Dr. Ian Tong cringes when his company, Doctor on Demand, is compared with other telemedicine providers. Whether that is because of DoD’s consumer focus or their video-only strategy, one thing is certain. With nearly $100 million in funding, this telemedicine provider has pockets deep enough to distinguish themselves in the market. Telemedicine spoke with Tong, who has been DoD’s chief medical officer for four years, to talk about his path to telemedicine and why the future is all about synchronous video consults. Interview by Logan Plaster
TelemedMag: Tell us a bit about how you got into telemedicine generally, and Doctor on Demand specifically?
Dr. Ian Tong: I wasn’t brand new to telemedicine. I had been exposed to telemedicine at the Palo Alto VA. That’s where I was doing most of my clinical work. I had launched an outreach program there that targeted homeless veterans. We did really well. We won a national award from the Secretary of the VA. That led me to find that there were other veteran populations who were eligible for VA services but couldn’t take advantage of them for a variety of reasons. And so about 10 years ago the VA set up a telehealth program. I got my introduction there. Then the first iPhone came out that year, and I kind of knew someday these things would come together. Fast forward to four years ago, when someone came to me and told me that Doctor on Demand was going to do the things that we only talked about in the VA, and on a mobile device.
TelemedMag: So one of the things that’s unique about DoD is that it’s co-founded by Dr. Phil and his son, Jay Mcgraw. What was it like launching the platform on daytime television?
Dr. Tong: We were busy getting the practice together and then about a week before launch on Dr. Phil’s Show, I found out that I was actually going to have to see a patient, on television. It was really cool to be on a nationwide television, but it was also very nerve-wracking. You don’t really practice medicine in front of an audience. But I believed that we could do a lot of good, and what better way to deliver the message to so many people that we’ve created a great service than to do it with a big megaphone.
TelemedMag: I read that you’ve had about a million people download the app. What are your usage rates like compared to those download numbers?
Dr. Tong: We’re seeing record numbers of calls right now. We have seen a doubling of the size of our practice, if you just want to count that in terms of visit volume or patient encounters. We don’t usually quote out the exact number. I think we’re close to 35 million lives that have access to Doctor On Demand, but they probably don’t all know it yet. They may have it through their health plan or through their employer, who hasn’t done much communication. And I think that’s kind of an industry-wide challenge. When people have it and use it, they love it. But if they haven’t used it, there are still a lot of questions, like “Can my problem be resolved there?”
TelemedMag: Who is using the platform? What are your demographics?
Dr. Tong: The core group is from 30 to 60 years of age; we see double digit percentage use there. And then it starts to tail off a little bit as you get above 60.
TelemedMag: Which is great to get things rolling, but in terms of actually tackling some of healthcare’s stickier problems, correct me if I’m wrong, but you don’t really move the needle if you’re only treating young people.
Dr. Tong: That’s right. By my background, you know that I didn’t focus on the easiest patient population to try to impact. I get satisfaction from targeting tougher problems and patients who really get the most benefit out of the services. The impact and benefit of telemedicine isn’t just about being a cool gadget that millennials find easy to use and that becomes some sort of social sharing application. It’s actually real healthcare. Telemedicine will eventually move from the younger population that is mostly healthy but understands technology to start to prove itself to be able to address more chronic conditions.
TelemedMag: How are you expanding your services?
Dr. Tong: We added mental health and behavioral health over the last two years, all doctoral level therapists. And then we added on psychiatry last year.
TelemedMag: I’ve seen in press releases that DoD has raised over $80 million in funding. That’s sort of a wild amount of money, even in this industry. How are you using that money to improve telemedicine?
Dr. Tong: The first thing is to continue to develop the video platform. The other big element is that we invest in employing our doctors, rather staffing our service with independent contractors who are moonlighting.
TelemedMag: Why invest so heavily in employing your physician workforce?
Dr. Tong: We are actually trying to create a career ladder for our doctors. When you do that, you can engage your doctors. You can implement a training program. For example, we have an antibiotics stewardship program that really trains our doctors to know when to prescribe and when not to prescribe. And when they don’t prescribe, to really know how to talk and to educate the patient. Having an employed workforce allowed us to implement that kind of program and have the longitudinal buy-in that you need from your physician workforce to continue to iterate and improve on that program. Because our providers are employed, we can put in the financial investment of time and resources to build out an integrated medical practice. So we can start to address chronic conditions and behavioral health.
Over time we know that patients are going to need more and want more and expect more from telemedicine. And at some point one-off doctors, and doctors who are just moonlighting can’t provide you the continuity you need and the relationship is not going to be as rewarding. And we see that in our reviews. Patients talk about the doctor specifically. I didn’t know that the patient would respond to the doctor that way and that over a screen, they would feel like they made that connection, but that’s definitely happening.
TelemedMag: Let’s say a patient calls up and gets one physician but that physician wants to hand them off to another specialist and maintain continuity. How does DoD set that up on your end, since these doctors are all over the country?
Dr. Tong: Yeah, so our doctors are all over the country, but they have licensure and are assigned to regions of the country. And so you’re going to see the same doctor is available depending on where you are. If you’re a patient and move across the country, that’s a little bit different. When you go through our app, you can select a doctor as your favorite or in your favorites. And so you can actually go back to that doctor. You can see their availability. And you can schedule an appointment with them for the future if you want. You can always come in through the on demand side. But you can actually go and schedule directly with them and get a follow up. And all the mental health practice is by appointment. Those are all longitudinal relationships.
TelemedMag: What about on the physician side? If you see a patient that you think needs follow up care, can the doctor seeing them over a video visit for the first time connect them to another doctor, and then follow that conversation longitudinally?
Dr. Tong: You’re kind of predicting a little bit of the future. We can do that now. We can connect you, but we’re going to be making that even easier. I can’t tell you too much about it yet, but it will allow us to leverage the expertise that we have across the entire practice for each individual patient, regardless of where they are.
TelemedMag: I saw that you have 1,400 credentialed physicians. How actively are you recruiting?
Dr. Tong: We actually are recruiting right now. It feels like that’s kind of become a never-ending part of the business. In terms of the number of clinicians on staff, that’s part of our secret sauce. When I look at other things that are in the press about the size of telemedicine practice, I think there’s so many different ways that our competitors could choose to report on that number. Rather than fixating on the size of our practice, we try to commit ourselves to the service levels themselves. So you know that you’re going to have about a five-minute or less wait time to see a board certified physician. We ‘right-size’ our practice to be able to deliver that service level across the country, 24/7. I don’t necessarily want to broadcast to my competitors how we do it or what size because I don’t think they know exactly what the number should be.
TelemedMag: Why should your typical ER doc consider working for Doctor on Demand? Give us the recruitment pitch.
Dr. Tong: First of all, that’s a tough career, right? Their careers can be shorter than a typical primary care doctor. What I find is that we are able to extend the emergency physician’s career a bit. And then they’re also really interested in lifelong learning. Often they do not see what happens to their patients when they triage or dispo them. With DoD they get to see the whole spectrum.
I’ll tell one story. One of our lead physicians is an ER doctor who was feeling a bit burned out in need of a change. One of the things that we trained our providers in was how to screen for and diagnose mental health conditions, and then provide psychopharmacology. This doctor became one of the leads of that program even though he’d had very little exposure to that as an ER doc. So I think there’s great potential for those doctors to be able to join our practice and thrive in new ways.
TelemedMag: What is the compensation like for these physicians on your team?
Dr. Tong: They will probably get paid more if they’re in a high volume emergency room in a rural area. But they could do very well here and extend the length of their career. In some regions, like San Francisco or in New York City, doctors can make above market working with Doctor On Demand. It’s very comparable what physicians will make in primary care fields. And sometimes it’s more.
TelemedMag: Let’s talk about the RAND study that came out recently, which talked about how some of our thoughts about telemedicine lowering the costs of healthcare might not be true. The study stated that only 12 percent of patients are using telehealth to replace a provider visit and the other 88 percent are tacking it on a new service. What are your thoughts about Doctor On Demand moving the needle on actual healthcare costs?
Dr. Tong: I know the author of that study, and I have high respect for them. But I do think you have to look closer. The study is really focused on telephone visits. Plus, the study pulled data from 2011. Telemedicine was in a very different place then from where it is now. I mean, DoD didn’t exist then and neither did the current ability to provide a video visit with a physical examination, the way we do. That’s a whole different ballgame. What we’ve found is that about 50 percent of our patients would have gone to an emergency room or urgent care. And we know the prices there. You’re talking about 4X, 5X sort of costs to the patient or to the payer or employer. Using our service, we know that it’s going to save money. We don’t have a formal study of it. But I’d really like to see one that looks at a video visit practice because I’m pretty sure it’ll contradict this RAND study.
TelemedMag: There’s been a lot of talk about large telemedicine providers having great services but not being profitable. Is Doctor on Demand profitable, and if not, what does the path towards profitability look like?
Dr. Tong: Again, that’s part of the secret sauce. Because we right-size the practice, I think we are able to control the cost. The revenue side is definitely something that you can tweak. You can increase the price or find the right price. So we came out with a lower price. We’ve raised our price already to adjust for that. And I knew coming in that the service was being offered for really cheap. But in Silicon Valley, it’s very common for a tech company to do that so they can acquire users and learn very quickly. I feel very confident that we have learned some things that no one else has learned yet.
TelemedMag: So the cost per visit is underpriced. Are there plans to raise those prices?
Dr. Tong: I don’t think I want to comment just yet on if we will elevate the price. We may have to. If we continue to see more complex cases and can continue to deliver solutions for things like depression and diabetes, that justifies a different price than what we currently offer.
One thing I did learn at the VA is that giving away free care could undermine the doctor-patient relationship. And so I think it does have to be the right price. It has to be valued by the doctor and the patient.
TelemedMag: The last thing I want to hit on are the key differentiators between DoD and the other big players in this space. You’ve mentioned that you employ your physicians. What are the other big differentiators?
Dr. Tong: The direct-to-patient facing nature and DNA of our company is unique. We were built to be direct-to-patient in the beginning, and that matters. We also were built on a more recent technology platform. So that makes for a better video physical exam. Finally, there is the fact that we’re video only. It baffles my mind that people think video and phone consults are equal. If you’re committed to video because of the quality reasons, I mean, you can save lives by seeing a patient. So I think that’s huge.
TelemedMag: But the big telemedicine providers, they all have video visits.
Dr. Tong: They like to show that they do. But you should look at the data. How many people actually use video on their platform? If you have good video that works, then you can get a higher quality medical visit. I think you can look at the patient reviews and there’s evidence there that tells the story. Companies who don’t lead with video, who aren’t committed to it, are compromising. Compromising might be okay if you’re talking about getting a different VCR or your cable service, but not in healthcare. I hope that that is obvious to the readership. And I hope it becomes obvious eventually to the rest of the country who want to get healthcare this way that there is a difference between video and phone telemedicine. It’s not the same.