Physicians and telehealth: Is it time to embrace virtual visits?

Telehealth services hired by employers and health plans are viewed increasingly as competition by physicians and healthcare systems, observers say. Like retail clinics, these services-which offer remote audio and/or video consultations with physicians on mobile devices or desktop computers-handle the kinds of minor acute problems that are the bread and butter of primary care.

A growing number of healthcare organizations are meeting this challenge by partnering with telehealth services such as American Well, MDLive, Teladoc, and Doctors on Demand. Healthcare systems that employ physicians are leading the way into this brave new world of virtual visits. But there are also ways for private-practice physicians to take advantage of telehealth. Indeed, they may be forced to use this technology as more and more of their patients demand it.

Because this trend has emerged so swiftly, many physicians may not have noticed it yet.

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It’s unclear how many healthcare systems offer virtual visits, but it’s likely that the number is increasing. “Any healthcare system with multiple hospitals in a region is likely to consider doing this,” says Jennifer Gingrass, MS, a principal with ECG Management Consultants in Seattle. The competition from telehealth services and other nontraditional players, she adds, “is forcing the health systems to reevaluate how they go about providing care.”

Christi McCarren, RN, MBA, vice president of retail health and service lines for MultiCare, a five-hospital system based in Tacoma, Wash., that already offers virtual visits, notes that other healthcare organizations in her state are doing the same thing. “I think everybody’s going to have this within the next year,” she predicts.

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The same dynamic is playing out in Virginia, where three overlapping healthcare systems are all moving forward on telehealth. Sentara Health Care, based in Hampton Roads, has had MDLive do its virtual visits since 2012. Recently, Riverside Health System, based in Newport News, has followed suit with American Well, and Bon Secours Virginia Medical Group in Richmond, part of the Bon Secours health system, expects to sign a contract with American Well shortly.

Peter Antall, MD, medical director of American Well, says the provider space is the fastest growing part of the company’s business. “Both the large healthcare systems and smaller providers have had their eyes opened,” he says. “They understand that telehealth is here-this is another way that provider-patient interactions can occur-and they’re beginning to find out what fits with their practice and their lifestyle and their patients’ lifestyle.”

Another indication of how quickly this phenomenon is expanding comes from the American College of Physicians (ACP). Wayne J. Riley, MD, MACP, ACP president, notes that many of the association’s 140,000 physician members “are involved in these telehealth initiatives.”

Overall, he says, “we’re very supportive of telemedicine as a way of providing healthcare. It also has the benefit of enhancing patient-physician collaboration. And there are studies suggesting that it can reduce costs.”

NEXT: Outside vs. inside services

Outside vs. inside services

In the early going, healthcare systems that partner with a telehealth service tend to use the vendor’s network of contracted physicians. The service is branded under the name of the healthcare organization, but people who contact it will speak with a doctor who is not their own physician. They usually pay out of pocket at a cost of $40 to $50 per virtual visit.

This approach can expand access to care for patients who often face long waits to see their primary care doctors, notes Claire Spain-Remy, MD, chief physician officer of MultiCare. “We’re trying to help people get care they might delay or might not get if it’s difficult for them to get in and see someone.”

Yet MultiCare and other healthcare systems are exploring the idea of having their physicians use telehealth services to do virtual visits with their own patients.

All three Virginia systems cited above are looking into that. Sentara wants to have its doctors use telehealth for chronic disease care in conjunction with remote patient monitoring, says Sentara Vice President Kenneth Krakaur. But it’s struggling to find the right software partners, he says, so this phase of its telehealth program won’t start until 2016.

Riverside’s primary care doctors are expected to begin doing virtual visits with their own patients in several months, says Barry Gross, MD, chief medical officer and executive vice president of the healthcare system. The physicians are asking for this, he points out, because “they want to have the connection to their own patients.” He adds that some doctors expect to find new patients via telehealth.

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Bon Secours plans to involve its physicians in telehealth from the outset. Robert Fortini, RN, MSN, chief clinical officer of the Bon Secours Virginia Medical Group, notes that the group has recently added primary care physicians as part of its effort to build a value-based care delivery model. Conducting remote consults with people outside of their practices can help these physicians attract new patients, which will also help the group meet its business goal of gaining market share, he says.

“To be effective, healthcare is based on a relationship with a patient, and you don’t have a relationship unless you get an introduction,” he says. “And that’s how I view telehealth--it’s a way of introducing the patient.”

Bon Secours also regards telehealth as a means of reducing health costs for the 13,000 employees in its self-insured plan, while capturing additional shared savings for the 27,000 Medicare patients in its accountable care organization. The average cost of caring for these seniors is about $800 per patient per month, Fortini points out, and much of that cost is generated by people who go to the emergency department because they can’t get in to see a doctor.

“If we can solve the access problem with telehealth and retail”-Bon Secours has its own retail clinics for employees-”we can save a lot of money,” he says.

NEXT: Physicians' mixed views

Physicians’ mixed views

Physicians have mixed views of these new developments. For example, Sentara’s physicians see outside virtual visits as competition, but they believe this is what the market wants, and they’d rather partner with a telehealth firm than not have a partner, Krakaur says. “A few doctors think our medical group should do the virtual visits, but the other doctors don’t see it that way,” he adds.

Riverside’s physicians, in contrast, are eager to do their own remote consults, says Gross. The same is true of some MultiCare doctors, McCarren notes. “Since we introduced Doctors on Demand, we’ve been hearing from primary care physicians who say, ‘when can I do this?’ They see the advantage of being able to do this for their chronic patients, to monitor diseases like heart failure.”

Chronic disease management represents an additional opportunity for virtual visits. While the telehealth firms don’t do it, healthcare organizations see it as an opportunity when their own physicians do remote consults. Virtual visits could also be used for postsurgical follow-ups or for medication reconciliation after hospital discharge, Antall notes.

Whatever they use them for, most healthcare providers have no established workflow for remote consults. Possibly, providers could squeeze in virtual visits at the end of their day, McCarren says. But Spain-Remy adds, “We have to figure out how to optimize providers’ time while making it convenient for patients.”

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Another scheduling issue is that patients expect to have virtual access to doctors outside of office hours. To make that work, some healthcare systems are using telehealth services to “backstop” their own physicians.

Then there is the question of reimbursement. Twenty-four states require private insurers to cover telehealth services in the same way as corresponding in-person services, but there’s a lot of ambiguity in health plan policies, says Antall. Medicare still covers only rural telemedicine visits, although providers can also get indirect reimbursement through Medicare’s new chronic care management program. Most state Medicaid programs cover some telehealth services, but they vary considerably.

If healthcare systems had their own doctors do virtual visits, they’d have to figure out how to pay them for their time, Gingrass points out. Currently, most groups pay physicians on productivity, so they’d have to change their compensation models.

Barry Gross of Riverside agrees that his system’s employed group will have to shift from straight productivity to some other compensation formula. But it will have to do that to accommodate more than virtual visits, he notes. As the group moves into population health management, physician incentives will have to change in any case.

NEXT: Telehealth for private practice

Telehealth for private practice

In theory, physicians in private practice could undertake virtual visits with patients on their own. But they wouldn’t have a secure communication platform or an automated mechanism to collect money for the service. The telehealth services have all of that figured out, and recently they’ve also begun offering mobile virtual visit apps to physicians and patients.

HealthTap, for example, provides mobile apps with its Concierge telehealth service, which enables physicians to do virtual visits with their own patients. Users can also access the service through a desktop computer.

HealthTap began a few years ago as a health advice service. Now it includes a network of about 69,000 U.S. doctors. In addition to Concierge, it sells a telehealth product called Prime that uses some of the physicians in that network.

Ron Gutman, MBA, chief executive officer of HealthTap, says that all network physicians have access to Concierge, but declines to reveal how many of them are using it. The “majority” of the $44 service fee that the company charges for each virtual visit goes to the doctor, he says.

In Gutman’s view, “virtual care augments in-person care. For certain types of care, virtual visits are easier, better and faster and higher quality than office visits.”

Ankush Bansal, MD, a hospitalist in Miami Beach, Florida, uses both the Prime and Concierge services for virtual visits. He does follow-up visits with some patients, such as those for whom he has prescribed a medication, so he regards those as “his” patients.

Bansal says that HealthTap’s fee split has “worked great” for him. The compensation is adequate, he notes, because most of the remote consults take less than 10 minutes. Usually he does virtual visits at the end of his shift or on days off, so they don’t conflict with his hospitalist duties, he adds.

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American Well also has recently started offering a virtual visit service that includes mobile apps designed for patients and doctors. This service “now allows individual physicians to bring telehealth into their daily practice and use it to care for and follow up with their own patient panels,” a company press release says.

The app has a number of workflow features, including a virtual “waiting room” and alerts that let a physician know when somebody wants a remote consult, if the doctor is willing to do virtual visits on demand. In addition, the software includes a feature that enables a physician or a staffer to schedule a virtual visit, notes Antall.

Business model

Most physicians earn less from virtual visits than they would from fee-for-servce office visits, says Joseph Scherger, MD, vice president of primary care and academic affairs at Eisenhower Medical Center in Palm Springs, California and a Medical Economics Editorial Advisory Board member.

But he believes that the concierge or direct primary care model, under which patients are charged a monthly fee for add-on services, can take care of that issue.

His own group at Eisenhower Medical Center has long used such an approach to cover the cost of secure online messaging, and he believes that it could work for other forms of telehealth as well. Under the Eisenhower Primary Care 365 model, patients pay $395 to $595 annually, depending on age, for unlimited email communication and care. The fees make up 55% to 60% of practice revenue, he says.

NEXT: Better continuity of care

Better continuity of care

Scherger sees a big benefit for continuity of care when doctors do virtual visits with their own patients. In his own part-time practice, 40% of the patients have elected to pay monthly fees for online messaging, “and I have greater continuity and deeper relationships with them than I ever had,” he says.

When care is prepaid or doctors are paid for care coordination activities, he notes, “telehealth is an asset, because visits are a time-intensive and wasteful way to address certain needs that could be met by telehealth. Telehealth is a brief and efficient way of answering people’s questions and delivering care.”

Scherger dismisses the opposition of some medical societies and boards to telehealth. “The medical associations are just trying to protect office visits in private practice,” he says. “And they use all kinds of doctor-patient relationship excuses.”

Under the ACP’s new telehealth policy, Riley notes, the association defines the patient-doctor relationship as one that can be established either in person or in a virtual visit. However, he adds, “we don’t look upon it as something that’s episodic or happenstance. Even if you haven’t had a face-to-face interaction with a patient, you can establish a relationship in an initial virtual visit that is built upon continuing longitudinal care of the patient.”

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Remote consults, Riley says, can occur in a wide variety of contexts, ranging from group visits for diabetics to tele-ICUs in which intensivists remotely support ICUs in small hospitals. “It’s a ‘soup to nuts’ approach to telehealth, and we think it’s a very exciting approach that many of our members will embrace and participate in,” he says.

Scherger, meanwhile, advises physicians worried about competition from telehealth and retail clinics to modernize. Along with virtual visits, he says, they might also consider adding secure online messaging.

“Nobody should be more available than you are,” he tells them. “So you need to go online and develop 24/7 access to communication and care. That doesn’t mean you’ll be woken up in the middle of the night for a non-emergency. But in the morning, you or a nurse can download whatever messages came in overnight and address them in a timely manner.”

NEXT: Telehealth legal considerations for physicians

Telehealth legal considerations for physicians

Forty-nine state boards, plus the medical board of the District of Columbia, require that physicians engaging in telemedicine are licensed in the state in which the patient is located. Maryland exempts physicians in adjoining states from requirements to obtain a Maryland license.

• Thirteen state medical or osteopathic boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine. These states include: Alabama, Louisiana, Montana, Nevada (medical), New Jersey, New Mexico (medical), Ohio, Oregon, Pennsylvania (medical and osteopathic), Tennessee (medical and osteopathic), and Texas.

• One state board, Minnesota, requires physicians to register if they wish to practice across state lines.

• Eighteen  states and the District of Columbia require both private insurance companies and Medicaid to cover telemedicine services to the same extent as face-to-face consultations. Those states are: Arizona, California, Colorado, District of Columbia,Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Mexico, Oklahoma, Texas, Vermont, and Virginia.

• Twenty states currently require only Medicaid to cover telemedicine services. Those states are:  Alabama, Arkansas, Connecticut, Delaware, Indiana, Iowa, Kansas, Minnesota, Nebraska, Nevada, North Carolina, North Dakota, Pennsylvania, South Carolina, South Dakota, Utah, Washington, West Virginia, Wisconsin, and Wyoming.

• Three states require only private insurance companies to reimburse for services provided through telemedicine. They are Massachusetts, New Hampshire, and Oregon.

• Nine states do not require any reimbursement parity for telehealth. They are: Arkansas, Florida, Idaho, Illinois, New Jersey, Ohio, Rhode Island, Tennessee, and Virginia.

Source: Federation of State Medical Boards