Billing for online consults

Insurers are finallyreimbursing for e-mailswith patients, butphysicians are worriedabout losing office visits.

More than a dozen health insurers in several states have begun reimbursing doctors for online consultations with patients. But even though medical societies have been pushing for years to get reimbursement for such e-mails, doctors have greeted the news with a big yawn. Not many are doing online consults, even though they can now get paid for them.

Since the beginning of 2004, for example, Blues plans in Florida and Massachusetts have been paying doctors about $30 for online consults, yet only a small fraction of their network physicians are doing them. Robert S. Mirsky, MD, senior medical director, professional programs, for Blue Cross and Blue Shield of Florida, blames doctors' reluctance to adopt health information technology, as well as security and liability concerns. But some physicians also fear that e-mail will cut into their office visits and, thus, their income.

Paul R. Ehrmann, MD, a family physician in Royal Oaks, Mich., has been e-mailing with patients about minor chronic ailments for four years without receiving any reimbursement for it. But even if the local plans offered to pay him, he says, he wouldn't want to expand the practice "because patients would want to use e-mail for everything, instead of coming into the office. And I don't think that's good medical care, especially for serious issues."

Internist Lynne M. Kirk, president of the American College of Physicians (ACP), acknowledges that a reduction in office visits is a "theoretical" problem. But she points out that not every health issue requires a face-to-face encounter; for instance, a hypertensive patient could e-mail a blood pressure reading to his doctor so that he could adjust his medication. Online consultations, she adds, can be a real asset in helping patients manage their chronic diseases and in dealing with minor acute illnesses. Whether an email exchange replaces a visit or leads to one, she says, "Our goal is to give the right care to the patient at the right time." So the ACP hopes that more plans will pay for e-mail.

That's very likely to happen for a variety of reasons, including the desire of employers to increase productivity and to get employees more engaged in their care. Here's how some physicians are dealing with-and embracing-this new medium, and why a growing number of plans are promoting it.

What doctors like-and dislike-about online consults

Leslie D. Wilson, MD, a family physician in Tallahassee, Fla., and his wife, also a family doctor, have been using a secure messaging service for about a year. Aetna and Blue Cross and Blue Shield of Florida are now paying the practice about $150 a month for online consults through the secure messaging service. The Wilsons also receive e-mails through a patient portal-a Web site used for secure messaging-that's attached to their electronic health record. About 20% of their patients have signed on to one of the portals, and the two physicians receive about 15 clinical messages a day. But they're reimbursed only for the consults they do through the messaging service, which most plans are using.

Wilson says he'd probably do online "visits" with patients even if he weren't being paid for them. "It doesn't generate a tremendous amount of revenue, but it enhances your efficiency and increases the communication with patients."

The reason for the increased efficiency, he says, is that the online consults have replaced phone calls. While his staff answers most phone calls after going through a multistep process that often involves him, he responds to more than half of the online messages himself. It doesn't take him much time to answer most of them, he says, because he can easily pull up the data he needs in his electronic health record (EHR).