A new survey that is part of a whitepaper by PWC suggests that most Americans are receptive to receiving on-line medical care. Perhaps fearing that access to providers will only get worse due to increasing demand from national healthcare reform, consumers say they would welcome the opportunity to receive some medical services by phone, e-mail, telemedicine, and remote monitoring. According to the survey, 50 percent of consumers said they'd be willing to seek healthcare through the Internet or other computer technology as a substitute for a face-to-face, non-emergency visit. Of those, an e-mail consultation was the preferred method of interaction (76 percent), followed by telehealth, question/answer fee-based consults and an online forum/chat room monitored by a doctor. Nearly three-quarters of consumers said they would use biometric electronic remote monitoring services to track their condition and vital signs.
So why hasn’t telehealth taken off in a big way? It takes two to tango and up until recently, a physician’s ability to get paid for doing any of the above has been significantly limited. But that is changing.
Here on HealthBlog I shared information about telehealth services that are now being offered by HMSA to residents of Hawaii. Working with Microsoft partner, American Well, and Microsoft HealthVault, residents of Hawaii are flocking to telehealth services and physicians there are getting paid for providing them. American Well has announced expansion of services that will soon include residents of Minnesota and eventual national distribution through a partnership with United Healthcare.
Getting private insurers on the telehealth bandwagon is one thing. But more than 60 percent of healthcare spending in America is by government agencies (Medicare, Medicaid, VA). Until recently, doctors providing telehealth services to Medicare recipients not only couldn’t bill for those services, but would be subject to severe penalties and fines if they tried to do so. Such services were considered by Medicare as part and parcel of services already provided in the office and no additional billing of any kind was allowed.
I recently received notification from a professional colleague that suggests Medicare is beginning to see the light. Dr. Thomas Gumprecht is an ENT doc practicing in the Seattle area. More than a decade ago, he began lobbing private insurers to remove contract language that forbids additional billing for cognitive professional services provided to patients by electronic means including the telephone. He actually got the insurers in our area to agree that it was OK to charge for these services so long as any patients receiving them had been notified well in advance, and in writing, that they would be charged.
Now it seems that the federal government may be giving a green light to docs who want a similar arrangement for patients receiving Medicare. According to Dr. Gumprecht, “CMS now permits direct billing of electronic services----and it is important to say ALL ELECTRONIC SERVICES---PHONE, FAX, EMAIL, VIDEO, TEXTING----because logically it is a professional medical service being rendered electronically and the exact mode should not be one or the other but a continuum between all of them. With this breakthrough, most other carriers will fall inline with the CMS approach, and at least permit direct billing of patients”.
Dr. Gumprecht asked me to help spread the word. He went on to say, “Too many busy doctors will hear the news of CMS permitting direct billing but will not know the nuts and bolts of adopting it, or they will not exert the minor effort it takes to reformat their patient intake sheets (on the disclosure you must say the patient is responsible for electronic bills), tell their receptionists and office nurses how to handle phone, fax, or email requests for service. Once you have a month or so getting patients to sign disclosure forms on their patient intake sheets, the practice can start billing patients directly for electronic services”.
Dr. Gumprecht and the American Academy of Otolaryngology, Head and Neck Surgery referred to this citation in Medicare regulations (see pages 2-4). So, it does appear that barriers are coming down on telehealth services and for the physicians who would like to provide such services. Finally, people will have ways to get health information and medical services from physicians besides making appointments and being seen in an office somewhere. And docs providing those services can be paid. It’s about time!
Bill Crounse, MD Senior Director, Worldwide Health Microsoft
This is a welcome and overdue move, although the resistance to the notion from government funding sources is understandable.
In health systems where doctors are paid per item of service, there is every incentive for them to encourage patients to use their services more (follow up that email/phone call, etc.) and virtually no incentive for them to use technology such as remote patient monitoring to reduce patients' usage of services by making their care more effective - which is the main rationale for telehealth.
Telecare Aware News Service
Do you think telehealth will increase or decrease the dollars spent in healthcare? Just curious what your thoughts are as access to health becomes more convenient, will more people engage elevating services rendered? I get the cost savings on the backend and fewer trips to the ER, etc, but wanted your opinion. Thanks for your feedback.
Good question, Chris. The literature suggests that 30 to 40 percent of primary care office visits are people seeking information or reassurance from a qualified health professional. If a $25 to $60 e-mail or virtual visit replaces what might have been a $100 or $200 office visit, then that is a good thing. If a $60 virtual visit replaces what might have been a $2000 ER visit, then that is a very good thing. Insurers like HMSA and United Healthcare have figured this out, and others will follow. Also, since many telehealth scenarios have patients picking up at least some of the costs (through co-pays or in full), patients have the option of trading convenience over coverage; and given that choice many consumers will actually choose convenience. Nobody likes waiting for appointments when they are sick and they especially don't like hanging around an ER for several hours waiting to be seen.
Bill Crounse, MD
As a Family Doctor, I spend a significant portion of my clinical time on purely cognitive services (counseling and education). These are currently reimbursible only when conducted face-to-face in the office. Requiring a patient to leave work and drive to the office for a 15-30 minute discussion seems unfair. But it is equally unreasonable that a physician couldn't collect for that time if the same services are provided telephonically or electronically.
We lose the subtle clinical cues: body language, gross neurologic inspection, skin color, etc. But much of the time, even these are not needed.
Do I need the patient sitting across from me to counsel on travel vaccines? Motion sickness medications?
Is there anything negligent about following up with a stable depression patient by telephone or video-conference?
I always feel a little guilty requiring office visits for these types of services, but it is my only option right now if I am to stay in business.
These are services I would love to provide remotely, but there are some obstacles:
1) Insurance contracts still won't pay for "virtual" visits
2) Most of my patients, for reasons I can't grasp, expect that telephone services and consultations should be free.
Even over the phone, I still spend the same amount of my professional time. I still accumulate the same liabilty (maybe even more). And I require the same level of cognitive work.
The potential downside of expanding access to tele-health is that patients will begin to expect more services in this fashion.
The majority of acute problems, and even a lot of chronic care, ultimately require a physical examination, even if it is a brief one.
I don't believe it is in the interest of the patient to forego the tactile and visual components of an examination in the interest of convenience or cost-savings.
Physicians must be cautious not to give in and compromise quality of care.
Patients must not abuse these visits by refusing onsite care when it is recommended.
The coding guidelines must also be clarified. If I understand correctly, the current guidelines for e-visits do not allow billing if the patient was seen within the last 7 days, or if the patient comes in for a visit within the 2 days following. That restriction devalues our time.
Time is time, work is work.
Attorneys and accountants bill by the hour. So do plumbers, electricians, and most other professionals. It keeps things very simple.
I hope the new CMS rules will be more respectful of our time and expertise.
Thanks for your thoughtful comments, Dr. Segal. I agree. Televisits will not, and should not, replace all face to face visits. But as you say, there are many times when an e-visit of some sort is better for both the patient and the physician. I am a strong proponent for physicians being paid for cognitiive services no matter how they are provided; phone, e-mail, video visits on the web, or in the office. If we ever hope to scale access to healthcare at a price society can afford, technology and telehealth must be part of the solution.
Agree with Dr. Segal above. Being an Endocrinologist and having run an electronic office for over 7 years, we know that telehealth or remote patient management offers great opportunity to provide real-time care without disruption to a patient's work or productivity. However we have struggled to get paid for any of these services. It is only in the last 3 months that UHC has agreed in principle to pay for non face-face visits, although still balking on e-visits. Others only pay if we use certain proprietary services such as Relay health. It is obvious that although the payers like to talk big about promoting telemedicine, they are unwilling to pay for it.
We have advanced far beyond simple emails, etc. But trying to find ways of reimbursement for such services remains a big hurdle. Perhaps, Dr. Crounse could help highlight such practices and their worth for patients.
Thanks Dr. Cavale. I have long been an advocate. Just do a search on HealthBlog for "unified communications" and you'll see that I have been very active in advancing the cause. In fact, during the late 1990's I co-founded a company that did some pioneering work in "virtual visits" on-line. I firmly believe that healthcare (and payors/governments) must move in this direction if we ever hope scale healthcare services to the millions (and billions) who cannot access such services today.
Yes, I have been following some of your comments. However, for this to become main stream, there has to be a push from a larger player than a solo practitioner. I also believe that employers could play a major role. If employers continue to fund insurance premiums (after Obamacare becomes law) they could team up with local physician practices and health plans to offer a benefits package that incentivizes healthy living and use of tele health option for those services that can be safely delivered this way. There should also be a commonsense method to offset any legal issues that may derail such efforts. I truly believe that any "reform" effort must come from the grassroots, rather than from govt, exactly opposite of what is happening now. Perhaps the big wigs in DC could come down and talk to the community docs and patients as see how well tele medicine works if used effectively.
The TransforMed project, via AAFP, did include eVisits, and several of the participating practices are still conducting paid eVisits (through 3rd party software which collects credit-card information at the time of the patient's encounter).
From what I have heard, these visits are used only sparingly by the patients.
Patients currently expect that telephone requests (eg, after-hours calls, prescription requests, etc) are handled without charge.
They will expect the same of eVisits. And when they find out they have to pay for an eVisit, many will protest.
It's a culture change at every level:
1- Physicians must adapt to the demands and technology by providing tele-care when medically appropriate.
2- Payors must respect our time, cognitive work, administrative overhead, and liability by paying fairly for these encounters.
3- Patients must respect our opinion when evisits are, or are not, appropriate. And they must be willing to pay for these services.
In my practice, through our EMR (eClinicalWorks), we may extensive use of secure email, electronic history-taking, and virtual visits. But our early efforts to bill and collect for these was painful and unsuccessful. So, as with many services, we've rolled over and do it for free.
Admitting my own guilt on this one, I ask: How do we implement such massive changes?
Thanks for your comment and for sharing your "pain". My attorney and accountant both charge for phone consultations. Why should physicians "give away" their cognitive services? Especially for primary care docs, knowledge is really all you have to sell. How many years did you train? How much does it cost you to maintain your continuing education and board certification? When we give away our services they soon become valued by what we ask our patients (or their insurance company) to pay; in this case zero. Yes, the transition may be painful, but unless you take the bull by the horns your services and your knowledge will continue to be devalued.
Bill Crounse, MD
Dr. Gumprecht claims that Medicare will now reimburse for e-visits and text messaging, but I cannot find any evidence that this is true on the CMS site. If it is in fact true, this is a huge step forward for healthcare.
I would appreciate it if someone could point me to the area of the CMS site that lays out the specifics of this reimbursement.
Thanks for your comment. To be clear, Dr. Gumprecht is not saying that Medicare will pay for e-visits. He is saying that Medicare will let you bill patients directly for such services provided you have a signed document on file where they acknowledge that they understand they will be responsbile for paying for these services.