Getting Paid for Mouse Calls

During the crazy winter flu months, solo internist Frank Dienst in Titusville, Fla., counts on a little help from the Internet.

Because his schedule is sardine-tight this time of year, Dienst has struggled to give same-day appointments or even free phone care to patients with acute problems like sore throats and sinus infections. Now he invites such patients to describe their symptoms in an online message, which he responds to within 24 hours. About one patient a day during flu season visits him via the Internet, and Dienst receives a fee for each encounter. “A lot of things can be treated online,” says Dienst. “Everybody benefits.”

His experience illustrates the potential of what’s called an online consult, virtual office visit, or a mouse call - easy access for patients, and compensation for a doctor’s precious time. So far, however, there’s a big gap between reality and potential. While polls show that most Americans want to exchange e-mails with their doctors, only 36 percent of doctors communicate this way with patients, according to Manhattan Research, which studies healthcare IT. The fear of malpractice - possibly overlooking an e-mail from a patient having chest pain - motivates many holdouts. Another worry is the prospect of unpaid work. It doesn’t help that only 36 percent of patients are actually willing to pay for online consults, according to Harris Interactive.

And making mouse calls profitable is an ongoing experiment. While some doctors have convinced patients to foot the bill, a handful of private insurers make individual online visits reimbursable, reasoning they’re less expensive than face-to-face visits. In fact, they can save employer-sponsored health plans 1.2 percent in medical costs, according to Milliman, an actuarial and consulting firm. Meanwhile, Medicare is more inclined to reward doctors indirectly for mouse calls.

Whatever reimbursement scheme becomes dominant, doctors will feel more and more competitive pressure to connect with patients electronically. New medical companies such as American Well and SwiftMD are based solely on online or phone care, while a New York City concierge practice called Hello Health aims to use e-mail, texting, instant messages, and even video conferences to treat Generation Google. “More than half of office visits are unnecessary,” asserts pediatrician and preventive care specialist Jay Parkinson, founder of Hello Health.

Maybe your vision of the future isn’t that radical, but it’s still a smart idea to virtualize your exam room - and join everybody else on the Web.

How the Web beats the phone

The premise of online consults is that you’re treating the same sort of minor, non-urgent problems of established patients in cyberspace as you would over the phone free of charge. However, the Internet works better. Nobody wastes time playing phone tag, and online communication lends itself to structured interviews that give doctors a better grasp of a patient’s condition. What’s more, every last word is automatically documented, protecting you in case of a malpractice suit.

But mouse calls represent the least common form of online interactions between doctors and patients. What’s really catching on are electronic requests for appointments and prescription refills, bill paying, test-results notification, and completion of preregistration and medical history forms, says Kimberly Labow, vice president of marketing and product management at Medfusion, which provides online communication services to doctors. “Only about 4 percent of our interactions are virtual office visits,” says Labow. “[Virtual office visit] service is ahead of its time.”

Other benefits of relying on online communication also add up. When patients contact you electronically for whatever reason, your employees don’t have to answer the phone as much. That’s good for practice efficiency. “Our staff can spend more time with patients in the office,” says Frank Dienst, whose phone calls have decreased 30 percent since he implemented online communication tools from RelayHealth. And when phones ring less, patients who do prefer to call get through more easily, notes family physician Steve Waldren, director of the Center for Health Information Technology at the American Academy of Family Physicians.

Still, while Dienst is sold on online consults, many colleagues aren’t. Internist Raja Bhat in Wilmington, N.C., worries about lowering the quality of care. “I don’t think this is the place to cut corners,” says Bhat, an otherwise digital doctor with an EMR. “You can’t lay your hands on the patient with the Internet.” But Frank Dienst counters that he would never go online to treat chest pain or shortness of breath, and that patients are warned not to send messages about such emergencies. Plus, he conducts mouse calls only with patients who can be trusted to accurately describe their symptoms. “We generally don’t put unreliable people through the system,” he says.

And while some doctors also fear getting swamped with e-cries for help, that problem hasn’t materialized, by most accounts. In fact, experts tell doctors not to expect windfall revenue from online visits. The heaviest users of online consults via Medfusion conduct only 5-15 sessions per physician, per month, says Kimberly Labow.

That said, Kaiser Permanente’s experience suggests that there’s still enough demand for mouse calls to reduce face-to-face encounters. A Kaiser study showed that patients who communicate electronically with their doctor schedule 7-10 percent fewer office visits per year. Note that such a decline wouldn’t financially hurt a salaried Kaiser physician in a capitated system, but it would hurt a fee-for-service doctor, especially since office visits usually pay more than their online counterparts.

Regular e-mail vs. secured messaging

In the HIPAA era, doctors understandably worry about e-mail’s privacy. Accordingly, many doctors turn to a technology called secure messaging, which banks and retailers use for online business. Unlike regular e-mail from the likes of Yahoo or Google, secure messaging is encrypted (just one of its safeguards). It’s recommended by organized medicine, private insurers, malpractice carriers, and the U.S. Department of Health and Human Services.

Here’s how secure messaging works: A patient logs in at a password-protected Web site to send an encrypted message to his doctor. Once the doctor replies, the patient is notified by regular e-mail that a message is waiting for him at the same Web site where the dialogue started.

While ordinary e-mail invites rambling messages from patients, secure messaging usually engages them in a structured interview that pinpoints the nature, location, duration, and severity of symptoms. Even so, patients still need an area for free text, says Kansas City internist Carrie Lehr, who uses Medfusion software. “The questionnaire may not address the patient’s every problem,” says Lehr, who persuaded Medfusion to add a free-text box to its program.

Doctors can implement secure messaging through physician connectivity companies such as Medfusion, RelayHealth, or Medem. You either plug their communication tools into an existing practice Web site or use an interactive site they supply. Medem charges $595 per doctor, per year for an interactive site; $495 if you belong to an affiliated medical society. RelayHealth and Medfusion charge $100 and $150 per physician, per month, respectively, for their services, which for RelayHealth includes e-prescribing. If you want Medfusion to build a Web site for you, you’ll pay a one-time charge of $1,000 per doctor.

Another route toward secure messaging is purchasing an EMR with an optional “patient portal” where patients can ask medical questions, request appointments, and the like. EMR vendor eClinicalWorks, for example, charges an additional $75 per physician, per month for its portal.

Still, despite the sophistication and data security of secure messaging, and despite endorsements from healthcare heavyweights, most doctors continue to use regular e-mail for online care, according to Manhattan Research. Doctors naturally like the price - usually zilch - and patients find regular e-mail easier to use because there’s no additional site to visit or password to remember.

And these medical G-mailers and Hotmailers aren’t necessarily violating HIPAA. The federal law doesn’t prohibit regular e-mail, nor require encryption, although it does encourage doctors to consider it. To play it safe, ask patients to sign a consent form warning them about the unsecure nature of regular e-mail, especially company e-mail that an employer can peruse. Google “e-mail consent form” and “medical” to find examples that you can customize.

Fee for service subscriptions

If you don’t want to give away online care, you can choose between two payment models. The first is fee-for-service. Family practice physician Naureen Mohamed in Williamsville, N.Y., for example, asks patients to fork over $35 through PayPal at her Web site before each mouse call. Once they do that, they describe their symptoms in a structured interview, transmitted to Mohamed by regular e-mail. With secure messaging, patients typically pay out of pocket by credit card.

A slowly growing number of private insurers also reimburse online visits one at a time, provided you submit CPT code 99444. Aetna and Cigna have done so on a nationwide basis since early 2008 but only if doctors use RelayHealth as the medium. Insurance reimbursement ranges from $25 to $35 per visit, according to RelayHealth. A transaction for Dienst looks like this: Patients hand over any copay to RelayHealth with a credit card number kept on file. RelayHealth collects the remainder of the fee from the insurer. Then, once a month, the company cuts Dienst a check for all his online consults during that period.

But charging visit by visit can get tedious. The alternative is assessing an annual fee for unlimited online consults. The Palo Alto (Calif.) Medical Foundation sets this fee at $60 for person. However, if a patient wants to electronically request a prescription refill or appointment, that’s free. Similarly, concierge practices, including Hello Health, include e-mail access as one of the services covered by their annual fee.

Insurers have yet to offer doctors global payments for online visits, but something close to that is emerging with the medical-home model of primary care. Insurers pay you extra - perhaps a monthly lump sum - for managing and coordinating a patient’s care on top of fees for individual services. One way doctors can create a more welcoming medical home, the argument goes, is by offering the convenience of 24/7 online communication.

That’s the thinking, at least, at Medicare, which is reluctant to reimburse mouse calls on a piecemeal basis, lest doctors suddenly get adept at e-mail. In 2009, Medicare will recruit 2,000 doctors to participate in a nationwide medical-home pilot project that would award a monthly care-management fee per patient (not all patients are eligible). Depending on the doctor’s qualifications, the overall monthly fee would be either $40.40 or $51.70.

Multiply a hundred or so patients by forty bucks a month, and it’s easy to see how the medical home concept could rev up a practice’s revenue. If the Medicare pilot succeeds, it could set the standard for private insurers, which are conducting their own experiments. You’d then have a powerful incentive to switch from the phone to the Web for communicating with patients between office visits. Years from now, you might wonder how you ever got along without mouse calls.

Robert Lowes is an award-winning journalist based in St. Louis who has covered the healthcare industry for 20 years. He can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the March 2009 issue of Physicians Practice.