AHIP Coverage (July/August 2008)
Take Two and E-mail Me at Your Convenience
By Chri stopher J. Gearon
In January, Aetna and CIGNA declared the doctor is in— on your home or work computer, that is. The health plans said they would pay doctors and cover members for “virtual” or e-visits—including secure messaging and e-consults. With this move, these major health plans expanded regional experiments with e-visits to most of their members and physicians nationwide.
Other health plans have taken similar steps to catapult patient communication into the 21st century. Studies show an overwhelming number of American consumers want to communicate online with their health care providers—nearly 90 percent, according to a 2006 Harris Interactive/Wall Street Journal survey.
Issues of reimbursement, patient confidentiality, liability, and physician fear of work overload have slowed the widespread use of patient-physician e-mailing and Web visits, but employers and patients are demanding it as traditional barriers are being crossed. For example, the American Medical Association (AMA) has established a permanent CPT-4 reimbursement code for online consultations, and studies to date on e-medicine indicate it improves provider productivity, reduces office visits, and saves money.
“Members are ready for this,” says Chere Parton, head of Aetna’s Provider eSolutions. The Hartford, Connecticut-based insurer began offering Web visits in 2006 to members and primary care physicians in California and Florida. In 2007, Aetna expanded e-visits to Washington state. The service is offered through McKesson Corp.’s RelayHealth, which provides a secure IT platform for physicians to communicate with their patients.
This year, Aetna has expanded the service to most of its members and physicians, including all primary care physicians and physicians in more than 30 medical specialty categories, nationwide. Through early spring, nearly 7,700 Aetna providers had registered to use Web visits through RelayHealth. Eligible specialties include allergy and immunology, neurology, cardiology, cardiovascular disease, oncology, dermatology, otolaryngology, endocrinology, psychiatry, psychology, gastroenterology, pulmonology, reproductive endocrinology, and rheumatology.
The online visit through RelayHealth is a HIPAA-compliant, clinically structured interview between a plan member and his or her provider on a secure Web server. The member fills out a short clinical survey upon initiating a Web visit. A single, centrally managed database is used for physician-member communications. The Web visit service is set up to help doctors with nearly 150 chronic and non-urgent acute symptoms.
In addition to Aetna and CIGNA, which are covering Web visits nationally, a number of health plans are now offering RelayHealth’s Web visit service in their specific markets. They include Blue Cross Blue Shield of Florida; Blue Cross Blue Shield of Kansas City; Blue Cross Blue Shield of Massachusetts; Anthem Blue Cross of California; Blue Shield of California; Empire BlueCross Blue Shield; Group Health, Inc.; Health Net; Lumenos—in California; and Presbyterian Health Plan.
Physician reimbursement varies by plan but typically ranges from $25-$35, says Ken Tarkoff, RelayHealth’s general manager and vice president.
The virtual visits are just one element of RelayHealth’s platform, which offers a suite of services designed to boost the efficiency of a physician’s practice and the physician-patient relationship. Besides the Web visits, the product offers electronic prescription refills and renewals, lab test results delivery, and requests for appointment scheduling and referrals.
“We recognize, as does the Institute of Medicine, that not all medical visits need to be face-to-face visits,” says Brad Kieffer, Health Net of California spokesperson. Because it saw “promising outcomes” during a pilot about five years ago, Health Net established its e-consultation program for HMO members in California. Doctors serving those members typically are not paid for e-visits directly, since physician groups are reimbursed on a capitated basis, he says.
To date, less than one-quarter of the plan’s contracting medical groups statewide have adopted the RelayHealth e-consultation platform, Kieffer says. “We expect greater adoption among medical groups when there is greater integration between the [RelayHealth] system, or similar functionalities, and electronic medical records,” he says.
While members are ready for the virtual visits, physicians traditionally have been more hesitant. As of last year, less than one-third of physicians were communicating with patients online, according to Manhattan Research.
CIGNA is doing its part to change that, encouraging its 550,000 health care professionals to register for the Web visit service through RelayHealth. CIGNA is “aggressively” recruiting its doctors to sign up for the RelayHealth service, says Wendy Sherry, CIGNA vice president for product development. About 10,000 doctors had signed up through early 2008. CIGNA is promoting the service heavily, picking up the first three months of the service’s costs for doctors. “There is a lot to be had for productivity gains [for providers],” notes Sherry.
CIGNA pays physicians $25 for a Web visit, compared with $75 or more for an office visit. If members are responsible for co-pays for e-visits, which are typically about the same as copays for office visits, the RelayHealth service can either collect the member co-pay via credit card on behalf of the physician or generate a bill to the patient.
CIGNA expanded its virtual house call benefits after initially offering the service to two large customers in 2006. Last year, it broadened the benefit to all members in Arizona, California, Florida, and New York, before opening it up to all providers and to three-quarters of CIGNA members employed by businesses that self-insure.
Currently, 170,000 CIGNA members can access their doctors via e-mail. So far, most of the activity is centered on administrative uses—appointment scheduling and referrals, for example.
But CIGNA expects that clinical usage will increase. “You have to get used to something before it takes off,” notes Sherry.
Through March, 93,000 Aetna members have used the service for prescription refills or appointment scheduling, and the plan has found a “high rate of satisfaction” among members and doctors. But plans emphasize that they are introducing e-visits as a way to extend the physician-patient relationship. “We look at it as an additional service,” Parton says. “It’s an extension of the relationship; it’s not a replacement of the physician-patient relationship.”
The national expansions of e-visits by Aetna and CIGNA came at the behest of employers, says RelayHealth’s Tarkoff. Several employers’ RFPs required that health plans reimburse for online visits and consultations. Some technology companies even are selecting doctors based on ability to communicate with workers electronically. These employers see they can help bridge the gap between consumer demand and physician willingness. “That’s a huge opportunity in the market,” Tarkoff says, adding that Kaiser Permanente has been promoting the ability of its members to e-mail doctors. “It’s just a matter of time.”
All Booted Up
Like many Americans, Traci Allen of Spokane, Washington, depends on e-mail to stay connected with work, family, and leisure-related activities. Unlike most, however, Allen also can rely on electronic communication to stay in contact with her family’s doctors. Allen says she counts her blessings that her family’s Group Health Cooperative (GHC) physicians have all booted up their computers and BlackBerrys to make virtual house calls for non-urgent medical issues.
Consider that her two-year-old son, Keaton, has had 22 ear infections in the last 18 months, or an average of one every three weeks. “It’s so nice just being able to e-mail a question,” Allen says. Even in the information age, most parents and patients are relegated to visiting the doctor, playing telephone tag with physicians, or skipping the doctor altogether. Not Allen, who can fire off a secure e-mail in the middle of the night should Keaton awake cranky. Or she can hold off until morning or whenever else it is convenient. Her son’s pediatrician typically responds within a day.
“It’s free, it’s fast, and the response is quick,” notes Allen. “It saves me time away from work.” The Web visits also feed into Keaton’s electronic medical record, a feature Allen likes, since it allows her to review physician notes. She and her husband have also e-mailed their own doctors, adjusting medication to treating hives.
The service saves more than time. “I’m sure I’ve saved money and my insurance saves money too,” she says. The password- protected Web visits are free to Group Health Cooperative members, whereas office visits require $20 co-pays. In the past year, the Allens have spent more than $1,500 on co-pays for a variety of doctor visits for Keaton, their oldest son. “It would have been significantly more if not for the Web visits,” she says.
Group Health Cooperative physicians and patients have been e-mailing one another since 2000. “I don’t ever want to go back” to doing it the other way, says Allen.
Doctors See Advantages
While Allen and millions of Americans shop, manage finances, and pay taxes online, communication with doctors has proceeded very slowly on the information superhighway. The reason stems largely from physician concerns that e-mail could increase a doctor’s workload without reimbursement for the clinician’s time. Issues of liability and patient confidentiality have also prevented doctors from logging on for patient care.
Many of those traditional barriers now are falling. Secure Web messaging offers a security improvement over e-mail, reducing liability and confidentiality concerns, experts say.
What’s more, programs like RelayHealth don’t require physicians to have electronic health record systems in order to use secure messaging.
In the experience of family practice physician Lisa Rankin, doctors’ fear of online consultation is based more on fiction than fact. “Electronic communication with patients is such an advantage,” says the Port St. Lucie, Florida, physician, who has used RelayHealth for two years. Aetna, Blue Cross of Florida, and CIGNA pay part or all of her $30 Web visit fee, while patients without such coverage pay the fee directly. Of the 8,000 patients in Rankin’s practice, more than 1,000 have signed up for RelayHealth.
The service has helped Rankin’s practice run more smoothly.
“It is very difficult as a physician to be in a short phone call with a patient,” Rankin says, adding she doesn’t play telephone tag as often. Web visits also are more focused than potentially wideranging patient phone calls—which are not compensated—and Web visits get documented as part of the patient record.
Research backs the efficiencies Rankin sees firsthand.
Patient-physician messaging is associated with decreased rates of primary care office visits and telephone contacts, according to a study of 6,400 Kaiser Permanente Northwest members published last summer in The American Journal of Managed Care. Members using KP HealthConnect Online saw adult primary care outpatient visit rates decrease by nearly 10 percent and made 14 percent fewer phone calls to the doctor than those not using online services. “Secure messaging reduces overall physician workload if it requires less time than the replaced visits and telephone contacts,” the article concluded.
Web visits also save patients time and make patients feel closer to physicians when online communication is available.
“The quality of care is perceived by patients to be better when you are available to your patient,” says Ted Eytan, Group Health Cooperative’s medical director, health informatics and Web services.
Web visits and secure messaging work well for many kinds of visits, from bladder and sinus infections to stabilizing patients adjusting to anti-depressants and other medicines, and many standard pediatric visits. Rankin has also noticed that some patients who would not otherwise come in for office visits for financial or other reasons are Web visiting.
Meanwhile, “certain patients who weren’t following up are following up now.” She has also found that “it is a good way to disseminate information to your patients,” whether alerting female patients about free Pap smears or reminding certain patients to get flu shots, for example.
Web visits, however, aren’t always appropriate. As AMA guidelines suggest, Rankin makes it clear to patients that Web visits aren’t designed for emergency care. She tells patients upfront that turnaround for e-visits could be up to 48 hours.
Meanwhile, patients suffering from multiple conditions may not be good candidates for Web visits. E-mail can “aid the health care delivery process,” the AMA says, adding that physicians should use secure e-mailing only for established patient relationships and only after patients are informed about privacy issues. Online consults have limitations in urgent matters, the AMA says.
Tarkoff says that Web visits can boost physician-plan relations because e-visits represent a new health plan reimbursement to physicians, and there are not many opportunities to do that.
“It’s good for consumers, it’s good for physicians, it’s good for health plans, and it’s good for employers,” he says.
Early Adopters Offer Lessons
Despite eight years of Web visits, positive anecdotes, and an emerging body of research suggesting that e-communication with doctors makes sense, Group Health’s Eytan understands an organization’s initial hesitation to adopt e-visits. “When you first do this, you need to take a leap of faith,” he says, but adds the payoff is worth it. “It’s been hugely successful, and I’m confident [Group Health] ushered in a new era in medicine, where health care is designed to meet patient expectations.
The best part is we—physicians, staff, the health system— discovered that our satisfaction with our work is much higher when our patients are satisfied with it at the same time.”
Today, 22 percent of primary care encounters in the Group Health Cooperative system are virtual. That equates to about four e-mails a day for a doctor with 20 patients. “It’s good for all the little questions when you don’t need a visit,” says Eytan. Over the years, e-mailing has become a standard part of the pre- and post-visit ritual among some GHC physicians and patients. “We’ve received a secure e-mail from patients on just about every continent,” he adds. And Web visits have been good for member retention, he says.
Over the last two years, Henry Ford Health System’s Health Alliance Plan (HAP) has found that while e-visits work well for low-complexity acute issues, “we’re finding they are best for managing people with chronic diseases, particularly hypertension and diabetes,” says Dwight Angell, system spokesman.
“It’s been a home run for that group of patients.”
E-visits have been offered by some 250 Henry Ford Medical Group physicians for 20 months. E-visits run $20, but HAP members pay no fee. Patient and physician satisfaction measures are extremely high. “The benefits to patients are numerous—it provides an easy touch point with physicians, [giving them] the kind of information they need to make a clinical judgment.
It also allows us to give RVU [Relative Value Unit] credit to the physician for the work effort. It’s recognition of the time it takes to make their clinical judgments,” Angell says.
Besides finding that online communication with doctors is a significant selling point, over the last three years Kaiser Permanente has also discovered the benefits that free member Web visits bring to chronically ill patients. Mark Snyder, M.D., infectious disease specialist and associate medical director of information technology for Kaiser Permanente, Mid-Atlantic States, notes that many visits with HIV patients, for instance, involve going over lab test results and talking about medication side effects. “A lot of that does not require face-to-face visits.” For example, Snyder has patients living in Baltimore who have to trek to Washington, D.C., to see him. Saving such patients a trip helps them enormously, he says Web visits also help patients better prepare for their office visits. Once Snyder would need to discuss with patients in person whether to start antiviral therapy, its side effects, and other options. Now patients are picking that information up in e-mails and online resources so when they actually come to visit Snyder, patients are asking more sophisticated questions.
As of April, more than 2 million Kaiser Permanente members nationwide were actively using the health plan’s “My health manager” personal health record, the gateway through which Kaiser members can send secure e-mails to their doctors. That’s more than 300,000 secure e-mail messages sent monthly to Kaiser clinicians. In the mid-Atlantic, more than 21 percent of the region’s members use secure messaging. Web visiting “improves the trust and lowers the barrier between patient and physician,” says Snyder. “It is helping to demystify medicine and helping to increase the trust.”
Christopher J. Gearon is a health and financial freelance writer based in Silver Spring, Maryland.
