The Intersection of Telemedicine and Men’s Health

Telemedicine (TM) describes seeing a health care professional without going to their office, which can be done through a video call or over the phone in certain cases. This type of care has been around for a while but during the COVID-19 pandemic, changes in regulation and reimbursement driven by the public health emergency helped promote its expansion. TM helps people who live far away from medical facilities or have other barriers to care because it can facilitate remote access to care from health care professionals.

Direct-to-consumer (DTC) TM emerged from pharmaceutical direct marketing in the 1980s, evolving to offer self-diagnosis and remote treatment. Initially addressing acute issues, DTC platforms have expanded to address chronic conditions like erectile dysfunction (ED).

Before the COVID-19 pandemic, TM accounted for <1% of medical visits, but COVID-19 accelerated its adoption globally. During the pandemic, telemedicine utilization rates rose as high as 50% of visits but tapered off to around 10% of healthcare encounters across all specialties. Even in urology, recent studies show TM utilization to be in the 5-10% range after the first year of the COVID-19 pandemic.

While the COVID-19 public health emergency declaration has ended, TM remains an important part of healthcare, offering safe and effective ways for patients to connect with doctors and other health care providers. At the time of this article, the most pressing issues around TM are care policy and regulations allowing for new patient visits to take place from the comfort of patients’ homes, and the question of whether reimbursement for video visits will remain equivalent to that of in-person visits, based on medical decision making. Without congressional action, these changes that were implemented during the COVID-19 pandemic will expire at the end of December 2024. Beyond these health policy concerns, nvestment in technology and infrastructure will be vital for sustaining TM’s growth, enhancing patient access, and improving health care delivery.

When it comes to urologic care, studies from 2010 to 2019 showed that TM was safe, feasible, and accepted by patients with various conditions like prostate cancer follow-ups, urinary issues, and post-surgery care. It reduced the need for in-person visits, waiting times, and costs while keeping patients and providers satisfied and safe. Importantly, when a doctor did not deem a physical exam or office procedure necessary, these visits served as valuable substitutes for in-person care.

As with other areas of medicine, there was a steep increase in urologic TM visits during the COVID-19 pandemic, with high satisfaction levels. In fact, studies found that urology was one of the surgical specialties with the highest rate of telehealth use to improve access for new patients during the early stages of the pandemic.

Advantages of TM include easier access to care, time and cost savings, and, during the COVID-19 pandemic, lower risk of viral transmission. Challenges include disparities in internet access, technology comfort, and preferences for in-person visits. For instance, during the pandemic, older patients, minority patients, and those needing an interpreter were more likely to use phone visits rather than video to connect with urologists. Since phone visits do not get reimbursed at similar rates as video visits, there is a concern that this could create a “digital divide” and lead to access issues for the patients who may prefer phone visits.

Many clinicians still worry about reimbursement given that the current telemedicine climate is due to expire in December 2024.  However, TM is seen as a valuable tool for delivering urologic care and connecting patients to specialty care, within the limitation that a physical exam is not immediately available.

DTC men’s health services, like Hims and Roman, have also been gaining popularity, even before COVID-19. These services offer online consultations and prescriptions for conditions like ED and premature ejaculation (PE). They can be attractive to consumers because they prioritize privacy, convenience, and cost savings.

On the other hand, they too lack physical exams, which increases the potential for missing other health issues. Health care providers are typically contracted separately and not directly employed by DTC companies. While convenient, DTC services raise concerns about overprescribing and patient safety. For instance, concerns have been raised about the appropriateness of DTC testosterone therapy regarding dosing, the testosterone level at which a person can start therapy, and a lack of transparency about the impact on male fertility. Overall, however, these services offer accessible but limited care, and men with more complex health needs would likely benefit from discussing their care with a specialist who uses telehealth but has the option of arranging an in-person visit if necessary.

In the end, TM has revolutionized healthcare by allowing remote diagnosis and treatment, offering convenience and access. In the realm of men’s sexual health, TM provides a private platform for discussing sensitive issues and receiving timely care, which is especially crucial for those stigmatized or in rural areas. It facilitates specialist consultations, ongoing care, and preventive measures. TM also aids in education, STI testing, HIV care, and sex therapy.

Still, challenges such as the reliability of long-term reimbursement and appropriate patient selection remain. Striking a balance between convenience and thorough assessment is critical for optimal health outcomes.

For more information on this topic, please read these publications from Sexual Medicine Reviews:

The pandemic, telemedicine, and andrology: what have we learned?

Use of Telemedicine for Sexual Medicine Patients

References:

Andino, J. J., Lingaya, M. A., Daignault-Newton, S., Shah, P. K., & Ellimoottil, C. (2020). Video Visits as a Substitute for Urological Clinic Visits. Urology, 144, 46–51. https://doi.org/10.1016/j.urology.2020.05.080

Bartelt, K., Piff, A., Allen, S., & Barkley, E. (n.d.). Telehealth utilization higher than pre-pandemic levels, but down from pandemic highs. Epic Research. Retrieved from https://epicresearch.org/articles/telehealth-utilization-higher-than-pre-pandemic-levels-but-down-from-pandemic-highs

Chao, G. F., Li, K. Y., Zhu, Z., McCullough, J., Thompson, M., Claflin, J., Fliegner, M., Steppe, E., Ryan, A., & Ellimoottil, C. (2021). Use of Telehealth by Surgical Specialties During the COVID-19 Pandemic. JAMA surgery, 156(7), 620–626. https://doi.org/10.1001/jamasurg.2021.0979

Chen, J., Li, K. Y., Andino, J., Hill, C. E., Ng, S., Steppe, E., & Ellimoottil, C. (2022). Predictors of Audio-Only Versus Video Telehealth Visits During the COVID-19 Pandemic. Journal of general internal medicine, 37(5), 1138–1144. https://doi.org/10.1007/s11606-021-07172-y

Dubin, J. M., Jesse, E., Fantus, R. J., Bennett, N. E., Brannigan, R. E., Thirumavalavan, N., & Halpern, J. A. (2022). Guideline-Discordant Care Among Direct-to-Consumer Testosterone Therapy Platforms. JAMA internal medicine, 182(12), 1321–1323. https://doi.org/10.1001/jamainternmed.2022.4928

Ellimoottil, C., Zhu, Z., Dunn, R. L., & Thompson, M. P. (2022). Trends in telehealth use by Medicare fee-for-service beneficiaries and its impact on overall volume of healthcare services. Preprint from medRxiv. https://doi.org/10.1101/2022.06.15.22276468

Eyrich, N. W., Andino, J. J., & Fessell, D. P. (2021). Bridging the Digital Divide to Avoid Leaving the Most Vulnerable Behind. JAMA surgery, 156(8), 703–704. https://doi.org/10.1001/jamasurg.2021.1143  

Sexual Medicine Society of North America (SMSNA)/American Urological Association (AUA) Telemedicine and Men’s Health White Paper. Khera, M., Bernie, H. L., Broderick, G., Carrier, S., Faraday, M., Kohler, T., Jenkins, L., Watter, D., Mulhall, J., Raheem, O., Ramasamy, R., Rubin, R., Spitz, A., Yafi, F., & Sadeghi-Nejad, H. (2024). The Journal of Sexual Medicine, 21(4), 318–332. https://doi.org/10.1093/jsxmed/qdad151