Editor’s note: During the past 15 years, HolaDoctor® has applied cultural awareness to connect with the Hispanic community and inform them about health insurance, access to care, the importance of leading a health-filled life, and both early detection and aggressive management of chronic illnesses.
In this TMT interview, Dr. Dirk Schroeder, who is Executive Vice-President for Multicultural Insights and Research, discusses the history of HolaDoctor®, its current initiatives, and the future for this Spanish-language health and wellness service.
Telehealth and Medicine Today encourages our readers to download this audio presentation. You many listen to it and share it with your colleagues at your convenience. Reproduction of the interview is encouraged, with attribution to Telehealth and Medicine Today, 2016.
TMT: What was the motivation for developing HolaDoctor®? [00:00]
Dr. Schroeder: The motivation for developing HolaDoctor® was to provide an online digital resource for Spanish-speaking healthcare consumers, worldwide. We founded the company in 1999, and we went out to establish a global presence that focused initially on Latin America. But we soon found that there really wasn’t quite the critical mass at that time.
In 2000, we redirected our focus on US Hispanics, which had just been determined through the US Census as the fastest growing population in the country. We found a big need directly with consumers who are Spanish dominant language, with limited English proficiency, seeking information and guidance on health. And we also found a big need among hospital systems, health plans, and not profit organizations like the American Cancer Society for better strategies, better material, culturally appropriate material for educating Hispanic consumers about health. And for the last few years we’ve been working very closely with health plans to help them educate Hispanics about the Affordable Care Act, and helping Hispanics enroll in health insurance through the exchanges.
TMT: What has been the effect of the Affordable Care Act on Hispanics? [01:18]
Dr. Schroeder: The effect of the Affordable Care Act on Hispanics has been significant. Prior to the launch of the Affordable Care Act and the opening of the exchanges, Hispanics had the highest percentage of un-insurance—still do. But through the last three years of the Affordable Care Act the percentage decrease among uninsured has been largest among Hispanics relative to other ethnic minority groups. It’s been significant, both in terms of the Medicaid enrollments and in terms of the enrollment of subsidy-eligible Hispanics into the exchanges.
TMT: What has been the effect of the Affordable Care Act on HolaDoctor®? [01:56]
Dr. Schroeder: The effect of the Affordable Care Act on HolaDoctor® I would say has been significant, like it’s had an impact on pretty much anybody working in the healthcare eco system. Prior to the opening of the exchanges, essentially we were working mainly with hospital systems: helping them develop Spanish language and multilingual healthcare websites and digital assets, doing the cultural competency training for physicians and others.
With the Affordable Care Act our business shifted maybe about 80% to health plans. We work with Anthem Blue Cross and Blue Shield, Horizon, Florida Blue—lots of “blue” plans and other health plans as well. What we’re doing for those companies is developing their strategic communications and membership acquisition, and care plans to improve quality.
We also have a platform (a digital platform) that we deploy to educate Hispanic consumers about the Affordable Care Act. During the early years of the Affordable Care Act we actually built an interactive health insurance center in Spanish, which provides sort of all the information you want about what are even just basics: what is health insurance, when to use a doctor, why not to use the emergency room, and the baggage of not being insured. And we worked with and continue to work with health plans across the country on educating consumers about health insurance, identifying those that are eligible. And by eligible, from my perspective, that really means folks that have documentation status and are eligible for subsidies generally because that allows them to afford health insurance.
TMT: What is the mission of HolaDoctor® Insurance Services? [03:47]
Dr. Schroeder: Most recently, last year we established a subsidiary company called HolaDoctor® Insurance Services because we are finding there just weren’t enough bilingual brokers and agents that could enroll Hispanics into health insurance products. So, we opened a retail center in Jersey City and actually have a physical presence with that. We are serving multicultural members outside of the open enrollment period. We are providing a service and care.
So, this is the point where we’re really into the care side of things, helping Hispanics and other multicultural consumers sign up for the preventive services that they are eligible for under the Affordable Care Act plans, helping them find a doctor that speaks Spanish, helping them access services that, you know, are going to benefit them and are linguistically and culturally relevant to their needs.
TMT: What are the benefits offered by HolaDoctor® to physicians? [04:43]
Dr. Schroeder: I would say the benefits to physicians of HolaDoctor® are a couple. One is we are working to increase the percentage of Hispanic consumers that are insured. About a third of all uninsured in the US are Hispanic. The other thing we’re doing, which I think is really relevant, is that traditionally Hispanics err on the side of traditional and complementary medicine. They procrastinate. I think we all procrastinate, but they procrastinate a bit more; and this is documented in research. It isn’t just me saying it. And they often come from countries, those who haven’t been born here, that have very different healthcare systems. So, these are very different ways of interacting with the physicians.
Hispanic/Latinos give a high priority to that interaction with the doctor. We’ve just done some research with our database and again found that Hispanics more than others are sort of less tolerant of non-real doctors and nurses for their care and guidance.
So, we educate in working with Hispanic Latinos across the country about the U.S. healthcare system, how it’s to be accessed, why they go in and they only have seven minutes with their doctor—which we all complain about but it pains them more.
And, I think, the opportunities for telehealth are great, and I don’t think we’ve really proven this yet, but theoretically the ability to communicate directly with a doctor and potentially for a longer period of time is an attraction, would be an attraction to Hispanic/Latinos based on their priorities and in terms of care.
TMT: Please describe the platform used by HolaDoctor®. [06:38]
Dr. Schroeder: First of all, we are digitally-centric. In 2000 we launched a consumer-directed website. And this is sort of most easily thought of as WebMD in Spanish. So, that’s the Spanish version of HolaDoctor.com. And HolaDoctor.com has a combination of translated and culturally adapted—very importantly culturally adapted—content that we access through partners that we’ve been translating culturally for the past 15 years.
And then Consumer Reports is another example where, I think we’re an exclusive help partner on the Spanish side to Consumer Reports. We translate for Consumer Reports health and then we deliver it through our website.
We also have teams of writers and producers. So, we develop a lot of original content and a lot of original programs. And probably the areas that we’ve done the most work in is in diet and diabetes, and these are areas that are very culturally rich in beliefs in regards to beliefs and what foods people can eat or can’t eat. So we’ve done a lot of work in obesity and diabetes. So, that’s the digital platform
In 2010 we’ve launched a mobile version of that site, and at the time, of course, there were just a few people accessing mobile. It’s now about 75% of our traffic comes in through the mobile version.
We’ve built our user base, in part, through an exclusive partnership that we have with Univision. So, a good amount of the health content on Univision.com is produced by us, produced by HolaDoctor®, as well as the mobile.
So, you’ve got the digital platform that then allowed us to build a database that we need for newsletters to provide alerts. We’re gearing up right now to potentially work with the CDC (Centers for Disease Control and Prevention) on an education initiative that would leverage this platform.
But we also have a series of call centers in Latin America (one in Colombia and in Mexico, and actually now one in Miami). And in a number of cases, and I’ll use health insurance as the example, we advertise and promote and educate in a digital format, and then we have phone numbers and the ability for people to call and talk on the phone with bilingual educated people that are essentially trained like the navigators about the Affordable Care Act insurance.
What is Obamacare (they’ll call it), how to buy it, where to buy it, who’s eligible. And I think it was over 150,000 calls to those call centers over the last couple years, because although there are similar services offered by through healthcare by the government, Latinos are often hesitant to call into a government agency, because even if they are documented they may have people living in the family or in a household that are undocumented. There’s a real hesitancy to interact with the government on many levels, and HolaDoctor® has become a place that Hispanic/Latinos can then go and can trust for objective information that’s nongovernmental.
TMT: Tell us about texting and Hispanic/Latinos. [10:04]
Dr. Schroeder: Texting has been really interesting. It’s not exactly high tech in a way, but first of all I think we’re all aware that there’s nearly 100% penetration of mobile phones among Hispanic/Latinos—I guess among everybody. Hispanic/Latinos have a higher percentage of population, that essentially their smartphone is their only connection to the Internet—25% or something like that—but it’s a significant percentage are only accessing the Internet through their smartphone. Mobile is really at the center of what we do.
So with that, two examples. One is we have a program called Farmacia. It’s a medication discount card-for-free program available to anybody really; but it’s targeted at Hispanics. This is something we put together with Univision and a PBM (pharmacy benefits management). That program, provides discounts in I think about 41,000 pharmacies. We found that one of the best ways to allow people to sign up is there are signs in those pharmacies in Spanish and English that allow people to send a word short code of the word Farmacia. And, if they do that they are instantly enrolled into this medication discount card program. They get a membership number directly, immediately back to their cell phone. They can then just turn the cell phone around and show that to the pharmacist and get a 40% to 80% discount off prescription and nonprescription medications that are on the formulary.
Again, that’s very easy, very on the spot, lots of usage especially in Puerto Rico. We’ve got a lot of activity in Puerto Rico with that program. I think we signed up about two million Latinos and saved I think it’s over 15 or 20 million dollars at this point in the last few years we’ve had that program.
The other area we’ve used texting most recently is again with the Affordable Care Act insurance program exchanges. We allow people to opt in for text messaging in our database when they sign up for various things. And we started testing reminders and alerts related to signing up for Obamacare. Nearly universally we got very high positive responses: thank you for reminding me that open enrollment is coming up soon, and I really need health insurance, or thank you for reminding me that I need to buy it by next Tuesday, or thank you for letting me know about the wellness program that Blue Cross Blue Shield of New Jersey is hosting in my neighborhood.
TMT: Is HolaDoctor® a for-profit company? [12:57]
Dr. Schroeder: When we founded the company we chose to be a for profit company to allow us to access the funds we felt would be needed to become a significant player. But we also have a social mission written into our founding document that essentially says that we’re planning to serve these consumers directly and also serve the healthcare industry—health plans and hospitals—and generate a profit from that.
We are essentially advancing a social mission—helping to address health disparities. So, we do quite a lot of work on the health equity and health disparities front as well, both pro bono as well as working with healthcare systems and nonprofits like the CDC, the Florida Department of Health, chronic disease and other state nonprofit organizations.
TMT: What is the main source of income for HolaDoctor®? [13:50]
Dr. Schroeder: We’ve got a couple of revenue streams. One is on the consumer site. We do accept advertising. We also generate revenues through our strategic consulting and research. Most of the projects or engagements relate to developing a Hispanic engagement strategy: how to do a better job engaging and communicating effectively with patients: if it’s a hospital system with members, if it’s a health plan it’s consumers; if it’s an organization like the American Cancer Society, and also to achieve the business goals: more patients, more members, more donors. So, that’s on the strategy side that’s really sort of consulting revenues; and then we also do translation and culture of patients so we specialize in translation of cultural education and health and healthcare content.
TMT: What does HolaDoctor® offer that sets it apart from other companies that do translation? [14:45]
Dr. Schroeder: There are a lot of translation companies out there, and it seems like it would be a commodity at this point. But really, there are some good ways and not such good ways to translate some of the health content. What we really specialize in is adapting material to integrate beliefs and value examples into the material so that it does a better job changing behavior.
TMT: Please give an example of how HolaDoctor® addresses cultural issues in their educational programs. [15:14]
Dr. Schroeder: Hispanic Latinos have beliefs around diabetes, quite strong beliefs. One of the causes of diabetes is like a sudden trauma in your life: be in a car crash, your mother can die. And there’s a switch essential you get that’s a susto that turns on diabetes. So, we tested, for example, adding a single sentence to some diabetes material, “Your grandmother” (it’s always good to talk about people’s grandmothers), your grandmother may have told you that diabetes is caused by susto. So, this is a good example of cultural adaptation that refers to the family, refers to traditional belief. It doesn’t say that it is caused by susto, but it suggests that we understand that this is something you’ve heard in your when in your childhood, you heard around the table. We’re sensitive to that, we’re culturally sensitive, but you know here’s some of the causes of diabetes that you may or may not know about, and you should really talk to your doctor about those.
TMT: What is the correct term when referring to people coming to the US from Mexico, the Caribbean, and South American countries? [15:17]
Dr. Schroeder: “Latino” tends to be used a little bit more on that west coast, “Hispanic” on the east coast. But “Hispanic” is used quite widely. “Hispanic” is a US denomination and “Latino” is regional. The Pew Research Group asked, this demographic how do you identify yourself, as “Hispanic,” “Latino” or other. And about 25% of respondents said “Hispanic.” I think a little less, “Latino;” but really the prominent self-identification was country of origin. They may even be second generation, but their identity really is with the familial country of origin
TMT: How do physicians incorporate the services provided by HolaDoctor® into their practice? [17:00]
Dr. Schroeder: We do some cultural competency training, and I think bringing the physician in a more active way. And we are looking at how we can work with physicians internationally as well to provide coaching and care for U.S. Hispanics here. This is something we’ve done in the wellness arena. We had a statewide program in Florida for example—a Hispanic obesity prevention education program for a large project. We integrated our interactive diet and healthy weight program, which is called MiDieta, into a website Dietary assessment or health assessment that we distributed to all the primary care physicians throughout the state of Florida. Those then were filled in by Hispanics waiting for their appointments, sent to us, we scanned them digitally, analyzed them.
We scanned them actually in Guatemala and then sent them back to each of the doctors’ offices who then provided this personalized culturally appropriate bilingual health and wellness assessment back to their patient based on the food you eat. So, these are really very Latino-centric in terms of dietary habits and practices.
TMT: What is the future for HolaDoctor®? [18:21]
Dr. Schroeder: The future for HolaDoctor® I think is bright. I’m really excited. I mean again, I’m a global public health guy, and really I relinquished tenure to do this because I passionately believe in the potential of technology to improve health around the world, including among multicultural populations here.
We’ve been working and testing digital solutions for the last 17 years. I really believe now is the time that we can do some of the things that we laid out in 1999 in the basement of a friend of mine, when we were putting this together. I think even then we had in our back of the napkin idea, doctors in Latin America providing service to Hispanics here. And for a lot of reasons we just weren’t quite ready for it. but I think that in the next couple years we really will be.
It’s going to be very common for a Latino in Atlanta, Georgia where I am who has an issue to boot up her cellphone and connect to the telehealth service of her choosing and be interacting with doctors across the country who are from her country and understand what she’s challenged by or even in her country as she’s seeking culturally relevant care and guidance.
Dr. Schroeder, co-founder of HolaDoctor®, currently directs HolaDoctor’s multicultural insights and research services, and oversees the development the Company’s health programs. Dr. Schroeder is an expert in global health and a former tenured associate professor at Emory University’s Rollins School of Public Health. Dr. Schroeder retains a faculty appointment at Emory in the Department of Global Health where he continues to teach.