Online Consults Increasing, Despite Physicians' Concerns

1 7 Portals Powering Patient Engagement

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Online consultations are spreading fast now that payers have figured out how to use them to save money. Last week, Health Affairs published a paper by researchers at HealthPartners -- a Minnesota-based health plan and physician group -- showing that online consultations with nurse practitioners for minor ailments saved the insurer $88 per episode of care.

In most cases, these "virtual visits" to Virtuwell, a HealthPartners subsidiary, replaced office visits and visits to ERs, urgent care centers and retail clinics. The online service produced a high level of patient satisfaction while delivering care that was said to be as effective as in-person encounters with providers.

Some HMOs, like Kaiser Permanente and Group Health Cooperative and a few integrated delivery systems such as Geisinger Health System, allow patients to consult online with physicians and midlevel providers. That makes business sense in organizations that take financial risk for care, because it reduces demand for care in more expensive care settings.

In the fee-for-service world, however, the online consults that have been available through services such as RelayHealth and MedFusion (now Intuit) for more than a decade never became widespread. Among the reasons: Doctors were concerned about potential liability if they treated patients online and were afraid that virtual visits would replace more lucrative office visits.

Few health plans covered online consults five or ten years ago, and those that did paid relatively little for them. But now some insurers have changed their minds and their model, for these reasons:

-- Retail clinics staffed by nurse practitioners proved they could lower costs for routine care while increasing patient satisfaction by being convenient.

-- Mobile communications became widespread and consumers began to demand the same level of online service they received in other industries.

-- Payers, under heavy pressure to cut costs, realized that they could save a lot of money if they launched their own telehealth services.

Some of the biggest health insurers are now on board. UnitedHealth Group, for example, offers online consults to its members in 22 states. WellPoint recently began letting its members in California and Ohio consult with doctors via live two-way video; if all goes well it plans to expand the program nationally. Aetna, Cigna and some big employers also offer virtual visits.

What most of these programs have in common -- besides offering online communications between patients and providers -- is that they don't use patients' own physicians. In fact, HealthPartners' Virtuwell doesn't use doctors at all, except as medical directors. What this means is that the health plans don't have to persuade physicians to go online with their patients, or pay them more to do so.

According to the Health Affairs study, Virtuwell NPs are following widely accepted clinical protocols for treating and prescribing medications for about 40 simple primary care conditions. In an interview with InformationWeek Healthcare, Patrick Courneya, MD, lead author of the study and medical director of the HealthPartners health plan, admitted that the clinicians have no prior medical knowledge of the people who contact Virtuwell, but he did not view that as a problem.

Because of the nature of the conditions Virtuwell has selected, he said, that's less critical than it would be in other cases. "Also, we're very careful to make sure that the information we gather [online] gives us what we need to provide care safely in this environment. We gather information about past medical history, potential risks, medications and their diagnoses so we can do this safely."

Virtuwell's nurses won't treat patients who have conditions other than the ones they're authorized to address. If consumers have more serious conditions, they're referred to other care settings or urged to see their own doctors, Dr. Courneya says, noting that the ratio between the number of website visitors Virtuwell nurses don't treat to those they do treat is about 1.4:1.

In the past, physicians have criticized retail clinics for interrupting the continuity of care, and it's likely that some will view online consults with other providers in the same light. But Dr. Courneya stressed that Virtuwell nurses follow up with patients a day or two after their virtual visits. And patients can either e-mail Virtuwell visit summaries to their own physicians or pull them up online during office visits, he said.

Health Partners is starting to expand Virtuwell into other states besides Minnesota and Wisconsin. The biggest barrier is that state laws affecting online consults and other types of telehealth are inconsistent. Some states require clinicians to be located in the same state as the patients they treat or require a pre-existing relationship for the provider to write a prescription online. What this indicates is a need for federal telehealth regulations that override state rules.

In any case, telehealth is here to stay. The current model, however, may only be a transitional phase. Once most physicians have patient portals and are taking financial risk for at least a portion of the care they provide, more of them might be willing to go online with patients -- or have their NPs or physician assistants do so.