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Why are telehealth companies treating healthcare like the gig economy?

Telehealth has taken off.

Spurred by the pandemic, many doctors in the U.S. now offer online appointments, and many patients are familiar with getting live medical advice over the internet. Given the obvious benefits, many experts have concluded that telehealth is here to stay. “It’s taken this crisis to push us to a new frontier,” said Seema Verma, administrator of the Center for Medicare and Medicaid Services. “But there’s absolutely no going back.”

Now the question is, where are we going? Telehealth has played an essential role during the pandemic, and it could do even more good in the years to come. But we are still in the very early days of its development. And if we are to realize telehealth’s full potential, then we must first reckon with the fact that there are serious flaws in the predominant way it is delivered today — flaws that endanger patients themselves.

Legacy telehealth services like Teladoc and others were built for a time when telehealth was a fringe phenomenon, mostly used to support acute needs like a bad cold or a troubling rash. They largely offer, in effect, randomized triage care. Patients go online, wait in a queue and see the first doctor who happens to be available. These companies market this as a virtual house call, but for patients, the experience may feel more like being stuck on a conveyor belt. Too often, they get funneled through the system with little to no choice along the way.

Insurance companies love this model because it is cheap to operate. But patients bear the cost. Doctors, in this arrangement, get paid to work the assembly line. Every minute they spend listening to patients — learning about their lives, building a personal relationship — is a minute they’re not moving them down the line, seeing the next patient and earning their next fee. The system doesn’t reward doctors for providing care; it rewards them for churning through patients.

As we build telehealth’s future, doubling down on this model would be a worrisome mistake since it is antithetical to how our healthcare system should operate. Healthcare has long been premised on the idea that you should have an ongoing relationship with a local care provider — someone with a holistic, longitudinal view of your health, who you trust to help navigate difficult or sensitive medical issues.

The randomized triage model breaks this bond and replaces it with a series of impersonal interactions that feel more like ones you have with an Uber driver — polite but transactional, brief and ephemeral. Healthcare, however, should not be treated in the same way as the gig economy.

As a physician, I am troubled by the prospect of what happens when you scale this model up. Every time a patient gets passed from one doctor to the next, there is a chance that critical information is lost. They won’t understand your baseline mood, your family context or living situation — all critical “intangibles” for informed treatment. That lack of longitudinal data leads to worse outcomes. This is why the healthcare system has long been designed to minimize patient handoffs — and why it would be a mistake for us to choose a telehealth infrastructure that increases them.

What, then, does a better approach look like?

We are at the very dawn of telehealth’s integration into our country’s healthcare system, and I won’t claim to know the full answer. But I do know that patients are far better stewards of their own health than a random doctor generator. A more effective approach to telehealth puts the power in patients’ hands. Because when we give them choices and then listen to them, patients tell us what they prefer.

Data gathered by my company makes clear that by a substantial margin, people want to make this decision themselves: Nine out of 10 telehealth patients prefer to schedule an appointment with a provider of their choosing rather than see a randomly assigned doctor after waiting in a digital queue.

Not only that: When given this choice, most patients — about seven in 10 — make an appointment with a nearby doctor when booking a virtual visit. Patients instinctively know that at some point, they’ll want or need to physically be in the same room with their doctor. And they know that choosing a local provider makes it possible to pick up the conversation in-person right where it left off online. They don’t want to be forced to choose between telehealth and an ongoing relationship with a trusted provider. And they’re right — they shouldn’t have to.

None of the legacy telehealth companies focus on this imperative. Instead, while the pandemic rages on, they are rushing to scale while their randomized triage model is still viable. And the markets may reward them in the near term for being in the right place at the right time. But long-term value will be derived from listening to, responding to and iterating on what patients want.

Experience suggests patients will reward whoever can give them the most control over their healthcare. That’s where I’m placing my bet, too.

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Dear Sophie: How will this election nail-biter affect immigration?

Here’s another edition of “Dear Sophie,” the advice column that answers immigration-related questions about working at technology companies.

“Your questions are vital to the spread of knowledge that allows people all over the world to rise above borders and pursue their dreams,” says Sophie Alcorn, a Silicon Valley immigration attorney. “Whether you’re in people ops, a founder or seeking a job in Silicon Valley, I would love to answer your questions in my next column.”

Extra Crunch members receive access to weekly “Dear Sophie” columns; use promo code ALCORN to purchase a one or two-year subscription for 50% off.


Dear Sophie:

The last 24 hours have been a nail-biter; I feel powerless and I’m angry that we’ve come to this. I’m worried things won’t improve and I’m confused about where we even stand.

Sometimes I just feel so very, very tired of the struggle. I am just so ready to let go. I want to live in a world where we can create harmony, peace and opportunity for all. Can I still find that in the United States?

— Wanting in Walnut Creek

Dear Wanting,

I hear you.

The good news is that there is great potential, even as the world watches the U.S. presidential election results. If anything, what the last four years have taught me is that two clichés are really true: necessity is the mother of invention, and, where there is a will, there is a way. I can relate to many folks around the world because I know what it’s like to have the world of Silicon Valley feel so close, yet so far away, at a time when I felt powerless to make a difference.

Looking back over the past four years, amazing things have been possible for our clients and my team at Alcorn Immigration Law. I founded the firm out of my kitchen just years ago when my kids were toddlers. I would look out my kitchen window hand-washing tiny baby dishes. I can still remember the feeling of the suds on my fingers as I gazed longingly at the tall building on Castro Street in downtown Mountain View where 500 Startups used to sit on the top floor. YC was just down the street.

I felt so powerless. I desperately wanted to make the world a better place, and reaching the world of Silicon Valley, even though it was just past my backyard, seemed like getting to Mars.

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From those humble beginnings to now, as I founded and bootstrapped Alcorn Immigration Law on my own journey of becoming a single mom, I know what’s possible, even during the last four years of the Trump administration. We’ve had amazing success — claiming thousands of victories in supporting companies, people and families to live and work legally in the United States. If I was able to grow my firm during the last four years, I know that it’s possible for anybody to follow their heart and succeed. It’s our human essence to long to be a creator in this world, and anybody can and deserves to make a difference.

And here is what else I know: immigration law is created by acts of Congress and signed into law by the president. Mere tweets may be intended to try to bend the rules, but they cannot break them. That is what democracy is about.

In democracy, we have agreed to abide by basic laws, such as the inviolable dignity of the human being and that we want to agree on procedures for how we make decisions, like the process of passing a law about immigration. Democracy is not about majority tyranny. Democracy is about the fact that we uphold a few principles and we agreed on a decision-making process. When Trump ignores our basic laws and he ignores our legal processes, democracy is in peril.

But democracy does not need to be disrupted, it only requires small adjustments to thrive. In any group it is possible to make jointly supported decisions, taking the needs and resources of all into consideration. “Although the world is complex and decision making is complex, the components of decision making are simple,” according to Richard Graf, founder of K-i-E. Simple tools like the DecisionMaker can allow a miracle to happen — in an environment of openness and anonymity, we can all safely share our needs and concerns so that proposals can be formed based on collective best practices, knowledge, experience, intelligence and intuition. Even if it’s a complex situation, the way forward can immediately become clear.

And in our democracy, the paths to live and work in the U.S. will always remain viable, even if we need to remove a branch or navigate around a new boulder. Here at Alcorn, despite the furor and fear-mongering present in the world surrounding immigration, we are continually securing real victories for our clients. Not a client yet? Global founders can still create a startup, pitch it to investors and secure pathways to live and work legally in the United States with visas, green cards and citizenship.

So I know this and will repeat: Whatever the election results, there will still be many ways for people to legally navigate the U.S. immigration process and access the opportunity and security of life here. For more insight on these ways, please join my Election Results Webinar next week.

In the meantime, here are my thoughts on how the election results will affect the future of U.S. immigration:

Looking ahead, if Biden takes the victory, he has pledged to undo all Trump-era immigration regulations in the first 100 days and support comprehensive immigration reform. He promised to promote immigrant entrepreneurship, which could finally mean a startup visa! He also wants to speed up naturalization, rescind the Muslim travel bans, pass legislation to expand the number of H-1Bs, increase the amount of employment-based green cards, exempt international STEM PhD graduates from needing to await a priority date, create a new type of green card to promote regional economic development and support immigrant entrepreneur incubators.

Alternatively, we can expect that a Trump administration would continue restricting immigration, leading to litigation and judges deciding the fate of many recent policies. We can foresee a continued COVID freeze on green card interviews at consulates.

Also, DHS recently announced its intent to remove the randomness from the H-1B lottery and prioritize the annual H-1B selection process from highest to lowest wage starting in spring 2021. I’m sure there will be litigation about this; in the meantime, Alcorn Immigration Law continues to recommend that all employers proceed with registering employees and candidates in the lottery as usual. These details will take time to shake out and we don’t want anybody to lose a chance at being selected.

In other updates, immigration is just continuing along and there is actually some great news for folks: The State Department recently released the November Visa Bulletin and it stayed the same from October. (If you think your priority date is current or may be current soon, please contact your attorney as soon as possible to discuss filing your I-485 this month to avoid the possibility of retrogression in December!)

And if you need the freedom to build your startup, but were told that you don’t yet qualify for an O-1A visa, EB-1A or EB-2 NIW green card, you can join me in Extraordinary Ability Bootcamp with promo code DEARSOPHIE to receive 20% off.

We’re optimistic about the future. Life always offers us opportunities to grow through contrast and uncertainty, and we remain passionate about our mission to create greater freedom, empowerment, knowledge and love in the world.

Sophie


Have a question? Ask it here. We reserve the right to edit your submission for clarity and/or space. The information provided in “Dear Sophie” is general information and not legal advice. For more information on the limitations of “Dear Sophie,” please view our full disclaimer here. You can contact Sophie directly at Alcorn Immigration Law.

Sophie’s podcast, Immigration Law for Tech Startups, is available on all major podcast platforms. If you’d like to be a guest, she’s accepting applications!

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We need universal digital ad transparency now

15 researchers propose a new standard for advertising disclosures

Dear Mr. Zuckerberg, Mr. Dorsey, Mr. Pichai and Mr. Spiegel: We need universal digital ad transparency now!

The negative social impacts of discriminatory ad targeting and delivery are well-known, as are the social costs of disinformation and exploitative ad content. The prevalence of these harms has been demonstrated repeatedly by our research. At the same time, the vast majority of digital advertisers are responsible actors who are only seeking to connect with their customers and grow their businesses.

Many advertising platforms acknowledge the seriousness of the problems with digital ads, but they have taken different approaches to confronting those problems. While we believe that platforms need to continue to strengthen their vetting procedures for advertisers and ads, it is clear that this is not a problem advertising platforms can solve by themselves, as they themselves acknowledge. The vetting being done by the platforms alone is not working; public transparency of all ads, including ad spend and targeting information, is needed so that advertisers can be held accountable when they mislead or manipulate users.

Our research has shown:

  • Advertising platform system design allows advertisers to discriminate against users based on their gender, race and other sensitive attributes.
  • Platform ad delivery optimization can be discriminatory, regardless of whether advertisers attempt to set inclusive ad audience preferences.
  • Ad delivery algorithms may be causing polarization and make it difficult for political campaigns to reach voters with diverse political views.
  • Sponsors spent more than $1.3 billion dollars on digital political ads, yet disclosure is vastly inadequate. Current voluntary archives do not prevent intentional or accidental deception of users.

While it doesn’t take the place of strong policies and rigorous enforcement, we believe transparency of ad content, targeting and delivery can effectively mitigate many of the potential harms of digital ads. Many of the largest advertising platforms agree; Facebook, Google, Twitter and Snapchat all have some form of an ad archive. The problem is that many of these archives are incomplete, poorly implemented, hard to access by researchers and have very different formats and modes of access. We propose a new standard for universal ad disclosure that should be met by every platform that publishes digital ads. If all platforms commit to the universal ad transparency standard we propose, it will mean a level playing field for platforms and advertisers, data for researchers and a safer internet for everyone.

The public deserves full transparency of all digital advertising. We want to acknowledge that what we propose will be a major undertaking for platforms and advertisers. However, we believe that the social harms currently being borne by users everywhere vastly outweigh the burden universal ad transparency would place on ad platforms and advertisers. Users deserve real transparency about all ads they are bombarded with every day. We have created a detailed description of what data should be made transparent that you can find here.

We researchers stand ready to do our part. The time for universal ad transparency is now.

Signed by:

Jason Chuang, Mozilla
Kate Dommett, University of Sheffield
Laura Edelson, New York University
Erika Franklin Fowler, Wesleyan University
Michael Franz, Bowdoin College
Archon Fung, Harvard University
Sheila Krumholz, Center for Responsive Politics
Ben Lyons, University of Utah
Gregory Martin, Stanford University
Brendan Nyhan, Dartmouth College
Nate Persily, Stanford University
Travis Ridout, Washington State University
Kathleen Searles, Louisiana State University
Rebekah Tromble, George Washington University
Abby Wood, University of Southern California

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