Referrals and Apps

Telehealth Companies 

Major telehealth companies include American Well, Doctor on Demand, and MDLive. If you want a consultation by telephone or skype, the rules and insurance coverage are constantly changing, so ask. Veterans hospitals have permission for any VA doctor to treat any VA patient, regardless of state licensing rules. Insurance and Medicaid may cover telehealth. Medicare has decided to do so too from 2019 on. A telehealth association has a 2019 report.

​All states now allow doctors to see patients by telehealth even from the first appointment, if they have the right license, but distant doctors refer too rarely to other local specialists, since they don't know them, so patients need to ask.

Concierge and luxury medicine are on a separate page

Software Apps

A Commonwealth Fund study gives examples of what to watch for in deciding if an app is safe to use. FDA has some legal guidance on apps and an overview.

Some apps will call a doctor to visit you at home, or you can use lists here to find doctors who visit homes and assisted living, and call them directly to build a relationship with the same doctor over time.

There are many health apps (some say over 100,000, others say over 1,000) competing to offer personalized service.  A commercial site with practicing doctors on its staff reviews many apps. The reviews are often specific and helpful. They also include articles written by or for advertisers. Each reviewer must tell the editors about potential conflicts of interest, and the editors decide what to reveal to the public.

Some computer systems go through your symptoms and tell you possible diagnoses. 19 systems ranged from 5% to 50% "right" on a 2014 test of 45 vignettes (sets of symptoms, 18 computer systems and one paper system), published in 2015. "Right" means the single diagnosis which the authors of the vignettes expected. No one checked if the other diagnoses offered were also fully consistent with the symptoms given, or perhaps even more consistent.

A long list of other systems use the same algorithms and would have had the same results. Many nurse help telephone lines use the same algorithms and would have about the same results, except when accuracy is changed by the nurses' own judgment.

When the systems were asked for the 3 most likely diagnoses, they included the "right" diagnosis as one of these 3 from 29% to 71% of the time, depending on system. Researchers at Harvard and 3 Boston Hospitals did the test. In 2016 they tested 234 doctors, who identified the "right" diagnosis 72% of the time and got it in their top 3 possibilities 84% of the time. Researchers did not report the range of accuracy from doctor to doctor, as they did for computer systems, but success did not vary much by level of training (intern, resident, attending doctor).

A study found poor quality in dermatology consultations based on sending photos through the internet. A RAND study of claims said that pharyngitis patients went out to get strep tests after 3% of Teladoc consults, compared to getting them (usually in the same visit) after 50% of office visits. RAND said bronchitis patients got (inappropriate) antibiotics after 83% of Teladoc consults, compared to 72% of office visits. Since the study was based on claims, it is not clear how many patients were told to get a strep test or antibiotic, and did not bother to go out and do so. 

​Amazon and Google are expected to expand into health care.

Referral Services  

Referral sites generally give you no choice of provider, and you know which one they selected only after paying the referral fee. If you have time to search the Specialists tab above, you can find the experience and cost of different providers and negotiate directly.

Referral services may give local or distant referrals.

ZendyHealth refers you to a local provider based on how much you want to pay ($49 referral fee). They cover only a few procedures, primarily imaging, tests, counseling, dental extractions or implants, cosmetic procedures. For these and other procedures they also refer you for a free consultation. More details are on the Costs page.

PinnacleCare charges $650 to set up a consultation with a specialist and transfer medical records. 

GrandRounds.com (formerly ConsultingMD.com) refers patients to local or distant doctors for initial care or second opinions and transfers medical records to them. They charge $200 to arrange an initial office visit with a local doctor in the "top" 3% or 10% of local doctors, or $7,500 for a remote expert opinion from a doctor in the "top" 0.1%. They also charge $7,500 for "STAT," an emergency telephone consult with the best doctor they can find at short notice.

• The first time you use their services they need time to collect your health records from your doctors and hospitals, and (with your permission) provide them to the doctors they refer you to. They do not say whether your health records are encrypted while stored in their offices. 
• They offer their telephone consult ("STAT") 24/7, but don't say how many hours it may take to find a relevant expert. They're ambiguous whether the expert talks to the patient/family or the treating doctor. If you cite both those links to them, you can insist they talk to both.
• The emergency STAT service is expensive, and is based on the idea that Grand Rounds has pre-identified doctors willing to consult by phone, which you would have trouble finding in an emergency. Dr. Kussin recommends that when you know what health conditions you have, make an annual appointment with a top specialist for a checkup, so you can call him/her as an existing patient in any emergency (p.206).
• The non-emergency $7,500 expert opinion seems aimed at big spenders. They warn you that the expert will not have "information that would be obtained by examining you in person and observing your physical condition." Without spending that much you can identify the top national experts in the Specialists tab above, and in your $20 subscription to UpToDate from Wolters Kluwer, call for an appointment, and go see them in person. 
• Their $200 fee to recommend and set up a local office visit is reasonable. You pay them to research doctors and transfer records instead of doing it yourself. You and your insurance will still have to pay for the visit itself. 
• A problem with Grand Rounds is that the terms of service require you to pay their legal bills for any problems which arise: "You agree to indemnify, defend and hold the Company and its directors, officers, employees, agents and contractors harmless from and against any and all claims, damages, losses, costs (including without limitation reasonable attorneys’ fees) or other expenses that arise directly or indirectly out of or from (i) your breach of any provision of these Terms, or (ii) your activities in connection with this Site." They don't provide any examples, but perhaps this would protect them if they misuse your information.
• Grand Rounds does not reveal its algorithm to identify top doctors, but says it includes: "Institution (is the physician associated with a top-quality one?), Training (where did the physician study?), Research (does the physician publish in his or her area of study?), Reputation (what do the physician’s peers think?)" Another page adds, "procedure volumes; and clinical outcomes." Another page says that the doctors' "success rates are well above national averages and that they follow state-of-the-art care practices." They say these top 10% doctors have "15% lower hospital readmission rates. 30% – 40% lower mortality rates, 20% – 25% lower complication rates, but again no information on how these differences were found, over what time frame, comparability of patients, etc. They describe their service as doing some of the same analysis this website describes, on procedure volumes, doctors rating other doctors, and researchers. They simplify the process, while hiding the details. 

PinnacleCare and Private Health Management help wealthy clients navigate the health-care system, for $16,000 per year or more, plus the cost of care.