Why Hasn’t Telemedicine Lived Up to the Hype?

Ashish Jha: 00:00:05

Hey everybody. Ashish Jha here from sunny Providence, Rhode Island, coming to you with a the podcast, a moment in Hell, where we talk about one data point, discuss one study and answer one question. Let's jump right in the data point I want to talk about today is 46% that's from the Kaiser Family Foundation tracking poll out July 24 46% of Americans think that one big, beautiful bill, the one that was recently passed by Congress, signed by President Trump, will generally hurt them and their families. Almost half the folks in this survey, about a quarter said they didn't think it would have much of an effect at all, and then about a quarter said it would help them. So half thought it was going to hurt. A quarter thought it wouldn't have any impact, and a quarter thought thought it would help. Now, part of the reason I want to bring up this data point, I think it's an interesting thing. How are Americans perceiving this is, as you all know, the bill was passed. It's going to be estimated to have about 10 to 15 million Americans lose health insurance. I have an op ed out in the Boston Globe recently which basically lays out what states can do. There's a series of things that one big, beautiful bill talks about, or has in it, around Medicaid, work requirement, eligibility checks. And the argument I basically make in the Boston Globe piece is there's a lot States can do to make things easier for people who are eligible. What we worry about is people who are eligible, who deserve to get Medicaid, who will lose their insurance because of the onerous work requirements. And that can be streamlined and made much, much easier if states get on it. States can do more outreach and make sure that people who are vulnerable and hard to reach places are getting the word to fill out their forms and get their eligibility stuff back in. They can work with community based organizations, healthcare organizations. There's a lot states can do. So check out my

Ashish Jha: 00:01:59

Boston Globe op ed on this where I talk about how we can minimize unnecessary health insurance losses.

Ashish Jha: 00:02:11

Okay, now I want to talk about the study of the week. And the study of the week is an exciting new paper that came out in the New England Journal, July 23 2025 It is a fantastic randomized trial showing the benefits of ivermectin. Now, ivermectin has been a controversial drug for reasons that I've been puzzled by. It's a it's a really important drug. It's a good drug for for very specific causes. And so let me tell you the study. It's called ivermectin to control malaria, a cluster randomized trial, again published in the New England Journal. It was a cluster randomized trial in in a community in Kenya among children five to 15 years of age who were living in areas with a lot of malaria. And basically what the study found was that they did a randomized trial, and they found that kids who got ivermectin had about a 26% lower incidence of malaria infection than kids who got Albendazole. That's the other drug that we often use to prevent malaria. Now, as you probably know, ivermectin is a very powerful anti parasitic it works very well against parasites, and malaria is a parasite, and so this was a pretty logical study to do, and it's great to see ivermectin really showing its wares. Last point I'm going to make about ivermectin, it's been puzzling to me from the beginning of the early days of the pandemic, how people have managed to somehow politicize and partisanize a drug. I mean, this is odd. Ivermectin is a great drug for very specific causes. It doesn't work in other areas. It doesn't work for covid. It doesn't work for most cancers. And somehow people have gotten into this pro ivermectin, anti ivermectin camp. To me, that makes zero sense. Where ivermectin works for a variety of parasites, and now, now data on malaria, we should use it where it doesn't work, like covid, we should not use it. That's how we treat every other medicine. That's how we should treat ivermectin. All right, so that's your study of the week from the New England

Ashish Jha: 00:04:16

Journal of

Ashish Jha: 00:04:22

Medicine. All All right, and now for a question of the week. To answer the question of the week, I have my friend and colleague ateev Mehrotra, professor of health services, policy and practice, chair of the department, and kind of really, one of the leading thinkers about innovative models for healthcare delivery, from retail clinics to E visits to telemedicine Ateev. Welcome to the podcast.

Unknown: 00:04:43

Thanks for having me. I'm excited. Excellent.

Ashish Jha: 00:04:45

Let's, let's jump into the question. The question I have been thinking about for a very long time is, why hasn't telemedicine been a total home run? And let me, let me set up that question a little bit. But. Everybody I know loves telemedicine, like it just seems like the most intuitively obvious thing in the world. Instead of making people go to the doctor's office and park and sit in the waiting room, and that for so much of healthcare, telemedicine feels like it should be a great substitute. It's cheaper, faster, easier, and so all of us and the pandemic really showed how good it could be. So there's been this sense that if we just made telemedicine widely available, it should both dramatically improve access, maintain quality. I mean, you do go see the doctor for some things, and substantially lower costs? Yeah, I feel like that's not where the data has landed us. So first of all, can you talk a little bit about, do you see this in the same way that has not been that home run that we all think it should and then, like, why not?

Ateev Mehrotra: 00:05:48

Yeah, well, let me start with the evidence. And it is, like you said, a little complicated, and it hasn't been the when I got into this, I had really high hopes, and it hasn't really I share your sense of like disappointment, because the results have been a little meh in terms of what what we found so far. So let me first clarify one of the things I like to remind people when I talk to them, and also remind myself, is that when we think about telehealth or telemedicine, be thoughtful. It's like drugs, do drugs work or drugs not work. It's a dumb question, and what drug which applications we do need to think about telehealth in that same way. What are we thinking about from there? Because there's going to be substantial variation depending on the application. About what the evidence demonstrates now, painting with a broad brush and ignoring my advice I just gave you, what have we found? So far? We have not in some areas, we have found some clinical benefit, but across the board, we have not seen a substantial improvement in quality that I had hoped for. There are some and for some patients, we'll get to that in a second. It has been really beneficial, but not that broad thing. In terms of costs, I have seen little evidence or say, Let's just put it this way, no evidence that I have really believe in that has shown decreases costs. And maybe the one that's been disappointing to me the most is I have not seen strong evidence that has improved the access barriers that so many Americans face. I'll just give you a quick example of that. Dr Oz, when he was testifying or is a confirmation hearing? In response to a question from a senator, described how, hey, telehealth could be this amazing thing, so that people who live in rural communities can get the mental health treatment they need. Yeah, I totally buy Dr Oz's idea. Totally buy that. Yet, in the research we still have ongoing we don't see any evidence of that that we haven't seen that

Ateev Mehrotra: 00:07:43

mental health specialists have really increased how much care they're providing to rural communities. We can get into why in a second. But I do think, hopefully giving you some sense when I say meh, in terms of the research, it hasn't really borne fruit as I at least as I had hoped. Yeah.

Ashish Jha: 00:07:57

So, so now tell us. Why not? Because it has so much face validity it should work. Like, why wouldn't it work? Yeah,

Unknown: 00:08:05

it's this is like, health policy 101, incentives. Like, why aren't the incentives aligned to do this? So I'm gonna give one comparison, and then also, then go into what I mean by the incentives. Let's focus on something very core to internal medicine, something we do, which is treat people with heart attacks. Cardiac catheterization an amazing development, amazing thing that we have introduced has saved a lot of people's lives. Yet, in net, it's grossly overused, and most patients who get a cardiac catheterization, at least where my read of the literature didn't get need to get into cardiac catheterization, yeah, and I think that kind of tension. So would you say, in net, cardiac catheterization was a good home run? No, and it has a similar framework here for telemedicine. So now let me get into the incentives. Let's go to the example of that dr oz example. Why aren't psychiatrists, psychologists, social workers who are taking care of mental health specialists taking care of patients in rural Montana, for example. Well, there's a lot of reasons. One, they're overwhelmed with demands. If you're a psychiatrist in Manhattan, why would you you don't preferentially go out there? Yeah, there's no financial incentive to do so, and there's a lot of logistics and pain for you to do so, so you actually have a disincentive to do so. So that's what I mean by incentives. Now, if we change those incentives, and that's what I've been working about on, or thinking about, then you could see it have that huge benefit that we're thinking about, but we need to frame the problem. Just introducing telehealth Into the Wild has not just led to what we're hoping for.

Ashish Jha: 00:09:45

Got it and so just to finish off, this thought, incentives can make it can make a difference. What kinds of incentives do you think we need, from a policy point of view, to make telemedicine more attractive, more. Useful, better targeted to people who would really benefit from it. If you could paint with a magic brush, what would you

Unknown: 00:10:07

do? Yeah, so for like, let's stick with the same example, because it's going to defer be different for different circumstance, but in terms of the situation where I want people in rural Montana to get more care from psychiatrists who live in big urban areas, the first thing there's no reason to pay a physician the same amount of money for the same care for you could pay more for rural communities. That'd be a good idea. You could create other financial incentives that if you have more patients from rural communities, that would also be a financial benefit, and then just start slashing some of the barriers. Licensure is a huge one. Malpractice, it's across state lines is very, very problematic. So those are two examples. Also prescribing. Each state has all these laws and rules about prescribing of, you know, anxiolytics, et cetera. So these are the kinds of things that we would need to do to try to address that. The other thing that I think is really important is, when you first introduced the idea, you said, you know, telemedicine could be used for so many circumstances. Yes, I agree with you. Many visits could be taken care of that way. But when we ask the average patient, an average physician, what do you think of the telemedicine visit, they're looking for just a little bit more. And what I mean by that is they're like, gosh, if I could just listen to the person's heart and have a stethoscope, or can I just get a blood, you know, glucose, or something else, we just need a little bit. And there also needs to be an infrastructure that's built so there could be, some people call it tele hosting sites, or where you go, where the patient goes just a couple miles down the road and they've got someone there to help them get the EKG do that stuff, you could really find a situation where you could go from what physicians view as inadequate care to the care that they really want to provide. And that would also help a lot. So

Ashish Jha: 00:11:56

sort of almost an intermediary between coming all the way to the doctor's office and going to one of these sites Ateev, that was amazing. That was very helpful. Thanks for laying that out again. It's one of those things where everybody I know loves telemedicine. Everybody wants to see much more of it, and yet the evidence has really not been there in a way that we'd expect to see. Thanks for helping us understand both what has been one of the limiting factors and how we might overcome it. That was very helpful. Thanks so much. Thank

Ashish Jha: 00:12:30

you. And there you have it, another episode of a moment in health where we talked about one data point, 46% about half, half of Americans who look at the new one big, beautiful bill that was passed and recently signed into law, and believe that it will generally hurt them and their families. So that's number 46% the one study where we talked about ivermectin, a oddly controversial medicine. Shouldn't be controversial. It's a drug. It works for some things and not others. And in this case, it showed a very nice 26% reduction in incidence of malaria compared to Albendazole in Kenya, showing that ivermectin has very specific uses for parasites, including malaria. And then the one question of the week, I went to my colleague and friend Ateev Mehrotra, really the country's leading expert on telemedicine, and I asked him a question. I have been a big fan of telemedicine. Everyone I know is a big fan of telemedicine, and yet the data seems to suggest it's not a home run. So I asked ateev, why not? And he said, Look, it's not a total surprise. Telemedicine is not a one size fits all. You would never say something like, do medicines work? Well depends, depends on the context, which medicine, which, what, what disease. He says telemedicine is somewhat similar in that way, and its effectiveness varies widely by use case. And so this not a one size fits all. One of the things that he talked about was that while it's a great tool and does have benefits. It hasn't done a lot to substantially increase access for rural health care. If you doesn't, hasn't done enough to improve access for mental health care. And if you think about it, on the other end of the telemedicine line has to be a doctor or a provider. And if you're a busy psychiatrist working in New York City, yes, it's true. Through telemedicine, you can provide mental health care in rural Kansas or rural Vermont. But why are you going to because you already oversubscribed and and so that's a big

Ashish Jha: 00:14:26

part of the problem. And last but not least, Ativ laid out some solutions, particularly policy fixes, including paying more for rural health care, streamlining licensure and malpractice laws. There's a bunch of things that policymakers can do if they really cared about making telemedicine more effective and improving access, and I think that should be a very bipartisan agenda that we can all get behind. So thanks again for listening to a moment in health. I'll be back next week with another episode where we talk about a data point. We talk about a study. And we will answer one question. Have a great week, folks. You.