As of Jan. 1, physician groups could enter the code "0074T" to bill health insurers for providing online medical evaluations. But few doctors should expect the chance to use it anytime soon.
Only a few health plans have agreed to pay physicians for online consultations-and most of those limit reimbursement to a sliver of their provider networks. Without the prospect of payment, most physician practices remain leery that online patient visits will become yet another task doctors must integrate into their daily workflow.
Surveys suggest that only a fraction of doctors routinely communicate with their patients online, ranging from less than 10% to 20%. It's a yawning chasm between the 90% of online consumers that some surveys indicate would like the ability to receive medical care online.
The new billing code, added in December 2003 to the listing of Current Procedural Terminology, or CPT, will make it easier for physician practices to bill for online visits. But it has no bearing on whether more insurers will start paying for them, according to the American Medical Association, which publishes and maintains the CPT codes.
A key barrier: Health plans have difficulty forecasting utilization rates and potential cost savings, says Mark Bard, president of Manhattan Research, a consulting firm focused on health technology.
"The reimbursement piece is holding a lot of this back," Bard says. "Health plans have no actuarial model to figure out how much online consults are going to cost."
Even so, a small but growing number of plans are experimenting with reimbursement for online consultations, lured by the dual prospect of cost savings and a marketing edge. Most have agreed to pay physicians $20 to $25 for a clinical online visit. Along with copayments from patients ranging from $5 to $15, that nets doctors anywhere from $25 to $40 per exchange. The demonstrations generally have gone smoothly, with plans reporting high physician and patient satisfaction and no spike in claims costs. Several that have tested models are now expanding their Web-visit programs to larger chunks of their provider networks.
Leap of faith
"It's a leap of faith," says Vinny Plourde, vice president of provider services at Blue Cross and Blue Shield of Massachusetts, which began a Web-visit pilot project last summer. The insurer this year plans to reimburse $20 per online visit to 500 physicians across the state. Plourde says the project is an effort to address a shortage of primary-care doctors in Massachusetts. "If physicians are able to carve off some of the straightforward, nonurgent-care cases in a Web setting, we thought it would be a way to address the access issue."
He insists the chance for cost savings was not the driving force. "It's a way to alleviate administrative hassles for providers and provide better service to members. If there are cost savings, great."
Although similar pilot projects have shown significant cost savings, some payers say the resulting data aren't sufficient to paint a clear picture. Blue Shield of California announced last October that it would broaden its Web-visit program after an experimental project in 2002 that included nearly 300 physicians and 3,700 members in the San Francisco Bay area. Using a control group, Blue Shield found that by reimbursing physicians $25 per Web visit, it reaped net savings of $1.15 per member per month on office visits, for which it normally reimburses $50 to $70 per visit.
David Joyner, Blue Shield's senior vice president of network management, says doctors and patients also reported high satisfaction levels. "It was one of those win-win-win opportunities that are so rarely evidenced in healthcare," he says.
Researchers at Stanford University and the University of California-Berkeley, crunched data from the Blue Shield project and two similar demonstrations, each coordinated by RelayHealth Corp., a provider of doctor-patient online communication services. The resulting study, released in January 2003, determined that the three payers combined had an average net savings of $1.61 per member per month on spending related to physician office visits.
The study is thought to be the only publicized cost-benefit analysis of health plan reimbursement for Web visits. But some payers view those results with a grain of salt.
ConnectiCare, a 280,000-member HMO based in Farmington, Conn., that participated in the RelayHealth study, decided not to expand its program. Paul Bluestein, ConnectiCare's chief medical officer, says he's not sure if the $1.61 monthly savings per member would carry over if the service were spread across its entire network. "I think it's limited experience upon which to base a business decision," Bluestein says.
ConnectiCare's pilot of roughly 300 patients represented only about 5% of the 5,700 patients included in the overall study, making its impact on the overall study "negligible," Bluestein says. The other two payers, Blue Shield of California and a group of 10 large self-insured employers in that state, accounted for nearly all of the results. Bluestein also says he would rather wait to see how the marketplace for Web visits evolves. Specifically, he has his eye on applications that support a patient-pay model rather than reimbursement from health plans.
Surveys consistently show, however, that there is a limit to what patients are willing to pay for online consultations. Preliminary findings of a report due out in February from Jupiter Research, an information technology researcher, show that only 8% of 570 consumers surveyed would be willing to pay more than $10 for an online consultation.
Matters of security, brevity
A lack of reimbursement isn't the only reason for most physicians' tepid response to online patient visits.
Liability remains a big concern, experts say, even though more than a dozen vendors now tout secure, encrypted messaging platforms that offer reliable authentication safeguards. Also, the AMA, the American Medical Informatics Association and other groups have published guidelines for communicating with patients online. But experts say many doctors recoil at even the specter of liability.
Another frequently cited barrier is that physicians are afraid of being deluged by frivolous or long-winded messages.
But the experiences of physician practices that have adopted the technology indicate that fear might be overblown. At Beth Israel Deaconess Medical Center in Boston, about 155 affiliated physicians accept online visits from some 16,000 patients through the hospital's own Web-based system, according to Daniel Sands, the hospital's director of electronic patient records.
Although Beth Israel's patient-messaging system has been in place for four years-and most physicians enthusiastically refer patients to the service-Sands says the message volume is manageable: an average of one clinical inquiry a day for every 100 registered patients.
A cursory check of his inbox one day in mid-December 2003 found just six patient messages from the previous week. (Sands, an internist, has 183 patients registered to use the site.) One was from a 50-year-old man, which read, "Any possibility of me still getting a flu shot? You suggested it during my visit on 12/3, but I stupidly said no. My concern is not dying but that I can't afford to miss a week or more of work."
Another message was from an 80-year-old man suffering from knee pain, asking if he should consider acupuncture. Sands replied that it would be OK to try it, but that he couldn't recommend a provider.
A 38-page report on online patient-physician communication issued last November by the philanthropic California HealthCare Foundation finds that online visits generally make doctors' lives easier. The analysis, prepared by the Boston office of First Consulting Group, based the conclusion on case studies of more than a dozen physician groups and health systems in several states.
Some of its key findings were that doctors can respond to messages when their schedule permits, reducing telephone tag; Web visits provide instant documentation of communication; and trimming some face-to-face office visits reduces administrative tasks and clears the way for higher-intensity-and higher-paying-cases.
A variety of systems
Some small practices use basic, unencrypted e-mail services such as America Online or MSN. Many vendors offer more sophisticated, Web-based online communication systems, which provide secure, structured messaging and the ability to automatically route messages to the appropriate staff member. RelayHealth, for example, charges practices $50 per month per physician for its messaging system, though it offers discounted rates to larger groups, says Senior Vice President Eric Zimmerman.
For large practices or healthcare systems with complex electronic medical records or practice-management systems, integrating patient messaging generally is more expensive, running as high as $10,000 per physician workstation for some EMR products, according to the foundation report.
Like doctors at Beth Israel, a handful of physician groups and integrated healthcare systems have embraced Web visits as a way to enhance productivity and as a marketing tool; they are moving forward regardless of whether they get paid.
Early this year the University of California-Davis Health System in Sacramento plans to be able to offer online consultations with all of its 1,200 physicians, says Eric Liederman, medical director of clinical information systems. UC-Davis is among the providers in Blue Shield of California's growing Web-visit program, but Liederman says his system would have expanded its service anyway.
"I think there's a substantial marketing benefit," he says, pointing to a 2002 poll by Harris Interactive, an Internet marketing research firm, that shows 56% of consumers say the ability to communicate electronically with their physician would influence their choice of provider.
Kaiser Permanente plans to introduce patient messaging to all of its 8.2 million members and 11,000 physicians within three years, starting in early 2005 with Hawaii and possibly other regions, says Kate Christensen, medical director for Kaiser's Web site.
Payers are eyeing the potential marketing edge as well. Blue Shield of California's Joyner says that the ongoing expansion of its online-visit program to large portions of its HMO will be "very worthwhile" even if it yields no cost savings.
"We're not really worried about the financial exposure, because the pilot results were so compelling," Joyner says. "What we wake up in the morning worrying about is, `How can we ramp this up quickly enough?' This has the potential to differentiate Blue Shield as a different kind of healthcare company."
Mike Colias is a Chicago-based freelance writer. Contact him at [email protected]