I love the Internet. I love convenience, and technology. The creation of new inequalities at a time of profound disparities in health care, however, isn’t my cup of tea. So I have mixed feelings about the fact that online medical consultations are gaining steam.
On the one hand, the pluses are obvious. As I’ve written in a previous post, Tom Delbanco from Harvard Medical School estimates that 50 percent of visits to the physician are unnecessary and could probably be dealt with online. Yet a measly eight percent of doctors use e-mail to communicate with patients, let alone set up their webcam to talk shop. That seems foolish.
But, Doubting Thomas that I am, I see some problems with the rise of Internet consultation. Ultimately it seems like another case of wrong-headed priorities. Once again, too much attention is paid to dispensable improvements that don’t address fundamental problems with our health care system. Enough with the bells and whistles already.
Traditionally, the biggest obstacle to online consultation was the fact that insurance companies didn’t reimburse doctors for web-based work. But recently Aetna and Cigna, two of the nation’s biggest insurers, have agreed to reimburse doctors for online visits. Other big dogs in the insurance world are likely to follow suit soon.
With these changes, the anatomy of the web-doc industry is beginning to come into focus. For online consultation to be reimbursed by insurers, paperwork needs to be filled; for doctors to have a booming Internet practice, they need a strong online presence. To help with both of these matters, new companies have entered the fray, with cookie-cutter names like RelayHealth and Medem (“medicine” + “modem”; genius!).
The L.A. Times describes how these companies work:
To begin using these online services, patients visit a doctor’s website or go directly to one of the Internet companies that handle such services…Doctors are typically encouraged to respond to patients within a day; they receive an e-mail reminder if they haven’t, with a phone call on the second day. Prices can vary from $25 to $125, which patients pay with a credit card at the end of the session.
The reason why the price range above is so wide is because doctors can
set their own online consultation fee. On the physician side of things,
the annual cost for Medem services to take care of online
infrastructure is a $395 subscription fee. Doctors pay to play, as it
were.
Right off the bat, it’s clear that the only physicians who will sign up
for these online consultation services are those who can afford to
shell out an extra $400 a year. This may not seem like that much, and
doctors could make this money back by charging their patients for the
service–particularly if they can charge whatever they want for an online consultation.
But this isn’t true for doctors who serve low-income populations. For
them, online consultation is a poor investment. 80 percent of all US
households have at least one computer, but just 58 percent of those
with annual household incomes under $30,000 have a computer at home.
Take into account the fact that doctors who serve Medicaid patients are
already subjected to alarmingly low reimbursement rates–and
the fact that primary care salaries are on the decline—and you can see
that doctors who serve the poor don’t have the wiggle room to incur
another sunk cost.
Unfortunately, it doesn’t look like the poor are getting online any time soon. In 2003, Stanford researchers found that
it will take 20 years for poor households to have the nearly universal
level of computer and Internet use currently seen in richer households.
But this probably won’t happen: rates of Internet adoption are forecasted
to stall for the foreseeable future. The demographics of the web have
more or less matured; the digital divide will be around for a while.
Translation: access to online consultation is predicted by income. And
with socioeconomic status being tightly correlated to poor health, it’s
exasperating to see yet another reform miss out on promoting
accessible, affordable health care to the bottom end of the income
distribution.
Admittedly, the cost of online consultations will likely be lower than
for in-person consultations. So it’s possible that, for those doctors
who do use the service with low-income patients, the latter would
actually save money by using the web. Even if only a few low-income
Americans take advantage of online doctors, those who do may still see
benefits.
But this is assuming that (a) the relative convenience of web
consultations does not drive up their volume and (b) online
consultations serve only to replace unnecessary face-to-face visits—not
to supplement them. Neither of these outcomes are guaranteed.
Indeed, if all goes as swimmingly as online advocates claim, the ease
of web consultations will lead to a spike in minor patient-doctor
meetings. It’s tough to do the math this early on, but you can imagine
a trend where the costs roughly even out: what patients save in
avoiding in-person visits is displaced onto more frequent online
visits. This risk is made worse by the fact that online consultations
are payable only by credit card. With an online system, a doctor’s
visit becomes an impulse buy, a purchase-now-and-pay later proposition.
This is something Americans are quite bad at dealing with: today the
average household has more debts than it does disposable income and the
typical family’s credit card balance is now almost 5 percent of their
annual income.
Another question mark is the assumption that online consultations will
replace in-person visits. I’m not so sure about this. Just as plausible
is the notion that online consultation ends up making more patients pay
twice: once for the Internet powwow and then again for a face-to-face
visit should it be necessary. And who decides if the visit is
necessary? Why, the doctors who can price Internet consultation at
their own discretion, of course.
There’s a real risk of online consultation adding an extra screening
process to doctors’ visits that can inflate health care costs rather
than streamlining them. Particularly given the central health care
ethos in the U.S.–do as much as possible at all times–it seems likely
that the most common response from doctors in online consultations will
not be "it’s nothing, you can take care of it yourself" but rather "why
not schedule an appointment to be sure?"
To be fair, some people will indeed benefit from online
consultations–but they are not the people who most desperately need
the attention of reformers. Consider the work of Jay Parkinson, who is
on the forefront of the web-based health care movement. Working
entirely through IM and video-chat, Parkinson’s patients are primarily
the uninsured—not the systemically impoverished and socioeconomically
isolated uninsured, but rather the self-selecting uninsured: the
freelance artists in Brooklyn, the 18-40 aspiring bohemian crowd, the
hipsters.
Yes, this is anecdotal, but it’s also telling: those most likely to
benefit from the web-doc movement are the young, affluent folks who are
already plugged in. We yuppies are a desirable target market, to be
sure. We are more willing to go into debt than other demographics, more
likely to splurge on technological goodies, and probably wouldn’t spend
a dime on health care unless it was made convenient and culturally
complementary to our want-it-need-it-now mentality. In this sense,
online consultations are a great way for attracting our health care
dollars, most of which the system would never see otherwise.
But if we’re talking about improving access to health care, is this really the right place to start?
In principle, I don’t have a problem with doctors going online. I
understand the excitement and frankly, will probably use the service if
it takes off. But it’s frustrating to see so-called health care
advancements constantly try to tweak the margins when there is so much
more to do. We trot out so-called groundbreaking innovations—miracle
drugs, advanced screening technology, biomarkers, what have you—and
bask in the promise of what “could be”; but we do little to address the
here and now of 47 million uninsured, systemic waste, a lack of
preventive care, and overall poor health. I refer you once again to my
favorite quote on the issue of flash-in-the-pan changes versus real
progress, courtesy of Steve Woolf of the Department of Family Practice,
Medical College of Virginia, Fairfax:
“Each year the nation spends billions of dollars to perfect the
‘technology of health care…and modernize delivery systems, thereby
saving thousands of lives. Correcting disparities in care, however,
would avert five times as many deaths.
“If policymakers adhered to the goal of optimizing population health,
greater priority would go to resolving disparities than to refining
technology, but reverse priorities prevail…Society has the resources to
enable the disadvantaged to attain better health but pursues other
priorities.”
You may think that I`m too conventional but with the face-to-face visit you could eliminate so many misunderstandings. There is no doubt if you have a lighter flu you can ask your physician what would be the best against it that`s a great advantage and you don`t waste time. As one of the Toronto life insurance brokers I claim that an eye-to-eye conversation is more convincing and benevolent. The Internet can provide useful information and possibilities but it never can replace the value of a human relationship.
I’m not sure from this post if these consults are going beyond the phone calls that some doctors will do. I’ve had docs call me for follow up, to discuss a next step after a test — not to diagnose! I think that email can serve as an adjunct for that kind of service. I know that I have played phone tag more than once! Email doesn’t present that problem.
Yes, there is the digital divide issue. There are centers and libraries (which I’ve used for internet access when in the midst of moving for example). I worked with inner city kids about 15 years ago — you’d be surprised how many don’t even have a phone! But, doctors still utilize phones with patients that have them.
One needs to separate the value of online consultation with its ability to change the problems with our health care system. Online consultation is valuable but won’t change the underlying problems. Taking cost out of the equation, there are things that clearly require a face to face visit and many things that can be taken care of online. A quick question handled asynchronously (no phone tag) is convenient and satisfiying for the patient, and time efficient for the physician (providing that patients don’t abuse this). Another possibility is disease management, which I have done on several occaisions. One example would be seeing a diabetic for face to face visit and initiating a plan, having them send me a weeks worth of blood sugar readings, suggest adjustments online, and return for a face to face follow up. This is an ideal set up, and with the digital divide decreasing and the possibility of using other platforms, such as cell phones, this could expand to the poor faster then expected.
The problem is cost.
Primary care physicians continue to see decreasing reimbursement for visits and need to see more patients in less time to make ends meet. Our current system reimburses for procedures, not time spent with a patient. Think of other professionals such as lawyers or accountants. Both will bill for time, including phone calls and paper work. Patients expect that their physicians will call them and fill out forms without having to pay. However, this takes time and also incurs liability. In better times, physicians were happy to provide these free services, but times are changing. Online consultations provide a new way for physicinns to capture revenue that they had previously not collected. Thus, online consultations in some ways are signs of the problems with our current health care system.
Currently, I communicate with my patients online for no extra charge, and actually encourage this practice because it saves me time. However, I am a salaried, university based physician. I don’t think I could afford to do this in private practice.
The only way to solve this problem is to change the way we pay for health care. If physicians are paid for time and prevention instead of procedures and treatment, online consultations could improve health care delivery for many patients.
http://www.drmintz.com
MedBlog Power 8
02/06/2008 – 02/13/2008Next revision: 02/13/2008
(Key: Rank, Blog name, Last week’s rank, Post of note)
Finally a chance to disagree totally with what’s written on Maggie’s blog.
This is complete rubbish Niko. For a start get some basic facts right. Medem & RelayHealth have both in business 10 years–not exactly newcomers.
Second, Internet penetration at home in poor households may be lower than we’d like, but at schools libraries workplaces etc it’s not. And the digital divide feared in the 1990s has not panned out. Especially when you consider cell phone use, where this type of virtual visit is increasingly ending up.
Third, in the place where these types of visits and surrounding communication has been put into place within a rational health care system (Group Health Cooperative of Puget Sound), office visits HAVE been replaced by these virtual visits.
Fourth, many of these visits are reimbursed by insurance. Aetna, Cigna, Kaiser & several Blues do it–because it saves them money. No reason why Medicaid cant too.
Fifth and most important, these types of technologies and those that are coming with them will soon give the power to generalists, including those in the community centers dealing with the poor who have problems accessing specialty care, to more easily integrate virtual specialty care into their practice and enable their patients to access it.
We all want the problems of the health care system to be fixed, but slagging off technologies that have some slight promise to help is not the way to do it.
MedBlog Power 8
02/06/2008 – 02/13/2008Next revision: 02/13/2008
(Key: Rank, Blog name, Last week’s rank, Post of note)
Hospitals (visa Hospitalists) have already taken patients out of the hands of their family practioner, who is able to make sure the hospital staff knows of the special needs of the patient because he/she knows the patient’s medical history cold. A recent NEJM study found that patients did about the same whether they were treated by the family doctors compared with Hospitalists.
The largest study to date evaluating the outcome of in-hospital care showed that care by Hosptialists isn’t noticeably better than by various physician types. The only benefits were to hospitals themselves in saving money, assembly-line treatment, rolling through as many patients as possible in the shortest time possible (and often conducting as many profitable procedures on as many patients as possible). Hospitalists have nothing to do with improving patient care.
The face-to-face visit is more than an eye-to-eye conversation. I was recently reminded of that fact by my physician-brother, who was visiting our mother in the nursing home, explaining to her the purpose of the stethoscope. A seemingly simple instrument used primarily to listen to the lungs, heart, intestinal tract, or blood flow in peripheral vessels. This cannot be accomplished over the internet. The personal contact can reveal volumes of information about the patient, at the moment.
I feel Dr. Mintz has a good point, like hospitals capture revenue with Hospitalists, online consultations provide a way for physicians to capture revenue they had previously not collected. Both, in some ways, are signs of the problems with our current health care system, not a solution to it. I also agree, at least one way to solve the health care problem is to change the way we pay for health care. If physicians are paid for time and prevention instead of relying so much on procedures and treatment, online consultations would not be that necessary.
The value of virtual communication to a patient depends on the situation, in terms of the available technologies and patient need.
For many patients, their initial call to the doctor’s office requires some form of triage to determine in an office visit is necessary and if it’s an emergency. An interactive web session (or responsive email exchange), it seems to me, can be just as effective.
Likewise, a great deal of health information can be obtained via the Internet for risk & wellness assessments. In many states, a patient can even access lab results, and these data can be added to the assessment.
But most importantly, imo, is that these virtual evaluations can examine the mind-body connection, and do it from an integrated sick-care/well-care perspective, by having patients spend all the time they need to complete comprehensive “whole-person” assessments, which is not possible via a face-to-face visit since doctors cannot spend the time. Having a whole person integrated understanding of a patient is important because: (a) Up to half of all primary care physicians’ cases are either accompanied by, or constitute, psychological problems; (b) Psychological problems cause, exacerbate, or impede healing of many physical illnesses; (c) Psychological treatment helps remedy many physical problems and thus reduces overall medical costs; and (d) Improving people’s emotional, mental, and physical functioning leads to increased productivity and a better quality of life. See See http://wellness.wikispaces.com/Tactic+-+Deliver+Biopsychosocial+Healthcare for more.
In addition, virtual visits can be a cost-effective method for answering simple health questions, counseling a patient to comply with a plan of care, etc. Virtual reminders about upcoming exams, medication reorders, inoculations, etc. are also useful. And we will, some day, have advanced technologies for diagnosing health problems, communicating results, generating care plans, and evaluating patient progress and outcomes — all virtually.
We still have a long way to go to make virtual care a reality, but it’s certainly worth the effort.
I add my voice to the (small) chorus of disagreement with the initial post. On-line communication with physicians isn’t likely to be full replacement for anything–be it face-to-face visits or the telephone–but it will be used by increasing numbers of patients in ways that they find valuable. And either party can opt into an alternative mode if they aren’t satisfied with the results of the on-line communication. A gentle correction to Matthew Holt–as a KP senior physician, I can say with authority that we do not reimburse our docs for emails or evisits, it is part of their jobs. Like Group Health of Puget Sound, we are a prepaid integrated health care system, and our physicians are not reimbursed on a fee-for-service basis for anything. I do agree fully with Matthew’s assertion that the digital divide is not as significant as the original posting worries. Our 8.6 million members are not fully reflective of the US population–after all, they are insured–but otherwise, they are demographically like the communities from which they are drawn. They are old and young, low, middle, and high income, and racially, ethnically, and linguistically highly diverse. More than 3/4 report routinely available internet access, and they are voting for these services with their feet. Nearly 2 million of them already have secure log ons (the PHR services on the portal are about 2 years old now), and roughly 80,000 more join per month, with no signs of letting up. They want it and they use it for the things that they find valuable. And that’s why we provide it.
MedBlog Power 8
02/06/2008 – 02/13/2008Next revision: 02/13/2008
(Key: Rank, Blog name, Last week’s rank, Post of note)
Sorry Nikos, another comment to tell you that you have it wrong. The digital divide is rapidly disappearing. Computers with Internet access are nearly ubiquitous and about the only place where your argument may hold some ground is in say some rural area like east Colorado, or the north country of Maine. And even there it is not so much an issue of access to a computer but access tot he Web.
Internet consultations make a lot of sense for the vast majority of the public and while it may not cure all the ills we have today with our healthcare system, this approach is certainly not contributing to making things worse and needs to not only be embraced, but actively promoted.
RelayHealth and Medem are looking to address this issue, both being active since ~2000 (not quite ten years yet Matt) and it is not as expensive as you quote for if you are a member of AMA, annual subscription costs for a physician is $295. Not all that expensive, something that can be easily written of as a business expense and in my mind, provides a value-added service to the patient/customer for Medem also serves as a PHR for that patient. Note, numerous other PHR providers are currently developing such capabilities as well for their solutions.
Also, let us not forget companies like FollowMe, a PHR vendor who is doing some ground-breaking work with rural clinics and migrant farm workers (typically Latino), providing them an online PHR through Mi-VIA. Nikos, missing something like that just tells me you really are not up to speed on what is actually occurring in the market.
Bottom-line, the current healthcare system is being stretched and will only see greater stresses in the future as the baby boomer bulge ages. We simply do not have the resources for face-to-face visits for each and every one of us. Internet consultations, along with retail clinics, txtmed, health sensor-webs in the home will all be needed.
And who knows, maybe if I visit my doc through an online consultation, he’ll have more time for one of those walk-ins that does not have access to the Internet.
As a FYI, personally focusing on these issues in my research which can be found at http://www.chilmarkresearch.com
Virtual Medicine-as we know it, is a infant. ‘Rogue’ online medical services is what the folks at the DOJ/FDA would have us believe. The V.I.P.P.S. pharmacies, (Verified Internet Preferred Pharmacy Services)claim to fame is that one must mail in or have them call your service provider for verification. This is not reimburable for the MD- but the insurance will probably pick up the tab (mail order is VERY cost effective for the insurer-as well as low/no overhead brick and morter pharmacy) via latter credit to your invoice come premium time/co-pay. The ‘Good Housekeeping Seal of Approval’ is a blessing for “Mother’s Little Helpers”
Some relarted websites regarding Statutes and Regulations. http://www.deadiversion.usdoj.gov/21cfr/21usc/ http://www.access.gpo.gov/nara/cfr/waisidx_04/21cfr1301_04.html
From our work with numerous healthcare organizations over the past ten years, about 75% of patient requests by telephone are for non-urgent “administrative” needs… appointment scheduling/changes, request lab results, billing questions, Rx refills, general healthcare questions, etc. where the doctor doesn’t have to be part of the interaction.
I believe that the highest value of a secure messaging service with patients is for these administrative needs and not direct patient-to-physician communications. This is all about decreasing “telephone tag” and patient dissatisfaction with waiting on-hold for lengthy times.
A define benefit of “patient to medical office staff messaging” is productivity gains and a higher degree of focus on in-office patients.
See AskMedica.com for an affordable secure and private messaging service.
We also see that a secure messaging platform with “boilerplate templates” as a means of rapidly communicating in a standardized manner for common repetitive questions. Phone requests with “telephone tag” can consume up to 10 minutes of staff time for a patient request. A template response, with some customization, to a patient’s question can many times be completed in less than a minute.
These tools can drive higher staff work-flow efficiency upwards of 15% and improve patient satisfaction.
Pictures of soma 750 mg..
Cheap soma watson. Soma.
nice one! thanx a lot
You may think that I`m too conventional but with the face-to-face visit you could eliminate so many misunderstandings. There is no doubt if you have a lighter flu you can ask your physician what would be the best against it that`s a great advantage and you don`t waste time. As one of the Toronto life insurance brokers I claim that an eye-to-eye conversation is more convincing and benevolent. The Internet can provide useful information and possibilities but it never can replace the value of a human relationship.
You may think that I`m too conventional but with the face-to-face visit you could eliminate so many misunderstandings. There is no doubt if you have a lighter flu you can ask your physician what would be the best against it that`s a great advantage and you don`t waste time. As one of the Toronto life insurance brokers I claim that an eye-to-eye conversation is more convincing and benevolent. The Internet can provide useful information and possibilities but it never can replace the value of a human relationship.
I just ran across on to your website for the first time. I’m impressed with your approach to the obviously broken system. Nice work! I wish you continued success!
I was looking for significant details with this theme. The data appeared to be vital like me on the verge of start my own, personal webpage.