Law Feature - March 2006
By Erin Prather
A Dallas-based medical service called TelaDoc has some physicians reevaluating the worth of telephone consultations. Is it, they wonder, a case of convenience not necessarily making good medicine?
Patients who subscribe to TelaDoc get direct telephone access to physicians 24 hours a day, 365 days a year, after paying a registration and recurring monthly fee, and completing an online medical history. Registration is $18, while the monthly fee ranges from $4.25 to $7, depending on what plan a subscriber selects. The company has 10,415 subscribers and 15 physicians.
The company charges $35 per consultation. Founded in 2003, its services are available in all 50 states, and patients talk only to physicians licensed to practice medicine in the state where the patient lives. Its Web site (www.teladoc.com) lists the "Most Common Medical Issues Treated" as respiratory and urinary tract infections, allergies, skeletal muscle pain, minor joint trauma (sprains and strains), back problems (acute and chronic), gastroenteritis, arthritic pain, and gastroesophageal reflux disease. It also provides birth control medication (only a month's supply), consultation for international and domestic travel, and immunization planning.
If the TelaDoc doctor thinks it's appropriate, he or she prescribes medications based on the telephone consultation. Although TelaDoc maintains that medication is prescribed only for routine, nonurgent conditions or ailments, some professionals worry the practice falls outside the ethics of good medicine.
One of them is Donald Patrick, MD, JD, executive director of the Texas Medical Board.
"A physical examination is crucial to a patient's diagnosis. Without it, physicians might miss something. This can unintentionally harm the patient."
Dr. Patrick says the board regularly receives complaints from patients "that their doctors only took down a medical history, but did not properly examine them. As a result, the physician missed something. If we find that is the case, that physician is told he violated the standard for care."
And, American Academy of Family Physicians President Larry S. Fields, MD, told the Associated Press in December that establishing a patient-doctor relationship should involve an office visit.
TelaDoc's proponents maintain its services do not replace physical consultation. On the contrary, they say, it complements a subscriber's primary care physician's services. The company's Web site says a TelaDoc physician will refer a patient to his or her primary care physician if it is deemed appropriate.
"TelaDoc is aligned with the most ethical medical practices and has been carefully designed to incorporate strict rules about what physicians should and should not do over the phone," said Robert I. Kramer, MD, the company's senior medical advisor and health care ombudsman . "It does not interfere with the established relationship between patients and their regular primary physician."
TelaDoc physicians do not write prescriptions for controlled substances nor treat patients younger than 12 years. Company President Steven Cooley, MD, says TelaDoc was created to help drive down health care costs and be a more convenient alternative for patients. He adds that the service resolves routine medical issues at a fraction of the cost of a normal visit to the urgent care facility, the emergency room, or the doctor's office.
"Subscribers have to pay only the fixed rate of $35 per consultation instead of the $100 average cost of visiting a primary care physician when it is not necessary to do so. TelaDoc is also an option for patients to manage their health care when their primary care physicians aren't available. It could be a weekend or holiday and patients cannot reach their physician. As an alternative, they contact TelaDoc to address a specific medical need."
Dr. Kramer believes the company also helps both uninsured and underinsured patients. He says that TelaDoc accepts patients with preexisting conditions, and these members pay the same monthly membership fee and doctor consultation fees as everyone else. The service also saves patients time; members receive a telephone medical consult within three hours of contacting TelaDoc or the consult is free.
"I feel very strongly that TelaDoc is helping to improve individual and family access to quality medical care. I believe it is lowering costs for everyone involved. The subscribers we've surveyed say the service is easy to use and that their minor ailments are taken care of before they become major problems," he said.
Responding to concerns about TelaDoc's quality of care, both Drs. Cooley and Kramer point out that every TelaDoc physician is licensed by the Texas Medical Board. Dr. Kramer says the physician-patient relationship begins during registration when patients give their medical history to build a personal electronic health record. The physician sees the electronic record before the patient's telephone consultation.
"You can practice good medicine when you have that kind of information in front of you, whether or not you are seeing a patient face to face," he said. "In my opinion, the medical record constitutes a preexisting relationship between the physician and patient. During the years I practiced, I would receive calls from my partners' patients. I counseled and treated them, even if I did not personally see them. At that time I did not have the benefit of a medical record. Actually, most physicians today don't have the benefit of a medical record before they counsel in those types of situations."
But Dr. Patrick says a proper physician-patient relationship exists only if a doctor's partner has already seen the patient physically.
"If a physician is in a group of 30, he or she is not going to know all of the partners' patients. It's typical for a patient to request medication for a short period of time if they cannot get in to see their actual physician until the following week. It is an acceptable practice because a physician-patient relationship has been established by physical contact. The concern with TelaDoc is its subscribers could be receiving treatment without any sort of physical examination."
A Texas Medical Association Board of Councilors ethics opinion says physicians who treat patients by telephone should not prescribe medications. TMA generally supports the American Medical Association's stance that patients should be able to receive medical information through services such as TelaDoc, provided the service does not prescribe any form of medication.
The Medical Board of California is investigating the company out of concern that TelaDoc's services violate state law.
At press time, the Texas Medical Board had not decided if TelaDoc complies with the state's Medical Practice Act. Dr. Patrick says although there is no specific statute against this particular type of medical practice, he remains cautious.
"Medical care is evolving in a wide variety of ways. We do not know what the future holds for medicine. But even though a consultation can take place over the phone or between two computer cameras, nothing can replace the benefits of a physical diagnosis. I cannot tell you what position the medical board might take, but I don't see a disappearance of the support for personal physicals anytime soon."
Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629.
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