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Web-based consults save money, boost satisfaction
Members, docs communicate on nonurgent matters
When Blue Shield of California conducted a pilot project paying physicians for Internet-based consultations for nonurgent conditions, the San Francisco-based health plan found the initiative reduced office visit claims by $1.92 per member per month and total health care costs by $3.69 per member per month.
An independent study conducted by researchers at Stanford University and the University of California at Berkeley of several health plans that use the web-based communications system from RelayHealth found that physician satisfaction ratings exceeded 90% among regular users, that more than half of physicians surveyed preferred an internet-based consultation to an in-office visit for nonurgent medical issues, and more than 70% of patients gave the service high ratings for convenience and ease.
Participants included Blue Shield of California, Blue Shield of California Foundation, self-insured employers within the Silicon Valley Employers Forum, a subsidiary and affiliate of Pacific Business Group on Health, and ConnectiCare, a Farmington, CT health plan.
The system, called webVisit®, allows patients to access a secure web site and consult with their physician’s offices for prescription refills, to get laboratory and test results, to set appointments, and to ask questions about nonurgent health conditions.
"Patient-physician communication over the Internet for nonurgent matters is a convenient way for members to get quick answers to their health care questions. There is the potential for savings. When members monitor their health and take care of problems earlier, they can stay healthier and avoid health care costs in the future," says Sejal Hingrajia, project manager, network management for Blue Shield of California.
Blue Shield of California started its first pilot project at a time when on-line communication between physicians and members was a hot topic of conversation throughout the health care industry, Hingrajia says.
The health plan was the first in California to offer the service.
"We wanted to see what the response to an opportunity to communicate via Internet would be from physicians and patients. We conducted the pilot project to determine the type of adoption rate we could expect and whether patients and physicians would be satisfied with such a system," she says.
After the initial pilot project with members in its PPO market, Blue Shield of California expanded its on-line communications services in a second pilot project involving 750 physicians from nine medical groups and 11,000 members in its HMO market.
"For the second pilot, we wanted to expand our scope and get more of a diverse population and treatment group spread throughout California. For this pilot, we chose physicians in our HMO market," Hingrajia says.
The web-based communication is a win-win situation for all parties involved, points out Robert Forster, MD, chief medical information officer and vice president for Blue Cross and Blue Shield of Florida, which started reimbursing physicians for web-based consultations in January, also using the webVisit system from RelayHealth, based in Emeryville, CA.
"The webVisit system improves access for patients and pays physicians for on-line visits. Overall, it doesn’t cost more on the premium side. It’s the best of all worlds," Forster says.
Communication over the Internet about minor issues avoids the telephone calls back and forth between the patient and the physician or a nurse. It takes care of routine requests, such as prescription refills without tying up the time of a staff member and keeps working people from having to spend a lot of time off work for an office visit for a nonurgent condition, he says.
"We know how difficult it is in parts of Florida for working moms and dads to take time away from work for an office visit for minor problems. This system helps patients get help with their low complex types of health problems effectively and efficiently," Forster says.
The system is helpful to physicians as well because they can answer the questions at a convenient time and avoid a lengthy office visit for a minor complaint, he says.
"We looked closely at the time element. The average patient inquiry takes about 6.5 minutes for the physician to review the complaint and the information questionnaire gathered. The reimbursement comes out to be more, based on the time it takes, than an office visit," Forester adds.
The system has far-reaching potential for other areas of the health care arena, points out Eric Zimmerman, senior vice president of marketing for RelayHealth.
"In addition to physicians, the system could work for case managers, nurse educators, disease management specialists, and others working in the medical environment. It allows patients to consult practitioners about a variety of issues related to management of disease, lifestyle changes, dietary questions, and monitoring health status," he adds.
Medical practices and independent research studies have reported a significant reduction in telephone calls and higher patient satisfaction when they communicate with patients over the Internet, Zimmerman says.
"When I talk to doctors, they tell me that the people with chronic conditions who are stable are the biggest users and those who benefit the most. They can send over their glucose level, weight, and blood pressure logs to the doctor and ask questions about their conditions in a way that the doctor can easily see what is going on. It’s a very convenient way to deal with situations that are important but not urgent," he reports.
About 75% of the physicians who use the system are primary care physicians.
About half of the webVisits involve chronic condition management, including medication issues and side effects, he says.
Some of the top reasons for webVisit consultations include: colds and flu, sore throat, sinus pain or pressure, urinary symptoms, coughing, abdominal pain, back pain, cholesterol, headache, rash, allergic symptoms, depression, foot and ankle injury, hypertension, muscle aches and pains, chronic pain, eye infection, and anxiety.
Only patients who were previously seen in person by the provider are eligible to use the RelayHealth service.
Here’s how the service works: When health plan members log onto their secure web page to consult their physician using a webVisit, the service checks the member’s eligibility for reimbursement, informs the member of the doctor’s response time, and presents a menu of choices regarding the health issue. The service offers members options to request or cancel an appointment, request a lab test or result, request medication refills, request a referral, or send a brief note to the doctor or the doctor’s office.
"These convenient services are free to the member and save the practice time when handled securely on-line," Zimmerman says.
When a member selects the webVisit option, the service presents an online interview that asks a series of symptom- or need-specific questions that gather information the physician needs for a response. The physician may pull the patient’s chart or access it on-line through RelayHealth’s integration with the electronic medical record.
The RelayHealth clinical development team has written more than 140 evidence-based, clinically structured interviews that have been reviewed by a team of physicians.
The questions use branching logic, similar to the questions a health care provider might ask when interviewing a patient about a particular problem.
Each webVisit interview is accompanied by the patient’s RelayHealth Personal Health Record, which is updated by the patient as part of the web visit and includes demographics, allergies, medical history, and medications that patient is taking.
"In many cases, it’s the first time the primary care physician gets to see the full list of medicine a patient may be taking because so many of them are seeing multiple physicians," Forster says.
The service notifies health care providers when a member is waiting for a response to webVisit, either by e-mail or fax or via a monitor available on the provider’s own secure RelayHealth home page. The webVisit message from the member is presented as a concise clinical note for the doctor that includes current complaint, history of present illness, pertinent health history, and comments.
"The information is prepared for the physician so that when he or she logs on to answer the question, everything they need to know is at hand," Forster says.
When a patient logs onto the system for an Internet visit with a physician, the system automatically runs an eligibility review and determines if there is a copay obligation.
Once the doctor responds, the member’s credit card is charged for the copay.
The preliminary questioning is thorough, and the on-screen instructions are carefully structured to remind patients never to use the service in an emergency situation, Zimmerman says.
"If a patient logs on with a complaint that doesn’t qualify as nonurgent, the system instructs the patient to take appropriate action and not use the service," he adds. With webVisits, the responsibility to determine that the patient’s problem is not urgent is with the physician, just as if the patient had contacted the physician over the telephone, Hingrajia points out.
"The doctor reviews the information from the member and has the option to say that the member needs to be seen in person," she says.
On average, physicians respond to patients using the Internet-based service within four to eight business hours, Zimmerman says.
For physicians in Blue Shield of California’s HMO programs, the payment for the visit already is included in their capitated payment. They do receive the member’s copay, however.
The copay is equal to the member’s standard office visit copay but is capped at $10. For instance, if a member’s standard office visit copay is $15, the member pays just $10 for the webVisit. The PPO physicians receive the copay and an additional payment, bringing the total for the web-based visit to $25.
When Blue Shield of California began its Internet-based patient-physician communication initiative, the health plan worked with its network managers to define a target list of medical groups, taking into account location, size, culture, and their level of proficiency in technology, Hingrajia says.
"We introduced the program to medical groups, and Relay Health worked directly with the interested groups to sign the contract. Each medical group takes a different approach to rolling out the program to their physicians," she says.
When a physician enrolls with the RelayHealth services, Blue Shield of California notifies members via a postcard that their primary care physician is available for visits on-line. Registered physicians also are listed in the provider search functionality on the Blue Shield of California web site.
The program also is publicized at the doctors’ offices with brochures and posters.
Blue Cross and Blue Shield of Florida linked its webVisit program to its pay-for-performance program, which rewards physicians based on several criteria including patient satisfaction, clinical quality and efficiency, and administrative efficiency.
"These two programs link very well together. It allows us to get more revenue to the primary care physicians and provides incentives for physicians to see patients for minor problems," he says.
The program started with 300 primary care physicians statewide and continues to grow.
Blue Cross and Blue Shield of Florida started signing up physicians for the Internet visits in January and notifying the members that their physician is available on-line. When members agree to communicate with their physicians via computer, the physicians have to sign off on allowing the member to participate.
"We felt that there may be some patients that a doctor might feel wouldn’t be good candidates for communicating on-line. We wanted to make sure the doctors were comfortable with communicating with their patients," he says.
Blue Cross and Blue Shield of Florida is the first health plan in the state to offer web-based physician services for its members.
"We felt that by being the health plan that brought this innovation to Florida, we could differentiate ourselves from the competition by offering something that has been proven to help facilitate relationships between physicians and patients," he says.
Forster had been watching the results of the Internet-based physician services for several years.
"The privacy issue is paramount. Once the technology had improved to the point that we could ensure privacy, we went forward," he says.
The idea is particularly appealing to young people who grew up with computers and who regularly use other on-line services such as banking and shopping, Forster points out.
"We know there is a national deficit of physicians and a growing population. This system can be particularly beneficial to the primary care physicians who administer 80% of the care," he says.