Patient demand for e-mail consultations with physicians is high, but willingness to pay is low. Physicians practices are finding they can accommodate the preference for e-mail by identifying suitable billing strategies.
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Research reveals a large discrepancy between how parents say they would like to communicate with pediatricians and how they actually do communicate with doctors. Three quarters (77%) of parents said they would seek out email advice from their doctors, but only 6% said that they are actually able to communicate with their doctors this way, a study released by the C.S. Mott Children's Hospital National Poll on Children's Health has found.
How physicians practices are accommodating the growing patient demand for e-mail consultations involves settling on a reimbursement strategy that makes financial sense and resolving questions about patient privacy concerns.
The study highlights the providers' concerns which revolve chiefly around how they will be paid for providing e-mail consultation services. Specific financial concerns noted are the variable nature of reimbursement for e-mail consultations, rather than the established ones for office visits, and the costs of implementing privacy and security systems for the communication exchanges.
A Time-Intensive Task
Matthew M. Davis, MD, MAPP, one of the authors of the study, said that providers consider carefully whether and how it is appropriate to charge patients for electronic availability due to the time it takes to review information and respond to an e-mail, rather than the instant access coming from a telephone call.
"When I receive an e-mail from a patient, I have to consider that patient's relevant past history and recent history of illness, diagnostic options and what's the best course of action," said Davis. "That's not a simple thing to manage in all or even most circumstances. So that's where I think physicians are starting to think that having some expectation of payment for an e-mail consultation would be reasonable."
How much patients are willing to pay for the service, may not meet physicians' expectations. Half of the parents surveyed (49%) said they believed a co-pay for an email consultation should be less than a co-pay from an office visit and nearly half said e-mail consultations should be a free service.
Healthcare providers, however, are finding ways to work around these cost issues. Davis notes two ways that providers are working around the co-pay obstacle. One is a bill-as-you-go system that focuses on the provider tracking the e-mail exchanges and billing accordingly. The method hasn't proven to be popular, as it is already difficult to bill for telephone consultations, and billing per e-mail might cause patients to be hesitant to contact or follow up with providers.
A much more successful method is to charge a fee for e-mail services that comes as a package, Davis says.
"Let's just charge a general service fee to make certain that patients who want to have this service can buy it essentially as a bundled package, and just go ahead and use it if they have that particular service… That allows them to use the service as they need to whenever they need to, and pay a set flat rate accordingly."
One provider that has already started using this approach is Group Health Cooperative, a non-profit healthcare system based in Seattle, WA, which currently runs a successful e-mail consultation service, covered by a fee included in the patients' premium.
Matt Handley, MD, Associate Medical Director of Quality & Informatics at Group Health Cooperative is one of the group's many physicians who uses e-mail to communicate with his patients. He says the this payment structure enables GHC to maintain financial feasibility.
A Cost Cutter
Since in-person visits carrying a higher cost than e-mail consultations, Handley says the organization has been able to trim practice costs.
Davis also views e-mail as a cost cutter for medical practices, mainly because it allows doctors to focus on their most complex patients who need to visit the office in order to be properly treated. "We need the patients who have the more minor complaints taking care of themselves or using other modes of care that may not necessarily involve us," Davis said.
"A patient who may have cold symptoms should probably stay at home and use simple home remedies and not necessarily come in for a visit that day. If an e-mail note about those cold symptoms can help a doctor or a nurse tell a patient 'you don't need to come in today,' that appointment slot is still open for that patient who may have a worsening of their heart disease or diabetes that day."
E-mail in Boutique Practices
Traditional health systems aren't the only ones using e-mail consultations. Choice Physicians is a concierge medicine practice that utilizes electronic messaging. Tiffany Sizemore-Ruiz, D.O., one of the co-founders of the practice, says that an e-mail consultation fee is built into the $1,500 retainer fee patients pay when they sign up.
Choice Physicians has a much smaller patient base than traditional physicians practices, so adding the service in the retainer fee is the only payment needed to finance the service.
"This is a 500−600 patient practice," said Sizemore-Ruiz. "So if you do the math, and you take the $1,500 and multiply it by 500 patients, that $750,000 a year. I don't need an extra $15−$20 to do an e-mail consultation."
Sizemore-Ruiz says she is available for her patients 24/7, and with her smaller patient base at its current size, is able to answer all the e-mails that come her way.
For a larger practice such as Group Health Cooperative, it's a team effort to keep up with patient e-mails. Increased workload was cited as an initial concern, but at GHC in Seattle, everyone has to come together to make sure all the patient inquiries are met, with the bulk falling to the primary physicians.
"A percent are answered by other members of the team, usually around a quarter to a third, and that's things like 'when did I last have my tetanus shot?' But two-thirds to three quarters are answered by their doctor," said Handley.
Privacy Matters
Privacy is another element that is vital to the e-mail consultation process, and it's an area of concern that Davis, Sizemore-Ruiz and Handley all take seriously in their practices.
"We actually share their whole health record online with them so they can see their immunizations, medications, [and] make appointments online," said Handley. "It's much more secure than a paper chart. We do that in a compliant way that meets all the industry standards for privacy."
"There are HIPAA-compliant e-mail companies that you can use and you can also password protect the e-mail and the patient also has a password," said Sizemore-Ruiz. "Also in our particular electronic medical records system, we can send e-mails through our EMR, which is HIPAA-compliant."
Patient demand for email consultations is clearly growing, but how quickly remains to be seen.
"I don't know how quickly this will move," said Davis. "There is such high patient expectation and demand that I think the opportunity is there for physician practices and health plans to try to sort this out sooner rather than later and capture the appeal of this particular way of interacting with physicians that patients are obviously seeking."