A virtual reality

Part one of a two-part series:

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.

Employers, plans and physicians looking to make such investments have several options to choose from. For example, Eads uses a secure Web portal from a company called Medfusion that offered a deal to American Academy of Family Physicians members. Other popular e-visit vendors include Verona, Wis.-based Epic Systems Corp. and RelayHealth of Seattle.

"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 added 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 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.

Steven Waldren, who directs the AAFP's Center for Health Information Technology, said reimbursement programs have picked up in the past 12 to 18 months and agreed that RelayHealth deserves some credit for that—but how much is debatable.

"E-business is bigger than RelayHealth, and it will grow regardless if RelayHealth is successful or not," he said.

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