Going Online

Texas Health Plans May Soon Pay for Online Patient Encounters

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Medical Economics Feature - March 2007

By Ken Ortolon
Senior Editor  

Abilene family physician Timothy Martin, MD, believes online communication between physicians and patients is a trend that will only continue to grow. About a year ago, he signed up with RelayHealth Corp., a provider of online physician-patient communication services, so he could correspond online with his patients and conduct clinically structured, secure medical evaluations over the Internet.

"I wanted to be familiar with online communication and use it, because someday it's going to be a standard part of an office practice," he said.

Dr. Martin charges a small fee for some of the online evaluations, which patients pay out of their own pockets. But soon, patients' health plans may reimburse physicians across Texas and the rest of the country for online consultations. Already, more than a dozen health plans in states such as California, New York, and Florida have partnered with RelayHealth to offer benefit plans covering Web-based consultations. And, at least two plans are considering expanding such offerings to Texas, possibly this year. (See "What RelayHealth Offers.")

Officials with RelayHealth and the health plans say online medical evaluations not only could produce a new revenue stream for and improve the efficiency of physician practices, but also provide convenience for patients and save costs for employers offering such coverage.

"Today, the only way an outpatient practice or an ambulatory practice is going to make money is if the patient comes into the office," said Ken Tarkoff, vice president and general manager of consumer solutions for McKesson Corp., parent company of RelayHealth. "Now, there's actually another way for them to generate revenue. It also creates some tools to allow them to better manage some of their sicker, chronic patients." 

Gone toTexas  

While other companies provide communication services for reimbursable online medical evaluations, most of those services require patients to pay the bill themselves. RelayHealth appears to be the only company offering a direct link with health plans to cover online consultations.

Currently, RelayHealth has contracts with 14 health plans across the country that cover online visits either in all or some of their plan offerings. In addition to California, New York, and Florida, such coverage is available in Massachusetts, New Mexico, some areas of the Midwest, and Washington state.

No Texas health plans currently offer coverage for "webVisits," the term RelayHealth uses for online medical evaluations, but Mr. Tarkoff says he expects 2007 to be a big year for his company in Texas.

"We have numerous health plans that are in discussion with us about the Texas market," he said.

Officials with Lumenos Inc., a subsidiary of WellPoint Inc., which largely offers consumer-directed health plans for self-insured, large employers, says they are talking to a major health system in Dallas about covering online physician visits for its 14,000 employees. CIGNA Healthcare also is eyeing the Texas market, but does not have immediate plans to offer such coverage here. CIGNA covers webVisits in other markets.

Michael D. Parkinson, MD, MPH, executive vice president and chief health and medical officer for Lumenos, says his company is interested in online communications to reconnect the financing of health care with improved physician-patient relationships. "Finding new and innovative ways that are efficient but also reimbursable for doctors to connect with patients is of value to patients," he said.

Not only is it more convenient for patients than having to take time off work to go to the doctor's office, says Mr. Tarkoff, but it also gets patients more involved in their own health. Because contacting their physicians online is easy, he adds, patients do not wait as long to seek care, thus avoiding more costly illnesses that might send them to the emergency room.

Wendy Sherry, CIGNA's assistant vice president for strategy, products, and marketing, says her company offers the coverage to employers because of the opportunities to reduce health care costs.

"An office visit to diagnose a simple, routine type of medical condition could be anywhere from $65 or $70 or even more," she said. "An online visit tends to run more in the $25-to-$30 range." 

Becoming More Productive  

While cost may be a major driver of this new technology, increased productivity for physician offices also may spur widespread adoption of online medical visits. RelayHealth officials say a recent study at the University of California at Davis indicates that physicians who fully adopt online visits in their practices can see roughly 11 percent more patients in a day.   (See   "TMA Urges Physicians to Follow Online Consultation Guidelines.")

Dr. Martin says he likes communicating with his patients online because it cuts the volume of phone calls to his office.

"Our biggest complaint around here, customer service-wise, is the phones," he said. "[Online communication] is less disruptive to the flow of my daily practice, and we probably can be more precise in the information we share with patients."

Dr. Martin says the volume of webVisits he conducts is still small, but the templates of questions asked of patients who log on for webVisits are very thorough.

"When I've gone through the questionnaire and the patient has answered all the questions and typed in other symptoms, I feel like I've got a thorough understanding of the history going on," he said.

While it's only a matter of time before health plans begin offering coverage for online consultations in Texas, plan officials say how quickly they begin marketing such products largely depends on RelayHealth's success in selling its services to Texas physicians.

Currently, RelayHealth has more than 18,000 health care professional subscribers across the country, but the company declined to state how many Texas physicians subscribe, adding that Texas numbers are low because the state has not previously been a target for its marketing efforts. That should change as Texas health plans come on board.

"This is somewhat based on RelayHealth's ability to build out their network of providers," Ms. Sherry said. "It doesn't make a lot of sense for us to move into a marketplace where RelayHealth doesn't have a strong presence with the provider community."

Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or email  Ken Ortolon.  


What RelayHealth Offers

RelayHealth Corp. is one of a growing number of companies offering personal health records, online physician-patient communication, electronic prescribing, and other online health services. But it appears to be the only one offering a direct link to payment for online consultations by health plans.

"While there were certainly other vendors out there offering some semblance of the services that Relay offered, they were clearly the leaders in this space," said Wendy Sherry, assistant vice president for strategy, products, and marketing at CIGNA Healthcare.

Online consultations are provided through structured clinical encounters that RelayHealth calls "webVisits." To conduct a webVisit, both the patient and the physician must sign up for a RelayHealth account. Patient accounts are free, but physicians pay a monthly fee based on the size of their practice and the number of services they subscribe to. Ken Tarkoff, vice president and general manager of consumer solutions for RelayHealth's parent company, McKesson Corp., says a solo physician who orders RelayHealth's full suite of services would pay less than $100 per month.

Patients can request webVisits for roughly 150 different medical conditions, ranging from chronic illnesses such as asthma and diabetes, to nonurgent acute symptoms such as back pain, colds, and more. Each condition has a template of questions the patient must answer. There also are safeguards to make sure the patient seeking the webVisit is an established patient of the doctor in question.

Physicians have the option of charging the patient for webVisits or waiving the fee. If the patient is paying the bill, RelayHealth charges his or her credit card. If the patient is on a health plan that covers online consultations and has a contract with RelayHealth, the company automatically files a claim with the carrier on behalf of the physician. Payment is made to the physician similar to any other claim the physician might file with that carrier.

Abilene family physician Timothy Martin, MD, has been using RelayHealth for webVisits, appointment scheduling, and other patient communication for about a year. He says he frequently waives the webVisit fee if he feels the encounter doesn't merit a charge. When he does charge, he says his fee is set below average insurance copayment amounts.

"I can set my charge, so the patients feel like they're getting a good deal," he said. "They don't get charged until the end, and I'm the one who decides whether they get charged or not. If I don't feel like it was worth a charge, then I unselect that box and they don't get charged."

Among other services RelayHealth provides physicians are online appointment setting and lab results, electronic prescriptions, secure colleague messaging and e-referrals, patient education materials, and more. Patients also are offered personal health records that both their primary care physician and any specialists they see can access.

Medem, a physician-patient online communication company founded in 1999 by the American Medical Association, the Texas Medical Association, and several national medical specialty societies, offers similar services, including personal health records, secure messaging, and online consultations. Medem, however, does not submit claims for online consultations directly to carriers.

For more information about services offered by RelayHealth, visit the company's Web site at www.relayhealth.com. More information about services offered by Medem can be found on its Web site at www.medem.com.

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TMA Urges Physicians to Follow Online Consultation Guidelines

Texas physicians thinking of entering the world of online patient-physician communications should take a moment to familiarize themselves with guidelines for these encounters developed both by organized medicine and the Texas Medical Board (TMB).

Both the American Medical Association and the Texas Medical Association have adopted guidelines covering electronic communication with patients and fee-based online consultations.

Under TMA House of Delegates policy 290.009, originally adopted in May 2001 and amended in 2003 and 2004, physicians are urged to have written policies in place covering electronic patient communication. Such policies should cover such issues as avoiding emergency use, heightened consideration of use for highly sensitive medical topics, appropriate expectations for response times, hours of operation, patient-identifying information that should be used in all communications, types of transactions that will be permitted electronically, and quality oversight mechanisms.

The policy also says online communications between physician and patient should be conducted over a secure network, with provisions for authentication and encryption in accordance with eRisk, the Health Insurance Portability and Accountability Act, and other appropriate guidelines. The physician is responsible for taking reasonable steps to authenticate the identity of correspondent(s) in an electronic communication and to ensure that recipients of information are authorized to receive it.

When conducting fee-based online consultations, physicians should ensure that such consultations occur only within a previously established doctor-patient relationship, must obtain the patient's consent to participate in the consultation for a fee, must maintain records pertinent to the online consultation as part of the patient's medical record, and must disclose the fee at the outset of the consultation.

TMB rules adopted in 2004 also lay out requirements on physicians using the Internet in medical practice. Those rules require physicians who use the Internet to:

  • Establish a proper physician-patient relationship that at a minimum includes making sure the person requesting the treatment is in fact who the person claims to be;
  • Reach a diagnosis by using acceptable medical practices such as patient history, mental status examination, physical examination, and appropriate diagnostic and laboratory testing to identify underlying conditions and/or contraindications to treatment recommended/provided;
  • Discuss with the patient the diagnosis and the evidence for it, the risks and benefits of various treatment options; and
  • Ensure the availability of the physician or coverage of the patient for appropriate follow-up care. 

"Treatment and consultation recommendations made in an online setting, including issuing a prescription via electronic means, will be held to the same standards of appropriate practice as those in traditional (face-to-face) settings," the rules state. "An online or telephonic evaluation by questionnaire does not constitute an acceptable standard of care."

However, the online questionnaire used by RelayHealth does not violate TMB rules.

"This method of communication is considered to be an enhancement to the practice rather than a new type of practice and would be used much like the telephone, in an established physician-patient relationship," said TMB spokesperson Jill Wiggins.

"It would be used for diagnosis and treatment of an ongoing condition, and it would be up to the doctor to determine if that is adequate or if the patient needs to be seen. In addition, the records must be kept in the patient's chart just as any other medical record, whether it's by e-mail or an online form."

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