MESSAGE
| DATE | 2005-03-02 |
| FROM | Ruben Safir Secretary NYLXS
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| SUBJECT | Subject: [hangout] Getting paid for your work...
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March 2, 2005 Digital Rx: Take Two Aspirins and E-Mail Me
in the Morning By MILT FREUDENHEIM
Doctors may no longer make house calls, but they are answering patient
e-mail messages - and being paid for it.
In a move to improve efficiency and control costs, health plans and
medical groups around the country are now beginning to pay doctors
to reply by e-mail, just as they pay for office visits. While some
computer-literate doctors have been using e-mail to communicate informally
with patients for years, most have never been paid for that service.
Brian Settlemoir, 39, an accountant in Folsom, Calif., recently sent
an e-mail message to his doctor at the Creekside Medical Group to ask
if it was time to reduce the dosage of a medicine after his cholesterol
level dropped. The prompt answer was "not yet."
"I'm sitting at work," Mr. Settlemoir said. "I've got e-mail open
anyway. It's much easier than calling and getting voice-mail prompts
and sitting on hold. It's very valuable to me."
Blue Shield of California pays his doctor $25 for each online exchange,
the same as it pays for an office visit. Some insurers pay a bit less
for e-mailing, and patients in some health plans are charged a $5 or $10
co-payment that is billed to their credit card and relayed to the doctor.
For doctors, the convenience of online exchanges can be considerable. They
say they can offer advice about postsurgical care, diet, changing a
medication and other topics that can be handled safely and promptly
without an office visit or a frustrating round of telephone tag. And
surveys have shown that e-mail, by reducing the number of daily office
visits, gives physicians more time to spend with patients who need to
be seen face to face.
For patients, e-mail allows them to send their medical questions
from home in the evening, without missing work and spending time in a
doctor's waiting room. In fact, many say exchanges in the more relaxed,
conversational realm of e-mail make them feel closer to their doctors.
The patients can also use the e-mail connections, which they reach through
secure Web sites, to get X-ray and test results and request prescription
renewals. Doctors are not paid for these services, except in time saved
in the office.
This shift toward online doctor-patient communication is important for
another reason. Physicians and health care technology specialists say
they believe that it could help spur the changeover to electronic health
care information systems, which government officials and industry leaders
say is needed to reduce medical errors and promote better care. Doctors
at the clinics of the University of California, Davis, grew accustomed
to using e-mail for clinical purposes before the clinics introduced
electronic medical records, said Dr. Eric Liederman, medical director
of clinical information systems at Davis. The messaging "gave them some
comfort and facility with using the computer," he said.
Early research at clinics at the university found that using e-mail
improved the productivity of physicians, decreased overhead costs and
improved access to doctors for patients, including those who still
telephoned. "There was a huge reduction in the number of calls," said
Dr. Liederman, who is a big fan of e-mail exchanges.
Doctors and insurers say online consultations can be especially useful
for patients who have chronic conditions like diabetes, asthma and heart
problems. They have been frequent users and being in touch can help them
to comply with regimens to cope with their diseases.
"Patients love this stuff; I love this stuff; the staff loves this stuff,"
said Dr. Barbara Walters, a senior medical director at Dartmouth-Hitchcock
Medical Center in New Hampshire.
One benefit of online messaging - perhaps because it can be done in a
setting less harried than a doctor's office - is that it gives patients
a greater degree of control.
"The intelligence of our patients never ceases to amaze me," Dr. Walters
said. "Patients can describe what's going on with them, if given the
chance and given the time." Since last year, several health plans
- Anthem Blue Cross, Cigna and Harvard Pilgrim - have been paying
Dartmouth-Hitchcock $30 for each online "visit," Dr. Walters said. In
some health plans, a co-payment by the patient reduces the insurer's
share. The medical center gives participating doctors credits - an e-mail
consultation is valued at half an office visit - that increases their pay.
Blue Cross and Blue Shield plans in California, New York, Florida,
Massachusetts, New Hampshire, Colorado and Tennessee are beginning to pay
doctors similar amounts ($24 to $30, including any co-payment) for online
consultations. Blue Cross of California has made the program available
to 160,000 of its 6 million health plan members. Last month, Empire
Blue Cross and Blue Shield began testing the payment system with New
York doctors at the Columbia University and Weill Cornell Medical Centers.
Kaiser Permanente, the nation's largest nonprofit managed care company,
has tested patient-physician messaging in the Pacific Northwest and
is starting the program this year in Hawaii and Colorado as part of
Kaiser's $3 billion information technology program. Kaiser's salaried
doctors get credits for messaging, adding to their pay.
System providers say overuse by doctors and fraud have not been
problems. RelayHealth, a secure electronic system used by the Blue Cross
and Blue Shield plans, for example, provides monthly user reports with
names of doctors and patients.
Doctors who use the medical messaging services are advised to limit their
replies to appropriate topics, and, under standard rules, the doctors
reply only to patients who have already been examined in the office.
The records could even be useful in fending off medical malpractice
lawsuits, according to Eric Zimmerman, a senior vice president of
RelayHealth, based in Emeryville, Calif., because allegations based on
undocumented telephone calls are often hard to rebut. "Good communications
with patients is protective," said Frank A. Sloan, an economist at Duke
University who has studied malpractice suits. "This kind of interaction
is helpful."
Many of the health plans promoting Internet consultations are also
introducing electronic systems that keep track of a patient's medical
records and send prescriptions to the pharmacy. For doctors in small
private practices who have hesitated to invest in computerized systems,
the e-mail exchanges are often a first step into the growing world of
health care information technology.
Online consulting is "one of the biggest changes to come to health
care since the beginning of the electronic medical record itself," said
Judith R. Faulkner, chief executive of Epic Systems, a health information
technology company based in Madison, Wis., that is working with Kaiser.
The federal Centers for Medicare and Medicaid Systems is sponsoring
a study of disease management programs, including payments for online
consultations, to help the government decide whether the benefits would
justify the cost to Medicare.
Dr. David J. Brailer, the government's health information technology
coordinator, said online communications between patients and physicians
were "one of 12 strategies to achieve President Bush's goal of widespread
adoption of technology" in health care. But he said more experience was
needed before asking Medicare to pay for those exchanges.
A bill introduced in the House on Feb. 11 by Charles A. Gonzalez, a
Democrat from Texas, and John M. McHugh, a Republican from New York,
for the first time included a provision to authorize Medicare to make
"bonus payments" to doctors for e-mail consultations.
To comply with federal privacy requirements, medical information
technology companies like RelayHealth, Epic and IDX, which is based in
South Burlington, Vt., make secure software allowing only the doctor
and his staff access to a patient's medical records, including the
e-mail exchanges.
Doctors can connect with the secure systems over the Internet from home
computers or laptops if they wish, but overnight messages are typically
answered the next day.
Some employers are embracing medical e-mailing as a way to help maintain
workers' productivity. "Why do I have to leave my office to check out
my sore throat?" asked Dr. Jeff Rideout, corporate medical director of
Cisco Systems, the big Silicon Valley technology company.
Cisco is paying the Palo Alto Medical Foundation for a one-year trial
with the first 500 employees to sign up to see if providing online
answers to medical questions eliminates unnecessary appointments for
employees. The company's health costs have been rising at 10 percent a
year, eroding overall productivity gains, Dr. Rideout said.
Sixty-nine of the foundation's 300 primary care doctors are online in
a system provided by Epic. Dr. Paul Tang, the Palo Alto group's chief
medical information officer, said it charged $60 a year for patients
using the service.
Dr. Tang said most users were people with chronic diseases who were
willing to pay for better access to their doctors. But other medical
groups said they would prefer that insurers pay for e-mail consultations
so there would be no barriers for patients.
The American Medical Association has issued a temporary identification
number for online visits in the association's "current procedural
terminology" code that doctors and hospitals use in sending bills. But
Robert Mills, a spokesman, said the association was waiting for more data
on how clinical messaging was being used before issuing code numbers like
those for office examinations and follow-up visits that payers refer to
in their schedules of fees. "All consumer surveys in the last several
years show patients want to be able to communicate through e-mail or
messaging," said Dr. Thomas Handler, research director at the Gartner
Group, the technology consulting firm. "The problem was, reimbursements
for the doctors weren't there."
That is changing quickly. One pleased consumer, Dona Gapp, a schoolteacher
in New York, who is expecting her first child in April, said she used
e-mail to ask Dr. Richard U. Levine, her obstetrician at the Columbia
University Medical Center, if certain vitamins and nonprescription
medicines were safe for her.
"It was much easier to have access by e-mail," she said. "When I had a
chance to call, it was after 5 o'clock and he was not there." He replied
to her e-mail within hours, she said.
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