Patients are eager to communicate with physicians and other providers by e-mail, and physicians are warming to the idea. But payment issues are bottlenecking efforts to adopt this patient-friendly practice.

The Value Potential

The buzz around patient-physician e-visits is enough to intrigue any healthcare leader.

  • The use of patient-physician e-mail among Kaiser Permanente members with diabetes and/or hypertension was associated with improvements on various quality measures, including blood pressure control (see exhibit below).
  • As of mid-2009, nearly 30 percent of outpatient "encounters" between Group Health Cooperative providers and members occurred through secure electronic messaging, which is similar to secure e-mail.a That online interaction is an essential component of Group Health's medical home model, which has reduced emergency department visits by 29 percent, hospitalizations by 6 percent, and total cost of care by an estimated $10.30 per member per month.b  

View Exhibit 

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As tantalizing as these studies are, they should not give the impression that e-visits are about to become mainstream, says Joseph C. Kvedar, MD, director of the Center for Connected Health at Partners HealthCare System in Boston. While a few integrated systems such as Group Health and Kaiser are using e-visits to help drive the transformation of healthcare delivery, most providers are just looking on in envy.

Of course, many health systems encourage patients to go online to pay their bills, request appointments, preregister for services, and review laboratory results. But actual online physician-patient encounters-for which the physician is paid-constitute an "infinitesimally small slice of the pie," says Kvedar. "The vast majority of care is still taking place between two people in a room somewhere."

Nearly 40 percent of U.S. physicians communicated with patients online in 2009, according to a Manhattan Research survey reported by the American Medical Association (AMA). But most of these physicians did not get reimbursed by an insurer.

That is because most physicians-whether they are independent or employed by a hospital or health system-are not set up with the technology or the insurance contracts to allow for reimbursement.

That includes physicians in the Partners system. Kvedar is one of the nation's top advocates for delivering patient care outside the traditional medical setting, but when he exchanges e-mail with his dermatology patients, he is not reimbursed for his time-and he does not expect that to change in the immediate future.

Kvedar cites three barriers to widespread adoption of e-visits:

  • Although patients want e-visits-in fact, the California Healthcare Foundation reports that 78 percent of survey respondents say they wish to interact with their physicians online-Kvedar's research suggests patients want e-visits in addition to face-to-face contact with their physicians, not as a replacement. That makes payers wary that e-visits will be an added expense.
  • Physicians who grew up with e-mail are open to communicating online with patients. However, physician enthusiasm will be mixed until the older physicians retire.
  • Payers currently reimburse for e-visits at a lower rate than for office visits, creating a disincentive for physicians to substitute an office visit for an e-visit.

Kvedar believes those barriers will melt away when the fee-for-service payment system is replaced by systems that incentivize providers to improve the quality of care and lower costs. That is why physicians and hospitals that are integrated with insurers-or preparing to enter into risk-based contracts-are at the forefront of online care.

"You better believe that when we get into bundled payments and capitation, providers will be much more incentivized to use these alternative forms of care," says Kvedar. "That points to adoption of e-mail visits eventually. But adoption will be slow until we get beyond both the economic and the psychological barriers."

Getting Paid for Electronic Visits

In 2008, the Current Procedural Terminology (CPT) code 99444 was created to allow billing for e-visits. But much of the online communication between physicians and patients-such as an e-mail follow up after an office visit-does not meet the criteria required for the code.

Like the codes for telephone visits (see sidebar), the code for online visits requires that the patient initiate the visit, which is not related to an office visit in the previous week. Also, any follow-up telephone calls and communication regarding laboratory or imaging orders are considered part of that visit.

CIGNA and Aetna have been reimbursing physicians for e-visits conducted via a vendor's proprietary online healthcare communication service since 2006. In January, Blue Cross of California began reimbursing physicians for e-visits through another online service provider, and many other insurers around the country have started reimbursing physicians as well.

That said, reimbursed visits are relatively uncommon. "It's going well in those places where people are willing to try it, such as larger cities where a lot of office workers are used to interfacing with people on the computer," says Joe Mondy, a CIGNA spokesman. "But it has not gotten the kind of penetration that we had hoped for nationally."

CIGNA pays physicians $25 for an e-visit; Aetna pays $30. All physicians in their insurers' networks are eligible to provide e-visits, if the physicians subscribe-for a fee-to the service provider the insurers use.

While only a few payers are reimbursing for e-visits, a growing number of physicians are offering online visits as a self-pay option, says Rosemarie Nelson, a practice management consultant for the Medical Group Management Association. The popularity of drugstore "quick clinics" has convinced physicians that patients are willing to pay out-of-pocket for convenient care for minor medical services, she says. Physicians see e-visits as a way of competing with quick clinics for their own patients.

At the same time, physicians are advocating for better pay for online care. In June, the AMA House of Delegates urged Medicare and other payers to adequately reimburse physicians for electronic visits. Although the AMA has sought such payment for a decade, its amended policy calls for the organization to advocate for "pilot projects of innovative payment models be structured to include incentive payments for the use of electronic communications such as Web portals, remote patient monitoring, real-time virtual office visits, and e-mail and telephone communications."

One Health System's Experience

Fairview Health Services, a seven-hospital system in Minnesota, is one of those forward-thinking organizations that is working toward the goal of becoming an accountable care organization by 2012. To that end, Fairview is working quickly to fundamentally change the way care is delivered with three goals in mind: reduce the total cost of care, improve quality, and improve the patient experience.

Fairview's 40 primary care clinics are experimenting with new ways to provide care, engage patients, and respond to patients' preferences and schedules. In addition to group appointments and nurse-only visits, Fairview's strategies include e-mail and phone visits. R. Andrew McCoy, Fairview's vice president of revenue management, believes nonface-to-face visits will eventually account for up to 30 percent of physician-caregiver visits.

But introducing e-visits is not easy, he says. When Fairview approached its payers about the e-visits and phone visits, the payers were willing to add these types of alternative visits to their contracts with the health system. However, when patients started connecting with their caregivers through e-mail and phone earlier this year, it quickly became clear that the visits were not covered by the patients' policies.

"There's a disconnect within payer organizations between the salespeople that sell policies to employers and the departments that do contracting with providers," says McCoy. "That's the gap that we're trying to bridge now."

He has been working with payers to solve this problem and hopes that, in 2011, most employers will update their benefit plans to include e-visits. But the experience has made him somewhat reticent about online communication.

"Some payers and employers assume that providers are using these phone and online consultations as a way to generate more revenue," says McCoy. "But that's not what we're trying to do. We're trying to create a better way to interact with the patient in a way that's more efficient for the patient."

His advice to other health systems: Be prepared to educate insurers about the patient-friendly benefits of online care, and make sure the insurers are educating their employer customers.

"You need make sure that these types of visits will be covered in a standard benefit set," he says.

Related Sidebar:Coding for Telephone Visits  


a. Ralston, J.D., et al, "Patient Experience Should Be Part of Meaningful-Use Criteria," Health Affairs, April 2010, vol. 29, no. 4, pp. 607-613.

b. Reid, R.J., et al, "The Group Health Medical Home At Year Two: Cost Savings, Higher Patient Satisfaction, And Less Burnout For Providers," Health Affairs, May 2010, vol. 29, no. 5, pp. 1-9.

Publication Date: Monday, September 27, 2010