The doctor’s in-box

The doctor-patient relationship is moving online. With 68% of American adults now using the Internet to search for healthcare information, it’s no surprise that many also want digital access to their doctor. Whether they have that option will depend heavily on doctors’ ability to get paid for the service.

Online physician consultations, also called e-visits, are already being used to treat patients for non-emergency conditions and to answer questions about minor ailments, symptoms or medications. According to Meredith Ressi, vice president of research at the health information firm Manhattan Research, about 42% of U.S. physicians say they’ve discussed clinical symptoms online with patients, and more than 9 million consumers report having had e-mail communication with their physician.

As of last year, however, less than 5% of doctors communicating online with their patients were being paid to do so. That’s slowly starting to change as big insurers, such as Cigna, Aetna, a number of Blue Shield plans, Wellpoint and Humana, have begun to reimburse doctors for online clinical consultations.

Payment averages about $30 per e-visit, as compared with $75 to $100 for an in-office consultation. Doctors usually are not paid for “convenience services” done by e-mail, such as scheduling appointments and providing lab results, as is also the case with traditional phone calls doctors commonly make to patients.


Various types of technology are used for e-consults, including simple e-mail but also live online visits using Web-based video or phone through companies such as RelayHealth, American Well, MDLiveCare and SwiftMD.

“Not all issues require face-to-face visits,” says Dr. Kevin Pho, an internal medicine physician at Nashua Medical Group in New Hampshire and author of the popular medical blog, “Face to face visits are inconvenient for the patient and expensive, and I think health insurers are starting to realize that compensating for e-visits can not only be a cost-saving measure but can also help with patient care.”

In addition to lower cost and convenience for patients who no longer have to travel to a doctor’s office for minor medical issues, experts say using e-visits enables doctors to respond more quickly to patient concerns and keep in-office slots open for those who really need to see a physician in person.

According to Paul Marchetti, head of Aetna National Network and Contracting Services, as many as 35% of medical cases could be treated in urgent-care centers, retail clinics or e-visits, instead of the doctor’s office. The company has been paying for online visits, which it offers its members through RelayHealth, since 2006.

Though use among Aetna doctors has steadily grown since then, Marchetti says that only about 1% of its providers have participated in the company’s webVisit program so far.

“It’s emerging technology, and adoption is very slow, but I’ve seen promise over the last few years,” he says. “Consumers have interest, and … they are starting to request doctors get online. The patient population is pressuring providers to adopt it.”

Based on a 2009 study of 8,600 U.S. adults, Manhattan Research estimates that 80 million additional consumers are interested in having online visits with their doctors.

But that kind of demand could break already financially pressured primary-care physicians: Although insurers have started to recognize the value of e-visits, most still don’t pay for them. Neither does Medicare. That makes e-mail communication just one more daily task that primary-care doctors are saddled with and not paid for — a list that is increasing, according to a recent study published in the New England Journal of Medicine.


Security concerns

In order to reimburse, insurers require that e-visits take place through a secure Web portal with high levels of encryption that comply with Health Insurance Portability and Accountability Act (HIPAA) privacy rules. Today, the bulk of the online communication between doctors and patients is done somewhat casually, and not through secure Web environments. That’s a mistake, says Lisa Gallagher, senior director of privacy and security at the Healthcare Information and Management Systems Society, a nonprofit organization promoting the safe use of healthcare information technology.

“Everyone wants to communicate with their doctor via e-mail, but there are security risks,” she says. “You have to find a way to ensure you’re communicating with the appropriate person on the other end. Also, today e-mails become wireless, which adds to the jeopardy,” because security cannot be ensured.

Gallagher says that sending health information to a doctor through a private Gmail or Yahoo account isn’t a safe practice. She recommends consumers communicate online only with healthcare providers who offer a secure site that requires a log-in with a user name and password.


Growing consumer pressure will no doubt force the healthcare industry, which traditionally has been slow to adopt technology, online. But, ultimately, it’s the money that will lead doctors to their computer screens.

“There is no incentive for doctors to change the way they practice without a change in reimbursement,” Pho says.

Thanks to the government, new payment mechanisms are on the horizon.

Currently, 12 states, including California, have laws on the books requiring health plans to pay for telemedicine services. Electronic visits generally fall under that umbrella.


The Federal Communications Commission has also laid out a broadband plan that — in addition to extending affordable access to broadband services to at least 100 million U.S. homes — includes a number of recommendations for deploying telemedicine.

As a result of the new healthcare reform law, a Center for Medicare and Medicaid Innovation has been formed to help facilitate technology that would let doctors meet with their patients through video chats, telephone checkups and in-home monitoring devices.

And most recently, the Department of Health and Human Services issued $220 million in grants to 15 communities around the country for creating three-year pilot programs to test the adoption of healthcare technology, including e-visits.

“With reform, we’ll see a lot more demonstrations,” says Jonathan Linkous, chief executive of the American Telemedicine Assn., a medical telecommunications technology trade group. At the same time, he adds, the infrastructure will be set up to allow e-visit technology to go mainstream.


“Medicare and states and the private insurers are going to move into this as just another way of providing healthcare,” Linkous says. “Five years from now, people will not remember any other way of doing it.”