Mitchell Tang
Dissertation Title: "New Tools, New Challenges: Navigating the Complexities of Digital Healthcare Delivery"
New digital tools, such as telemedicine visits, remote physiologic monitoring, and patient portal messages, hold immense promise for improving health care access, quality, and efficiency. At the same time, they may also introduce new challenges for healthcare organizations and policymakers. My dissertation examines three potential challenges brought about by three distinct forms of digital care, providing recommendations to managers on how to navigate them and policymakers for how to incentivize appropriate use.
Chapter 1 - From Rooms to Zooms: The Hidden Costs of Hybrid Work in Primary Care
With A Jay Holmgren, Robert S. Huckman, J. Michael McWilliams, and Maximillian J. Pany
Today, many workers have hybrid work schedules with a mix of in-person and virtual meetings. Though virtual meetings have clear benefits, they can introduce new frictions when integrated into predominantly in-person schedules. We examine these frictions in the context of hybrid primary care practices, which offer both in-person and telemedicine visits. Using data for 35 practices at a large academic health system, we find that transitions between visit types can burden providers and negatively impact patient experiences. Telemedicine visits following an in-person visit often see delayed starts; patients are 75% more likely to abandon the visit before being seen, and the visits that do occur are 25% less likely to begin on time. These disruptions also result in less comprehensive visits and a higher likelihood of after-hours work. Dedicated telemedicine-only blocks in provider schedules help avoid these costly transitions but can also lead to reduced capacity utilization when there is insufficient demand for telemedicine visits in that time window. Indeed, we find that telemedicine-only slots see a 10% lower booking rate relative to similar slots without such restrictions. Telemedicine visits are often framed as a useful tool for improving patient care access. However, we show that, depending on how they are incorporated into hybrid schedules, they can lead to negative care experiences, chaotic clinic days, and ironically even reductions in patient access. Our findings also demonstrate the tradeoffs of dedicated telemedicine blocks and highlight potential changes to managerial practices and clinical workflows to improve performance of hybrid practices.
Chapter 2 - Practice-level Effects of Remote Physiologic Monitoring Adoption
With Ariel D. Stern, Felippe Marcondes, and Ateev Mehrotra
Use of remote physiologic monitoring (RPM), the remote transmission of patient physiologic measures (e.g., blood pressure) to care teams, has grown rapidly. For practices, establishing an RPM program can increase revenue and improve patient care, but may also require substantial reorganization within the practice. No prior work has quantified the impact of RPM on practices. Using national Medicare claims, we identified 754 primary care practices that began billing for RPM from 2019-2021. After these practices adopted RPM, Medicare revenue increased by 20.1% relative to similar matched non-adopting practices. This was driven by RPM billing as well as more outpatient visits and care management. While adopting practices had a 3.0% increase in their number of billing providers, the increase in revenue was predominantly driven by increased activity per provider. Adoption of RPM and resulting increases in visits for patients receiving RPM did not seem to come at the expense of other patients.
Chapter 3 - The Doctor Won’t See You Now: Examining Drivers of Care Team Response to Patient Portal Messages
With Ariel D. Stern, Lisa Rotenstein, Rebecca G. Mishuris, and Michael L. Barnett
Patient portal messages have become an important channel for patient-provider communication. However, there are well documented disparities in rates of portal use. Additionally, prior work has shown that even when minority and Medicaid patients send portal messages, they are less likely to receive responses from attending physicians, seemingly driven by lower prioritization in message triage. Using natural language processing, we analyze the text of patient portal messages from a large academic health system to understand what drives these differences, enabling us to separate three potential mechanisms: differences in the underlying request of the message (e.g., medication question, referral request), differences in the way the messages are written, and non-clinical bias. We find that, while the category of message request is a significant predictor of care team response, it cannot explain observed differences across demographic groups. On the other hand, the way the message is written – including message characteristics such as length and formality – accounts for nearly half of the observed differences in care team response. Our findings identify a clear mechanism underlying disparities in care team response, highlighting avenues for mitigating them and deepening our understanding of care disparities broadly.