The Internet has transformed the way most service industries interact with their customers, and it’s likely to have the same effect on health care. Despite growing interest in online communication with patients, physicians’ concerns about reimbursement issues, time demands and privacy have prevented many from trying it. The first article in this series discussed the availability of newer, more secure options for online communication with patients which may change that. (See “Want to learn more?”) This article describes ways to overcome other barriers to online communication with patients by examining the reimbursement options available for this type of care and how to successfully integrate online communication into practice.

Reimbursement options

Although a number of physicians, especially those in fee-for-service practices, cite reimbursement concerns as a major impediment to online communication, it can be handled in ways that increase practice efficiency and reimbursement:

Spend less time on the phone. Routine appointment scheduling, prescription refills, billing inquiries, test results and the discussion of common symptoms are abundant in a busy practice but are generally not reimbursed, and they contribute greatly to practice overhead in terms of the personnel time involved and the cost of multiple phone lines. Providing care over the telephone means other office work is interrupted, but providing care online is done at the mutual convenience of both parties. Communicating online also saves documentation time, since the information needs only to be saved rather than written down as would be the case with a telephone service. Even if a practice doesn’t charge for online communication with patients, the money saved by reducing telephone services would be enough in itself to warrant use of online communication.

Charge your patients. In some cases, physicians may be able to bill patients’ insurance companies for online communication. Several years ago, Blue Shield of California and First Health began paying $20 to $25 for “e-visits” for certain chronic illnesses, and now Aetna, United-Health, ConnectiCare and other Blue Cross Blue Shield plans have started pilot programs.¹Some payers will reimburse a fixed amount, such as $25 per communication, and others will allow the physician to collect a patient co-payment for the service ($10 to $20). Since a physician may be able to handle 20 to 30 online communications per hour, this type of reimbursement would be substantial in a fee-for-service practice.

However, Medicare, Medicaid and some other payers do not allow physicians to bill patients for this service under the terms of the physician’s contract with the payer. Consequently, some primary care physicians have opted out of health insurance altogether and instead charge up-front online service fees in cash-only practices.

The hassles of billing patients for each online communication can be avoided by charging the patient a monthly or annual fee for the use of online services. Some online communication vendors, such as RelayHealth (http://www.relayhealth.com) and MyDocOnline (http://www.mydoconline.com), provide the option of billing patients directly for any online communication between the physician and the patient. In my experience, most patients do not abuse online communication, so charging a monthly fee (to a credit card or checking account) of $20 per individual or $30 per family is quite feasible for the practice and affordable for the patient. Indeed, these figures are more than the per-member-per-month fees that most capitated managed care plans pay us for comprehensive care! A practice might also offer discounted annual fees of $200 to $300 payable up-front.

A final note about the cost of online communication: Appropriately replacing visits with online communication actually makes great sense in a capitated environment, where the incentive is to carefully manage the costs of care. Perhaps the mutual convenience of online communication for patients and physicians will give rise to a resurgence of capitation in primary care – hopefully with better results.

Setting guidelines

Online communication is limited in its clinical usefulness since the appearance and voice of the patient are absent. There is no opportunity for a physical examination and no assurance when the physician will receive the message and when the patient will receive the physician’s response. To provide quality patient care with online communication, physicians must set strict guidelines and ensure that patients consent to them and understand them clearly. They should be included in the practice brochure, on the practice Web site and perhaps even on the back of each physician’s business card.

Daniel Z. Sands, MD, MPH, has pioneered the appropriate use of online communication with patients and played the lead role in developing the American Medical Informatics Association’s “Guidelines for the Clinical Use of Electronic Mail with Patients” (available at http://www.amia.org/pubs/other/email_guidelines.html). Here are some of the key guidelines:

• Do not use online communication for urgent matters.

• Establish an explicit turnaround time for messages (e.g., one to three days).

• Have an explicit privacy policy for messages that is agreed upon and signed by the patient. (This can be included in the Health Insurance Portability and Accountability Act Notice of Privacy Practices form.)

• Decide which types of transactions will be permitted online (e.g., prescription refills, appointment scheduling, sharing of test results, communicating symptoms and chronic disease information).

• Inform patients of the proper identification and completeness required with any online communication.

Bringing back the joy

At first, online communication with patients may seem like a cumbersome intrusion into the routine practice of medicine, but once physicians and patients become comfortable with it, mutual satisfaction seems inevitable. For patients, online communication will allow them to connect with their personal physicians from the comfort of their homes. And for physicians, this personal connection with patients, done whenever and wherever the physician wants, may bring the joy of closeness with patients back into the practice of medicine.