At insurer’s new online link, the doctor is always in

Patients often have medical questions that could be resolved with a simple e-mail to their doctor, but physicians have had little incentive to respond outside scheduled appointments. Now they do.

Beginning next year, Blue Shield of California members may choose to consult with their doctors online about such non-urgent concerns as medication side effects, menopausal symptoms and back pain.

Blue Shield, the state’s third-largest health plan (behind Kaiser Permanente and Blue Cross), will be the nation’s first major health insurer to make the online consultations financially feasible. It will reimburse doctors $20 for the Web visits.

The insurer decided to go forward with online consultations based on the successes of a pilot study involving about 250 of its doctors and 2,000 subscribers.

“The idea is to improve patient access,” said Dr. Jeffrey Rideout, president of Blue Shield of California Foundation, who said it remains to be seen how many Blue Shield doctors will want to participate. “When we got results back showing us this saves money, we were delighted.”

A recent analysis, conducted by Stanford University and UC Berkeley researchers, found that the insurer could save more than $1.50 per member per month by giving patients and doctors the option to use the Internet for some medical matters. If 10% of the plan’s current 2.3 million members use the system, Blue Shield would save $4 million a year in office visits, Rideout said. Doctors who tried the pilot program said that reducing the number of patients coming into the office with minor problems gave them more time with patients needing more complex care.

Patients said the online consultations let them get timely answers to questions, saving them a drive to the doctor’s office and inevitable waiting. “If you don’t feel like going out for a doctor’s appointment, all you have to do is go in and describe specifically what is wrong,” said Gloria L. Smith, 51, of Sacramento, who said she also has used the system to make sure she’s taking new medications properly.

Blue Shield is using technology from RelayHealth of Emeryville, Calif., designed to allow confidential communication between patient and doctor. Blue Shield subscribers sign on to the system through the insurer’s Web site.

A series of questions establishes whether they need administrative help -- with setting up an appointment or getting a prescription refill, which can be done through the system -- or whether they need the doctor’s help. The system asks about medical history, medications and the nature and magnitude of their problem, then delivers a detailed message to the doctor.

About a quarter of patient messages result in a return message from the doctor, called an online clinical visit, for which the doctor charges, said Eric Zimmerman, RelayHealth Corp. vice president for product marketing.

Patients in a Blue Shield HMO have a $10 co-payment for the online consultation, while those in a PPO plan typically have to pay for some portion of the visit, said Rideout.

“We’re not trying to have physicians do over the Internet what they wouldn’t feel comfortable doing over the phone,” said Rideout, the health plan’s former chief medical officer. “It’s not meant to be used for anything that’s clinically complex. It’s always meant to be used for established patients.”

Doctors are encouraged to respond to patients within a day. If that much time has passed and they haven’t responded, the system sends them an electronic reminder; it generates a telephone call to the doctor if he or she hasn’t responded within 48 hours, he said. And, if they habitually don’t answer patient queries, Rideout said they can be dropped from the online program.

Among pilot participants has been Dr. Winni Loesch, a family-practice doctor in Sacramento, who said the system lets her get information directly from the patient.

“Normally, patients call and they have to leave a message on voicemail, and it has to be transcribed [by staff] and you have to read their handwriting and hope they took down everything the patient said,” Loesch said.

The online exchanges are particularly useful for patients with minor complaints or those who need to let the doctor know how they’re faring on a new medication or how they’re recuperating. While the online consultations are similar to telephone conversations, for which she is not reimbursed, Loesch finds them more efficient and focused than telephone calls. While on the phone, a patient will often say, “Now, while I have you on the line” and then enumerate other issues the doctor may not have time to address.

Some of her patients like the online access too.

“It’s really more effective [than a short office visit] because I have more time to think about what I’m writing to her and describing it better to her,” said Smith, who works for the state Department of Justice in Sacramento.

Plus, if Smith is in a hurry and forgets to ask something during a scheduled appointment, she knows she can always type it into the computer and get a response within 24 hours.

Smith said online communications with Loesch have helped her manage mood swings and menopausal symptoms following a hysterectomy and control her cholesterol. Of course, Loesch is the ideal participant: She’s comfortable on the computer and finds it easy to check for messages several times a day. Her two partners, she said, aren’t similarly inclined.

Rideout said that one obstacle in getting more doctors onto the system is dispelling the perception that online medicine will add to their workload. Given that, he said: “if we got even 10% of our physicians signed on, we’d be thrilled.”