay rent and payroll, so they accepted telemedicine visits due to no revenue coming in. Medicare allowed FaceTime and whatsapp to be used on an emergency basis. They will not allow it once emergency is over.

  1. Documentation: sounds relatively simple but doctors are not sure how to document visits. This is important for payments and medicolegal justification.

Sounds like an integration or product expansion opportunity. If there is a need I’m sure it will be addressed. SaaS is great at this sort of thing.

Sure. But it’s going to be for those who continue to use it. And polls that doctors are using it dont account for the number of patients that they will see with it (I haven’t seen number of patients seen by those whom are still using it.)

  1. Reimbursement is lower than face to face. Usually by 10-20%. Why would a physician accept that?

I believe the assumption is that cost savings and/or patient acquisitions make up the difference. If these visits are more efficient you can do more of them. If you offer this and others do not you may win more patients and multiply the effect of efficiency. I know I would pick a doctor offering this over another. Regardless I would be shocked if a doctor couldn’t do 10% more visits in the same amount of time. Just guessing here but seems logical to me.

Your assuming that doctors don’t have a busy schedule as is. Doctors are not efficient. Sitting down and asking the same 50-100 questions lends itself to creating systems that can capture these questions on preprinted questionnaires. You can even further specialize each questionnaire based on symptoms. You can then have the entire intake done by nurses who can input everything into the EMR before the doctor enters room. You can also have the nurse fill out your assessment and plan based on symptoms.

You can even have all this done online prior to the patient showing up online at home. Even better, you can have AI that asks questions based on review of symptoms and create assessment and plans with labs & radiological tests to order before the patient is even seen. Physical exam is then inputted into computer to modify plan (which in adults is useful only 10% of the time).

This is all available now (except AI…IBM is working on it with Watson). How many here have had their doctors give online login to fill out intake history for a scheduled visit?

Doctors are very slow adopters. Those on teladoc now are docs trying to supplement their practice as it grows or slows down. Or the national specialist that deals with a rare disease.


  1. Medicolegal: will juries remember why we were doing telemedicine to begin with and why face to face visits werent offered. Because patients will.say they requested in person visit and doctor refused if something goes wrong.

I don’t get this one. Seems flimsy.

You would think so. Just finished reading an article explaining the importance of physicians to document that Covid is occurring now because juries will not remember the panic in 2-5 years. Found it ludicrous, but so many medicolegal cases are. The patient that says they wouldn’t have had surgery if they had known a colostomy was a rare possibility, but the consent form says understands risk of hemorrhage, paraplegia, blindness, and death.

Lawyers are creative.


  1. Physical exams: how are you going to do a gynecological or colorectal exams? Or listen to heart and breath sounds. Will patients forego face visits for convenience and clicial signs are missed?

I don’t see how this is different before, during, or after the pandemic.

Doctors weren’t doing telemedicine before the pandemic for this reason, they made an exception during covid, and will revert after it’s over. Most doctors want an exam documented every 3-6 months. (It justifies the higher level codes for reimbursement).

The biggest reason this won’t go back to the volume from before is that PATIENTS WANT IT and doctors who adopted it are more attractive now and know how to do it. I’m sure volume will subside a bit but how much is anyone’s guess. My guess is it won’t be all the way back. I can tell you I will definitely be seeking out a doctor with remote capabilities. I always hated the idea of giving up rest when I am most sick to travel to a waiting room where I sit with other sick people, suffering sitting up, just to be told there is nothing to be done; or given an prescription which then requires another trip. I’d rather stay home in bed and have a prescription delivered to me, if possible. I assume there are services that do this.

I appreciate this point. But telemedicine was available before covid and it wasn’t being offered. Those reasons haven’t changed.

Patients can demand, but they rarely pay.

Reimbursements have not gone up in over 20 years. The first thing a practice management consultant will tell you is to stop giving prescriptions and lab results over the phone or to charge for it. The amount of lost revenue on a yearly basis can be in excess of $20,000 per physician. Patients want the convenience of a prescription called in but they won’t pay for it. And neither will insurance. So doctors have patients come in.

Telemedicine might help bridge that gap. That’s the only usefulness I see with telemedicine. Capture lost dollars. But it all goes back to reimbursement.

I wish you luck finding a doctor that is forward thinking enough to provide those services for you.

Some state laws mandate exams before new prescriptions are given and once a year exam to refill a prescription. Anaphylaxcgic reaction to a medicine prescribed over the phone without an exam is a suit for your policy limits.

Medicolegal is a word:
med·i·co·le·gal. adjective. Of, relating to, or concerned with both medicine and law, as when medical testing or examination is undertaken for a legal purpose.

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Sound recordings are recommended to never be done by defense attorneys. Its similar to ultrasounds. The technology is able to capture the entire exam.

But then the physician is responsible for every frame taken. Instead pictures of key anatomic landmarks are taken and physician is only responsible for what’s on the picture.

I meant documentation recommendations are different for telemedicine and have certain requirements to be defensible in court as suggested by attorneys.

Definitely not a deal breaker, just a pitfall.

One of the things which I think is being confusing here is that we are talking both about Teladoc and about one’s local physician without making a clear separation. Moreover, some authors are talking about the local physician without any recognition that current practice with in-person visits might change in a world of remote visits.

For example, with my local family care physician standard practice with an in-person visit that I would arrive and wait, then be collected by a nurse or technician would would check vitals, meds, etc. and leave me in one of the rooms. The physician would then come in at some time later … sometimes 20 minutes or more … and do whatever the visit was about. About a year ago, they switched to pairing the physician with an NP (nurse practioner) and the NP would come at the point when the doctor previously came and do all the question and answer to get all the information, then fetch the doctor, summarize to him, and have a short interaction to close off the visit. Supposedly, this was in order to make the doctor more flexibly available for same day or next day visits. The last visit was telephone, not video and with the doctor only.

Point being, if a practice is going to incorporate video remote visits, they are probably going to make changes to the current structure of the practice to accommodate them. Least likely is to rotate three in-person rooms and the office for video. More likely is a block(s) of time dedicated to video. Possibly, there would be some effort to provide an on-demand service like Teladoc does, but that would seem less likely unless staffed by an NP. I could see a practice which provided one NP dedicated to on-demand, who then set up specific time appointments with doctors as needed, but who might just consult with the doc off-line and take action based on that interaction … like a change of prescription, a referral, some other change of treatment, etc.

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Very valid points.

Teladoc is different than telemedicine with your local physicians.

A physician (or most likely ARNP) would find a block of time to schedule several follow up visits (lab discussion results).

But it cannot replace most visits and most specialties that require physical exams.

A primer on billing will explain why I have strong doubts for telemdicine in the future.

To charge an insurance you must submit a CPT code explaining what you did during the visit. You have 2 ways to bill: 1. Level of difficulty 2. Time.

Time is broken up into blocks of face to face time.
Level 1 5 min $22
Level 2 10 min $43
Level 3 15 min $63
Level 4 25 min. $96
Level 5 45 min $145

Complexity of medical decision making uses the information acquired during visit. This entails a history, update since history since last visit, vitals, exam, and information reviewed.

The problem is that vitals are a key component. If you dont have vitals, it drops the visit to a level 1 or 2 visit.

So you can lose 50% of revenues by not having it included. On top of that, a billing specialist for the insurance company can review your note and if they feel your history did not contribute to diagnosis. To avoid this, a physical exam is done by many PCPs to meet the minimum requirements just in case.

A level 3 or 4 visit can be done in a few minutes (less than 5 min face time with provider). Going to time would bring a $96 visit to $22.

Teladoc is a niche for visits that can triage medical issues. I see it good for level 1 and 2 visits (UTI and colds, scrapes and bruises). Level 3 visits and up for initial complaints should not be handled by telemedicine.

I won’t comment anymore as I don’t want to clutter the board with anecdotes.

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Medicare (CMS) will change billing in 2021 - billing other than time will be based solely on complexity of decision making. So vital signs won’t matter anymore - actually, vital signs don’t matter now either - for the 99213 you only need 2 of 3 to reach medium complexity (the 3 elements are history, physical exam and complexity of decision making).

Of note, while insurance plans other than Medicare generally will follow Medicare billing changes, they don’t always.

There are also capitated contracts.

One last detail - copays are not being collected in some situations with telemedicine.

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedici…

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It would seem insurance companies are encouraging more expensive visits especially with the “vitals” part, something done by a nurse or even lower paid people. Alas so much of what doctors do is controlled by these faceless companies.

Note that with a cheap thermometer and a BP cuff (gives both BP and pulse) patients can do their own vitals

Certainly I am not going to call Teladoc if I have a stroke , but isn’t level 1 and 2 a big market?

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Thanks for CMS update and correction.

Just reviewed the 1995 documentation guidelines - which are at the organ system level- comments such as ‘ill appearing’ or ‘well-appearing NAD’ count as constitutional - so you don’t actually need vitals.

Very helpful.