E-Doctors: Virtual Visits Give Patients Options

Oct. 10, 2014 -- Lindsay Kolowich wanted to see her doctor for unrelenting pain after her foot surgery. But the operation had already forced her to miss work at a new job, and she didn’t want to ask for more time off.

Instead, she went home at the end of the day, logged onto the Internet, and paid a doctor a virtual visit. Such visits -- via smartphone, tablet, or computer -- are gaining in popularity, and an increasing number of insurance companies and health care providers tout telehealth’s potential to deliver cost savings, efficiency, and convenience without compromising quality.

“The convenience factor was really important to me,” says Kolowich, 23, who lives in Cambridge, MA.

Companies like Teladoc, MDLive, and Boston-based American Well, which Kolowich used, offer 24/7 access to doctors, who see patients via webcam for common, acute problems that don’t require emergency or ongoing care. That includes colds, coughs, rashes, diarrhea, allergies, and other problems.

Though the number of companies offering such services is not clear, the American Telemedicine Association estimates that as many as 500,000 patients will see a doctor via webcam this year, and that number is rising. An August HIMSS Analytics report found that 46% of more than 400 hospitals and doctor practices surveyed reported already using some form of telemedicine, most commonly videoconferencing. Dozens of hospitals and insurers are embracing it, with the number growing rapidly.

The consulting firm Deloitte predicted in August that out of an average 600 million general practitioner appointments in the U.S. and Canada this year, up to 75 million could be e-visits. Even if only 30% to 40% of office visits are replaced by e-visits, that could make up a $50 to $60 billion market, Deloitte found.

A few moments after Kolowich signed up for American Well’s online service, she was filling out a medical history form and selecting a doctor. She chose one at nearby Massachusetts General Hospital because of the positive reviews he had received from other American Well users.

“He walked me through a self-exam,” she says, describing how she flexed her toes as the doctor watched remotely. He then assured her that the pain was normal and made several recommendations, including: avoid excessive walking, take ibuprofen, and watch for any signs of infection. “It was great, and easier than I thought it would be.”

She maintained regular appointments with her surgeon, but the ability to see a doctor when it was most convenient to her helped ease her concerns over her pain.

Paying for Telehealth Visits

Companies often charge a set fee per virtual visit. American Well and MDLive, for example, charge $49. Some companies offer group plans and subscription services. Your insurance company may reimburse you for the cost.

“Insurance coverage was a major barrier a few years ago, but it’s not quite the same today,” says Jonathan Linkous, CEO of the American Telemedicine Association. “Many of the major payers are now the ones providing the support for the expansion of such services.”

But Medicare does not cover video visits unless they’re conducted at a doctor’s office, a hospital, or a rural health clinic, which limits their convenience. Medicaid, on the other hand, does reimburse for some telemedicine services, including virtual visits, in 46 states.

“Clearly, we still have a ways to go,” Linkous says.

Right now, most users include professionals working for companies that pay for the service, he says. Most telehealth companies do not provide pediatric appointments; Teladoc is one exception.

Besides convenience, other reasons may explain the rise in e-visit demand. The Association of American Medical Colleges has warned that barring a dramatic change, there will be a shortage of more than 130,600 doctors by 2025. That could mean longer waits for an appointment.

In addition, virtual visits cost less. Teladoc reports on its web site that without remote doctor visits or teleconferencing, patients say they would have gone to an emergency room, urgent care clinic, or seen a primary care doctor or specialist -- all pricier options.

Types of Services

Patients sign up and pick an available doctor, who diagnoses their problem and prescribes treatment, if necessary. But not all states allow virtual doctors to write prescriptions.

Other services are also offered at varying prices. Kolowich, for example, paid $25 for each of her two visits with an online nutritionist.

“For many patients, telehealth is a lot more convenient,” says Samuel Skootsky, MD, an internal medicine specialist and chief medical officer of UCLA’s Faculty Practice Group and Medical Group. “For employers, it’s attractive because workers don’t have to take off half a day to go see the doctor.”

UCLA Health System recently signed on with LiveHealth Online, a service developed by health insurance company WellPoint in collaboration with American Well. The partnership makes UCLA’s 1,500 doctors available online to people in California. LiveHealth Online, like other such services, is available in all but a few states. “Our doctors will handle 10 to 12 common problems,” Skootsky says. “If patients start describing something that can’t be handled this way, the online doctor will advise them to see a doctor in person.”

Skootsky emphasizes that online health care services are not meant to replace all doctor visits. Ideally, patients will have an established relationship with a primary care doctor.

“But a lot of people don’t have a doctor,” he says. “If they don’t know where to go, they can go to this type of platform. A good experience there may motivate them to establish a relationship.”

Skootsky acknowledges that virtual medicine is a work in progress: “I don’t think the health care profession knows what’s going to work.”

The American Telemedicine Association is at work on accreditation guidelines for virtual providers to follow. Linkous says he expects they will be published before the end of the year. The guidelines will emphasize the importance of transparency, so that users will know exactly what they will get.

Here are some questions that Linkous says all users should ask when visiting an online telehealth provider:

  • Does the site provide all the information you need about the doctor you will see?
  • Does the site explain what types of services doctors can and cannot provide?
  • Does the site explain fees? Is it clear how much you will be charged?
  • Will the site protect the privacy of your medical records? And will they share them, on request, with your primary care doctor?

Virtual visits don’t just use video. At Boston-based Partners Healthcare, for example, their virtual care program primarily uses online questionnaires. A patient who has already established a relationship with a Partners doctor answers questions on a secure web site. Then, his or her regular doctor reviews the patient’s submission and responds with recommendations. If necessary, the doctor will encourage a video visit or a telephone call.

These visits are directed primarily at patients with chronic conditions, which often require frequent appointments.

“Most of the expense in health care is not in UTIs [urinary tract infections] and sore throats; it’s in chronic disease,” says Ronald Dixon, MD, director of the Virtual Practice Project at Massachusetts General Hospital, a Partners affiliate.

It’s a different model than that of American Well and LiveHealth Online, but it offers similar convenience.

What Do Doctors Think?

Dixon and his colleagues have studied their virtual practice and learned that it shaves significant time off appointments while giving patients the same level of care as face-to-face visits. But he says some doctors are not sold on virtual medicine.

“We found that while patients were very satisfied, the clinicians were less so because they could not touch the patients during exams,” Dixon says. “Some clinicians thought that while we can make decisions remotely about their blood pressure, their diabetes, their reflux, or their cholesterol, it’s weird that we can’t touch them. While some like it, some don’t want to practice this way ever.”

Milford, NE, doctor Robert Wergin, MD, emphasizes the need for an ongoing, in-person relationship with a regular doctor. But he sees the appeal of virtual visits, especially for rural patients who may have to drive 100 miles or more to see a specialist. In such cases, he prefers his patients come to his office, where they can both sit at his computer and talk to a remote specialist together.

“I think it’s important to coordinate telemedicine through the usual source of care,” says Wergin, president-elect of the American Academy of Family Physicians.

Even for acute care of simple cases, such as sore throats and colds, Wergin tells patients to see their primary care doctor whenever possible.

“I don’t want there to be any missed opportunities,” Wergin says. “If I have a patient who comes in for a sore throat, I can look at her chart and see, for example, that she has not had a mammogram in 6 years. That’s something I’ll want to talk to her about.”


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