Don’t LOL at virtual visits

The doctor doesn’t have to see you now.

Thanks to new technology, patients may not always need a face-to-face visit with their doctor to get the care they need.

And thanks to a growing awareness of this fact on the part of health plans, structured, Internet-facilitated and reimbursable “virtual visits” are on the verge of entering mainstream medicine. Virtual visits also are seen as a tool that will save money, provide convenient care and maybe do something to solve the problem of patients not having access to their doctors.

This is especially true in Minnesota, where five of the six largest private health plans reimburse physicians about $35 per virtual office visit, and the last holdout announced that it will soon join the club. Unresolved, however, are issues over standards for billing and legal jurisdiction matters concerning doctors conducting e-visits during travel to states they are not licensed to practice in.

Health information technology vendors are helping to bring the parties together, and a message is being spread that virtual visits benefit patients by offering affordable and convenient access to their doctors; help providers more efficiently process routine cases; aid employers by reducing absenteeism created when workers take time off to see their physician; and—perhaps most significant—assist insurance companies in saving money.

“I would hope that 100% of the companies will be doing this in the next few years,” said independent family physician and e-visit advocate Michelle Eads of Woodland Park, Colo. “Once the insurance companies get it through their thick skulls that it saves money, they’ll be more than willing to do it.”

Eads is also the sole practitioner in a pilot study Kaiser Permanente of Colorado Springs is conducting exploring the use of virtual visits by in-network independent physicians. She receives $50 for an online consultation and said preliminary figures from 2006 show that Kaiser is saving between $70 and $120 on each virtual visit.

Larry Boress, president of the Midwest Business Group on Health, said that e-visits have not been heavily pushed by his organization, but added that “our interest is in physicians adopting technology to improve the quality of care they deliver and their communication, so this is just part of that.”

Internist Paul Tang, the vice president and chief medical information officer of the Palo Alto (Calif.) Medical Foundation, believes employers should pay more attention. He said, in a study, his organization found that for every $1 employers invested in virtual-visit programs, they received a $4.50 return—mostly in the form of savings generated from having less lost productivity.

“It’s early in the evolution of mainstream adoption—but more and more people are recognizing the value,” said Ken Tarkoff, vice president and general manager of consumer solutions for RelayHealth, who said that his company is currently working with more than a dozen insurance companies on programs to reimburse physicians for the time they spend using his company’s secure online communication services.

These arrangements began about five years ago, first with Blue Cross of Massachusetts and Blue Shield of California and have grown to include Aetna, Cigna HealthCare and WellPoint Blues affiliates. Tarkoff said RelayHealth-facilitated reimbursement programs were developed in Florida, Kansas City, Mo., and the New York City tri-state area, and are now being established in Illinois, New Jersey and Ohio.

Tarkoff said after RelayHealth was purchased by McKesson Corp. in June of 2006, interest has really taken off as the giant corporate parent has been able to grow the network of participating providers. “We’re working with a number of payers to accelerate growth,” Tarkoff said. “Traditionally, the relationship between a physician and a health plan may not be completely positive. This offers an opportunity to change that.”

Under the RelayHealth program, physicians are reimbursed $30 for reviewing the answers patients provide in an online interview, which Tarkoff explained represents about 40% of the usual reimbursement for a Level 3 office visit where an established patient comes in and presents symptoms.

“The reason health plans reimburse for our e-visits is because physicians are able to prove that a certain level of healthcare service was provided,” he said.

Cigna HealthCare spokesman Joe Mondy said laws prohibit him from discussing negotiated discount rates and stop him from disclosing how much Cigna reimburses physicians using RelayHealth, but acknowledged that $50 was “in the ballpark” for their physicians in Arizona, California and the New York City tri-state area.

WellPoint, the parent company of 11 Anthem Blue Cross and Blue Shield plans and three other Blues-related companies, has completed a pilot study in Denver, and has two pilots in New York and Indiana where $25 is the standard reimbursement, according to spokeswoman Cheryl Leamon.

Tarkoff predicted that RelayHealth will be involved in virtual-visit partnerships in some 100 markets in two to three years, and that Medicare will be reimbursing for Web visits within five years.

But Medicare reimbursement is not imminent. “I don’t want to reimburse a physician every time he sends an e-mail,” said Kerry Weems, acting administrator for the CMS. While not opposed to reimbursing physicians for electronic care as part of an overall reimbursement package, per-e-mail reimbursement is something Weems currently opposes. Physicians might get “very adept” at e-mailing, Weems said.

Minnesota might be the epicenter of e-visit reimbursement. At Fairview Health Services, a Minneapolis-based integrated health system, 34,000 people—or roughly 5% of the Fairview patient population—signed up since July to use MyChart, its secure portal for e-visits offered by Epic Systems Corp., according to Barry Bershow, Fairview’s medical director of quality and informatics.

About 1,000 patients are being added each month, he said. “Just like ATMs were bizarrely rare in the beginning, now no one can imagine banking at a bank that doesn’t use them,” Bershow said.

Bershow estimated that state insurance companies have reimbursed Fairview for about 500 e-visits since the July launch at $35 apiece, although he’s not sure how that dollar figure came to be. “It mystically appeared in one payer’s proposal and it seemed fair and reasonable to us,” he recalled. “So we said ‘Sure,’ and once it was out there—and no one seemed to have an explanation why—everyone picked the same number on both sides.”

Patient response has been overwhelmingly positive, he said, except for two complaints from people who had gotten used to communicating with their physician via e-mail for no charge. Physician response has been mixed.

“We have some docs with over a thousand people signed up, but we also have some with only about 35,” Bershow said. “So, obviously those physicians are clearly not into this.”

Blue Cross and Blue Shield of Minnesota spokeswoman Jan Hennings said her company recognizes a $35.70 level of reimbursement for an e-visit, but if a member has a $20 copay, her company may only pick up $15.70.

Medica, the last major holdout in Minnesota, provides reimbursements through its Patient Choice business division, which is a health plan for self-insured employers, and reimbursements will go companywide soon, said spokesman Greg Bury.

Although health plan giant UnitedHealthcare is based in Minnesota, Hennings said state laws mandating that health insurance companies be not-for-profit prohibit UnitedHealthcare from doing business there. Regardless, if it did operate in Minnesota, it probably wouldn’t reimburse for e-visits because, according to company spokeswoman Debora Spano, UnitedHealthcare policy calls for only reimbursing for face-to-face visits.

Eads, speaking at the AAFP’s annual scientific assembly in Chicago earlier this month, said it takes about 16 minutes to complete the typical virtual visit, and that they have been particularly useful in monitoring patients with hypertension and depression. Besides chronic conditions, Eads said these visits are also helpful for patients who work nights or who are just under the weather.

“I live in the mountains,” she explained. “Some people don’t want to drive into the mountains just for me to say ‘Yes, you’re sick.’ ”

E-visits also work out for patients without insurance who find the $50 online-consult fee easier to swallow than the price of an office visit, Eads said.

Miami-based family physician Bernd Wollschlaeger has nothing but self-pay patients in his cash-only, paper-free practice, and he said his patients don’t mind paying for electronic communication. Fees start at $15 to $20 for a prescription refill, $25 for chronic condition management, and then go higher the more complex the task. “Most people in my practice understand that my time is money,” Wollschlaeger said. “I’ve never heard a complaint.”

While they don’t complain about the cost, Wollschlaeger said they do ignore his directions to use the secured communication portal offered through a Medem personal health record. Instead, they prefer to send him regular e-mails instead. If that’s what they want to do, Wollschlaeger said he makes them sign a statement confirming that.

Wollschlaeger said one time a patient didn’t want his wife to know that he was having medical tests done, but the secret was revealed when the patient didn’t use the secure portal. “He asked me ‘Why did you tell my wife?’ and I said ‘I didn’t, she read your e-mail,’ ” Wollschlaeger recalled.

Wollschlaeger does information technology consulting for the American Academy of Family Physician members in his state, as does Louis Spikol, a family practitioner with the Allentown, Pa.-based Lehigh Valley Physician Group, but the similarities end there. Spikol said he fields several patient e-mails a week and conducts a handful of structured e-visits a month, but he doesn’t bill for them. “The hospital wouldn’t know what to do with it,” he said. “I don’t think they have any mechanisms for paying for that.”

Instead of a per-use method of payment, Spikol said he would prefer a retainer-type method. “I would rather get paid on a global basis—like the cable company where you pay $30 a month and you get to see TV,” he said.

Tang of the Palo Alto Medical Foundation thinks he has an answer to the billing dilemma: Use standard office-visit criteria such as conducting an exam, taking a medical history and making a medical decision. Tang, who is also chairman of the American Medical Informatics Association, said Palo Alto has 93,000 patients, 46%, who use the MyChart communication portal, and his team analyzed 122 e-mails between 112 patients and 69 PAMF physicians to see if two out of those three actions took place.

The analysis found that 22% of the messages contained enough evidence of history-taking and medical decisionmaking to warrant billing.

“This is a way of qualifying an

e-visit using existing rules,” Tang said. Now that he has developed some rules, Tang may need to find someone to follow them. “No one is reimbursing us—that’s the reason I wouldn’t call this ‘mainstream’ yet,” he said.

A multitude of studies have also shown that electronic communication increases patient satisfaction, and that patients rarely overburden their doctors with too much information and too many e-mails. One of the most recent studies was published in the October issue of the American Academy of Pediatrics’ journal, Pediatrics.

While researchers, physicians and patients report positive findings, however, the lawyers have yet to speak up. John Bachman, a physician at the Mayo Clinic in Rochester, Minn., addressed the potential problem of e-visits during a program at the AAFP’s assembly in Chicago. “I’m here in Chicago, my patient is in Florida … but I practice in Minnesota,” Bachman said, noting that the Mayo Clinic’s legal team has suggested to him that conducting e-visits while in a state he is not licensed to practice in may not be a good idea. “Technology is always faster than our laws.”

Fairview’s Bershow said he’s decided he won’t wait for the law to catch up.

“Nobody knows for sure what to do, because the laws were written before this was a possibility,” he said. “We’re proceeding from the stance that it makes sense to do this and there’s no reason not to.”

What do you think?