\ ACP Observer, December 2004 - How two practices are taking patient visits online—and getting paid for them

American College of Physicians: Internal Medicine — Doctors for Adults ®

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How two practices are taking patient visits online—and getting paid for them

From the December ACP Observer, copyright 2004 by the American College of Physicians.

By Janet Colwell

San Francisco—Just a few years ago, family physician Christa Danielson, MD, wouldn't even consider dispensing medical advice to patients online. How could communicating through a computer, she reasoned, ever replace the traditional, hands-on encounter? And even if e-mail visits were more convenient for patients, how would she get paid for her time online?

Today, Dr. Danielson is among the vanguard of physicians expanding their use of online consultations. After grudgingly signing on for a pilot e-visit program at her practice in Eugene, Ore., she quickly became one of its biggest champions.

"It's a different kind of interaction with a different emotional impact, but I find that many patients like it," Dr. Danielson said during a presentation on e-visits at the fall conference of the Medical Group Management Association (MGMA). "Patients seem more likely to absorb what I say via e-mail than in person, and they are less distracted and stressed."

That assessment was echoed by another MGMA presenter, psychiatrist Barbara Walters, DO. Dr. Walters is the medical director of Dartmouth-Hitchcock Medical Center, a Lebanon, N.H.-based nonprofit that rolled out its e-consult system in 2001. As many as 10% of the center's patients now opt for e-visits, with the center having more than 10,000 active patient accounts across 250 participating providers.

"Our patients are very articulate in e-mail," Dr. Walters said. "We get much better information than we did playing phone tag and using nurses as intermediaries."

Dr. Danielson's group and Dartmouth-Hitchcock are on the cutting edge of a growing trend toward more use of e-mail as a substitute for office visits. As more patients become Web-savvy, the likelihood that they want to wait—either on hold or for a call-back from staff—diminishes.


After signing on for a pilot e-visit program at her practice, family physician Christa Danielson quickly became one of its biggest champions. She finds patients are "less distracted and stressed" in e-consults than in office visits.



Many physicians are reluctant to go online with patients, fearing a deluge of e-mails and one more uncompensated drain on their time. But Drs. Danielson and Walters both noted that patients send only appropriate messages, and that some health plans are starting to reimburse physicians for them.

Getting started

According to Drs. Danielson and Walters, patients' surveyed response to e-visits has been overwhelmingly positive. Patients tend to be more focused when writing about symptoms than during an actual office visit. E-consults are brief and easy to document, and patients who use them are more than willing to pay for the online access.

"They want the doctors to get paid," Dr. Danielson said. "Then patients don't feel like they're interrupting or bothering their physicians." The program at her practice—which is part of PeaceHealth, a three-state nonprofit health care system—is still in its pilot phase, with eight participating physicians and 4,600 patient accounts. She said she expects volume to increase quickly as the program expands, based on the growing number of e-visits over the past six months.

Start-up costs vary depending on system size, said Dr. Walters, but groups have to purchase a software application with encryption. Dartmouth-Hitchcock's application is embedded in the center's practice management software, while patients there and at PeaceHealth sign on via a secure, password-protected Web site.

Although security is a major concern, both physicians said that billing is an even bigger sticking point. The Centers for Medicare and Medicaid Services (CMS) has yet to recognize e-consults as equivalent to office visits, although ACP has urged the agency to do so (For more information, see "E-visits: practical, but are they profitable?")

Many health plans are hanging back until the CMS signs on for reimbursement. But both PeaceHealth and Dartmouth-Hitchcock have had some success getting health plans on board. PeaceHealth has signed on one large payer, Providence Health Plans of Oregon, while other payers are considering coverage in 2005.

Dartmouth-Hitchcock is still waiting for Anthem, its biggest plan, to cover e-visits, but has agreements in place with others including Cigna, Harvard Pilgrim Health Care and Blue Cross Blue Shield of Massachusetts.

The key to getting reimbursed was actively selling the merits of e-consults to payers, Dr. Walters said. In pitching the concept to health plans, Dartmouth-Hitchcock used study data that linked e-consults to lower overall health care costs.

"We also told them that e-visits were something our patients were asking for, which would boost patient satisfaction," she said. "Plus, we pointed out that employers wouldn't have employees taking off a half-day from work for a face-to-face visit—a good selling point for the plans." The center now bills a typical e-visit, she said, at about half the rate of an office visit.

As soon as patients sign on for an e-visit at either practice, they submit a credit card number for their co-pay, or for the entire e-visit fee, if they're covered by a plan that doesn't reimburse for e-consults. (PeaceHealth charges up to $20 per visit, while Dartmouth-Hitchcock charges $30, and individual plan co-pays vary.) If the "visit" entails more than two or three back-and-forth messages, the physician usually asks the patient to schedule an office visit and cancels the e-visit charge.

Separating e-visits from e-mail

Another hurdle for insurers, Dr. Danielson pointed out, is separating an actual e-visit from routine patient e-mail.

Providence Health, for instance, will reimburse only those e-consults that fall into one of the following categories: extended counseling when person-to-person contact would involve an unwise delay; relapse treatment that requires physician time and judgment; and counseling and education for patients with complex chronic conditions.

To be reimbursed for an e-visit, PeaceHealth physicians must respond within 24 hours, confirm member eligibility and have a pre-existing relationship with a patient. Providence Health does not reimburse for patient e-mail for prescription refills, appointment or test scheduling, or for follow-up to a medical procedure when no complication or new condition is indicated.

According to Dr. Walters, even though practices don't get paid for routine e-mail, encouraging patients to use e-mail for prescription refills or scheduling is an added convenience and an incentive for them to go online for an e-visit. Many patients use e-visits to report symptoms for conditions like sinusitis and get a prescription. Many e-visits and patient e-mails arrive between 10 a.m. and noon, the toughest time for patients to get through by phone. Staff triage and handle incoming messages, and route only official e-visits to physicians.

So far, neither physicians nor staff has had to set aside blocks of time to process e-visits, fitting them in instead around office visits with other patients. But that may change if more patients choose to go online.

"We found that clinical messaging was the No. 1 use of e-mail by patients," said Dr. Walters. "That was a big surprise. We thought it would be prescription refills or appointments."

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E-visits: practical, but are they profitable?

While many patients may want to use e-mail to communicate with their physicians, medical groups that would like to accommodate them run up against a major obstacle: Most health plans don't reimburse e-visits. So far, online consultations are taking hold sporadically across the country. Some physician groups, like PeaceHealth in Eugene, Ore., and Dartmouth-Hitchcock Medical Center in Lebanon, N.H., are starting their own programs and making a case to payers for reimbursement.

Some insurers are encouraging members to use e-consults, but make them pay for that interaction themselves. The Regence Group, a group of BlueCross BlueShield affiliates in several Western states, for instance, urges members to use Medem, an online communication service sponsored by the AMA and several other medical societies. Once physicians join the Medem network, patients can log onto the San Francisco-based company's Web site for the consult and directly pay their provider, about $20 per visit.

A few insurers have taken the initiative to pay for e-consults. Kaiser Permanente, the California-based health maintenance organization, now allows members to communicate with their doctors via a secure Web site.

The Illinois-based First Health Group Corp., a preferred-provider organization, began paying for e-visits in 2001 after data showed that increased e-mail contact with physicians helped reduce hospitalizations for chronically ill patients. And Blue Shield of California began reimbursing e-visits in 2003 after a pilot program showed that e-consults saved more than $3.50 per member per month in overall health care costs.

Most insurers, however, are still on the fence. In a 2003 policy paper, ACP called on the Centers for Medicare and Medicaid Services (CMS) to take the lead and reimburse e-visits as separate from a typical evaluation and management service.

In the policy paper, the College proposed standards for determining what types of electronic visits should be reimbursed. Routine communications, such as reporting normal test results or approving prescription refills, would not be covered, while eligible e-visits should be with established patients who have been seen in the office within the past year and whose conditions can be adequately assessed over the Web.

And the AMA has recognized the e-visit as a legitimate form of medical evaluation. It recently released a new CPT code, 0074T, for online consultations that physicians can use starting next July.

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