Insurer to pay physicians for e-mail consultations

Project returns physicians to disease management

In an effort to ensure that chronically ill members get the most effective and efficient health care services, BlueCross BlueShield of Tennessee has developed a pilot project to pay physicians for e-mail consultations, telephone calls, and group visits with members with diabetes, hypertension, or congestive heart failure.

"We’re developing a disease management program that puts the doctor back in the middle of the game," says Steve Coulter, MD, senior vice president and chief medical officer for the Chattanooga-based insurer.

The pilot project, which started May 1, involves about 1,300 physicians, representing 10% of the health plan’s physician network and will be tested against the company’s traditional integrated disease management programs.

About 3,000 patients have been selected to participate in the program. They will have the option of continuing in the standard disease management program or participating in the physician-centered program.

The company will pay physicians $25 for an e-mail, $25 for a telephone call, and $20 per person for a group visit with chronically ill patients who choose to participate in the program. Patients do not have a copay for any of those services, unlike with office visits.

The company also may reimburse for services provided by nurse clinicians, such as diabetic nurses who work in the physician office.

"The whole goal of an incentive program is to try to get someone to do something you want them to do," he says.

Physicians would like to spend more time giving advice and assistance to help patients manage their chronic illnesses, but most simply don’t have the time to provide a service for which they’re not reimbursed, Coulter points out.

"The purpose of a good disease management program is to empower the patient with the knowledge of the disease, the tools to help them manage the disease, and a support structure to facilitate the process. We’re not trying to intrude ourselves into the doctor-patient relationship. One of the problems with disease management programs is that people perceive them as being too much meddling by the insurance company," he says.

The insurer is providing physicians in the pilot project with an interactive e-mail tool by RelayHealth Corporation, an Emeryville, CA-based provider of on-line physician-patient communication services.

The e-mail program prompts the patient to give the right kind of information so the physician can give the right advice.

Physicians also may bill for telephone calls and for group visits for the purpose of educating patients about their disease. A few physicians have tried group visits for their chronically ill patients, Coulter says.

The aim of the pilot project is to test ways to realign incentives for the players in the health care system, Coulter says.

"All of the players in the health care system, whether they’re patients, doctors, employers, payer, or hospital, have the same fundamental set of values. We just need to get the incentives to line up with those values," he adds.

Fee-for-service medicine encourages physicians to do more complex procedures, while the capitation system creates incentives for physicians to do too little, Coulter says. "These systems have created an inherent mistrust that is part of the overall rebellion against managed care," he adds.

The idea for the project came from a brainstorming seminar the insurer held for representatives of large employers, hospital administrators, physicians, and academicians at Vanderbilt University in Nashville, TN.

The objective was to develop a pilot program that would better align the incentives of patients, physicians, and insurers.

"The providers made the point that our current system just doesn’t create incentives to practice quality medicine. It creates barriers. We do pay for coronary bypass surgery, but we don’t pay for low-cost interventions like phone calls and e-mails," Coulter says.

Low-cost interventions produce more value for the dollar, particularly with people with an ongoing chronic disease who need guidance and advice on a regular basis, Coulter says.

"At this point, we’re offering incentives to try to move the barriers. Next, we plan to attach incentives to program metrics," Coulter says.