Home Forums Discussions General Discussion Survey shows 1/2 of pts unwilling to pay for email

Why should we offer it, if they aren't willing to pay for it?

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As someone said long before the start of the present round of health care reform: "Americans want the best health care system that other people's money can buy".

That's a great line.

I paid to get email advice from a vet once and was very satisfied. The lady I contacted has gone to only working a few hours in her office and makes a lot more money doing email consultations. There were a number of different vets to choose from doing this. They guaranteed a quick reply and they guaranteed satisfaction.

It seems like vets have a really nice life-procedures, quick visits, very little charting, sell the medicines that are needed and name your own hours. Maybe I should have paid more attention in comparative anatomy....

You shouldn't. Unless you only offer it to the other 1/2 that are willing to pay.

Oh, a question for everyone. What do you think is a "fair price" for you to perform an "Online Consultation" for a patient? Assume that the patient is someone you have seen before so that you have some information about them...if only what you gather on your new patient intake forms.

The insurance companies have decided that $30 is the appropriate fee. Currently.

I think this is a very difficult subject. For instance, even though my attorney charges for each email, with a patient where do you draw the line between one consultation and another or when it is finished?

This assumes you don't think the patient needs to be seen. And, there are even rules about how long before and after an online consult can be.

Patient: I feel like I need a steroid inhaler? Which do you recommend?
Doctor: Flovent 110 mcg 2 puffs twice daily and see you in two weeks.
Patient: Can I take that with my albuterol?
Doctor: Yes
Patient: I don't think I need an aerochamber. Do you agree?
Doctor: No.
Patient: Can you call that in for me?
Doctor: Sure.

So, that is $30.00

Then five hours later or the next morning:

Patient: Should I use this everyday or just when I am having an exacerbation?
Doctor: It is meant to be used daily.

Do I charge for that? After five hours? The next day? If I charge, do I charge the same amount.

And, do I charge another patient the same price who asks:

Patient: My Proair MDI has expired. Can I still use it?
Doctor: I should call you in a new one.

And, from the insurance company's point of view, while it may save them money, it does seem like it could easily be used fraudulently.

The attorneys have set the precedent. $30 for every 15 minutes. Boot up time, sign in, typing, spell check, chart review time, save to record -- it all counts. Set the email client to check for new messages every 15 minutes. We're ready.

Bert we have been playing with the software, "Instant Medical History" (IMH) with the intention that it will be useful for this very purpose. You cannot use e-mail in my opinion because you are stepping onto a merry go round that you cannot get off and it seems obvious to me that you will not be able to charge for every message, and the messages will snowball. The IMH software can be set up on a portal, (and be careful with what I say, as I am too ignorant to be quoted on the exact details) which your staff can direct patients to after they have triaged them. If the patient wants to use the service they may chose to do so, it is not, (IMHO) a covered benefit and we will not offer it on the insurance plan, but if they wish to use it, the cost is $35.00 on the credit card before they start. The IMH takes them through an algorhythm and based on that I may, 1- phone in an Rx. 2- call them for more details and then decide on a plan of action and finally, 3- Decline to treat over the phone, directing them to come in immediately or directing them to the ER. In that case I refund the $35.00 charge.

Thats the theory but we are still getting used to the software and I am not comfortable enough with it to contemplate trying to treat a patient with it.

In theory it should be most excellent for the recurrence of a chronic condition or for the simple things a person doesn't want to take time off work, and is really uncomfortable discussing on the phone at work, (I need a refill of the Anusol HC, those hemorrhoids came back.) For those situations the convenience should make it worth the $35.00.

If I every get it going, I'll let you all know.

We are using it for pre-op history and for new patient history and it is awesome, most especially when it takes the history in Spanish and sends it to AC in English. Really like that.

Does it interface into the ac chart or only import?

I am rather sure it imports into the chart. Great idea, and I am glad it is working for Martin. We wanted to use it badly, but the owner just wouldn't allow for enough customization, and what you could do was very labor intensive.

Now, if you like the templates that come with it, it's probably fine. It is also rather pricey. But, again, it can be very useful.

Using IMH for this may be problematic mainly because of the idea of using "Open" email. Of course, you could encrypt the messages. Just the HIPAA issues. But the questioning could be ok for this purpose. RelayHealth and Medem both offer facilities for this with "secure messaging."

@Bert: I get what you mean concerning the second message. Let's say if you receive an additional question about a previous (recent) Online consult as in your example, you have a lesser "Online Follow-up" fee. You pick the follow-up fee. I'm really interested in what people think is a proper fee assuming that you feel it is appropriate to address the issue online at all. If you don;t, you respond appropriately (You must come in for this, go to ER immedialtely!, etc)and don't charge the fee.

For example, you receive a request for the online consult. They are complaining of UTI symptoms. They asswer some questions (pre-set and online)concerning their symptoms. You agree to do this one. What do you feel is the appropriate charge?

Two responses above commented that if the patient was sent to the ER based on the email communication, that they were not charged. Another commented that we couldn't charge for multiple back and forth messages. Why not? Because the problem wasn't solved by the email?

This is exactly why we are in this death spiral of decreasing payments, because we don't recognize that our time, advice and experience are valuable, and we should be paid for it. Let's not begin providing a new service for which we are underpaid!

I got the impression from WCog's answer that patient would not be charged because the doc opted not to respond in any clinically meaningful way, that is: "can't help you by email on this..."

Regarding attorneys, while they do tend to 'have it made in the shade', I don't think I want to start thinking or charging like an attorney. That's just me.

For one thing, before I open the email can 'o worms, I'd like some precedents. What if you don't answer in a timely fashion?

Patient: I'm having chest pain, what should I do?

Say you don't get to that one? I dunno...it goes to junk mail, or you just miss it or something, then what?

And you mistype something or forget a disclaimer and POW!!! your email correspondence is available to testify against it's creator--you!

I DO do some email with a paltry few who I happen to know well on a personal level outside the office, but not much else.

I agree with Peter and John. Personally I believe practicing medicine by email is ridiculous, dangerous and just another way insurance companies and lawyers can make our lives miserable and undervalued. I specifically tell patients when they ask that I do not respond to clinically relevant emails so they should not send them. Put email medicine together with mid-level "practitioners" and soon we physicians will be sitting in our offices (or our homes because we no longer can afford an office) on our butts, without any patients on the schedule, trying to figure out how we got in this predicament.

Leslie

Peter, thanks that is what I meant. I (we--Dr. Alice & I) also agree with you on the liability issue. This is why she only "does a few". Most she doesn't feel comfortable with doing this way. One she does like to do is the "apparently uncomplicated UTI" but even with that--you don't have a urine culture to see what the 'bug' actually is.

Peter, I actually agree with this. My desire is to get an idea of what some practicing doctors believe is the appropriate pricing, not what the insurance company or co-opted AMA exec believes. There does seem to be a place for this,but yes you must do it while avoiding that death spiral you mentioned.

Take my UTI example. Its Sunday, you're about to go to church. La de da. Then there is a call from your patient. "Initial" UTI symptoms. Its 40 min one-way to the office to see her. You can send her to urgent care clinic or er, or tell her to wait till you get back. She's mad and miserable. Or....she can do an Online (email)Consult. Fills out the questionairre on her symptoms. You go over it. Yep, sounds like that. You send response to her. Included in response is "if no relief w/n X days" or "If begin relief, then symptoms return" then come into office. She included her pharmacy in the email, so you send her Rx directly to the pharmacy electronically. Then you go off on your Sunday. Yes, you did have to review her chart probably (remote access to your EMR?). So, what is a fair charge for this service. $30 like the insurance companies say? $50? This is an example of how it would be done using RelayHealth or Medem. The questionairre for symptoms is built into their system.

Well, let's say you charge only 50% for the online follow-up to an online. (nice mouthful).

Which leads into my next example:

You receive a patients lab results back. They are completely normal...except...+HSV1. You send the patient their labs with your comments, suggesting they come in to discuss HSV. They ask for an Online Consult. Sure!

You do the online consult providing them quite a lot of info on HSV, transmission of HSV, etc, etc. OH, I forgot, you've done this one before, so you had saved the previous response as a template. Good thing too, because its rather verbose. Would have taken you 30 minutes just to type it.But its saved! For this one, you make some minor changes to the template and send it. This patient has an insurance plan that doesn't cover online consults, so you are not limited to charging $30 for the consult. So you charge $45 (that's your actual fee schedule for the online consult). Took you about 10 minutes. (uh, did I underestimate the time here?)

The next day, you receive another email to address possible suppression therapy (turns out they get fever blisters ALOT). You charge $22 for the online follow-up to the online consult? So, assuming you would do this, is this a fair price?

Personally, I believe the charge should be the same whether it's online or not. Using E&M coding, we have the history, ROS, PMH, and medical decision-making aspects available for this coding. Only the physical exam is not available. If the patient says, "I'm covered with blisters", that would have to be part of the history since you cannot see them (unless you invoke imaging into your email medical care).

Since when should bettering your service--convenience for patient not having to come in or wait for an opening--mean reduced compensation? Presumably the quality of care is not impaired. The liability for sure has not decreased. There is no reason to charge any less than a face to face consult.

That's a fair answer. And a good point--you are adding convenience for the patient, and investing in infrastructure to do so, but charging LESS. Hmmmmm. Most business models charge more for thst.

Any other takers?

I still think that if I ask a mechanic a question over the phone it feels like a free service. I am just asking a question. If I need to bring him my car to look at, then I will probably be charged. I think people would have a difficult time coming to terms with the idea of "communication = charge".

@Guitar:

I agree with you to a point. Beyond that point I would charge. If I call a mechanic and asked him a simple question, I wouldn't expect a charge. Similarly I wouldn't charge a patient for asking "how many times a day am I supposed to use my inhaler?"

On the other hand, if the mechanic is helping you fix your car over the phone (if you knew a mechanic that would do that for you) and such a service was not just a rare event, I bet he would start charging.

I agree, but most of the time, people know that talk is cheap. They also know that time is money. They just don't always put the two together. The train of thought many people have is that if it's bad enough that a mechanic needs to see it in order to diagnose it, then fix it and charge. If you can tell me to take over the counter meds or even if you call in a script it seems like it was no big effort. I think that for this type of system to work patients would have to better realize the benefits.

I think this sort of service would work well for some patients but not others. It should be an option with costs specified before the visit. Right now people do not understand how much their visit costs. They understand their copay, but the true feeling that your 15 minutes is worth much more than that doesn't usually sink in. 15 minutes on the phone or in the room, giving the same advice, should be a charge - I totally agree. Getting patients to agree may be difficult. Had similar discussions with a local doctor regarding telecommuting for visits via a web cam and voice chat.

Your are right, there are patients who will not agree.

And you know what happens when I go to Wal-mart and don't agree to pay x dollars for that stereo? I don't get to have it. So if a patient doesn't agree, I'd tell him "OK, get in line."

Many patients do not realize we are billing for time and experience. I (and probably most) have heard the attitude that if I didn't give a prescription, I shouldn't charge for the visit, because I "didn't do anything." I guess my history, exam, and decision-making were worthless to the patient once I told him he had a viral respiratory infection and did not need antibiotics.

Exactly, it's all in the perception of the patient. If they don't want it, and don't want to pay for it, no problem! Business as usual! I still think that without seeing a person it is harder to give good advice. So to me, less accurate advice, less money.

I have had patients call and 1) be upset that she couldnt see them that day or treat over the phone (even on a Saturday--we dont have weekend hours) but then also want to balk at the idea of a fee for the Online Consult since it wasnt covered by their insurance. (they didnt have BCBS, GhI, or Aetna--who often cover it for $30). We tell them wait 'till Monday.

But the first 2 patients that acutally did an Online consult w/ us (uncomplicated UTI) were actually really thrilled that there was a way other than the ER to get treatment that Saturday. Their isnurance did not cover it and they did not care.

Wow, I didn't think my first little post would lead to such an interesting discussion. A lot of it is what people are used to. For instance, it seems like anytime our office starts talking on this subject, the analogy of the lawyer comes up. "Your attorney wouldn't do that for free. And he/she wouldn't" It's amazing the amount of things we are asked to do for free by patients. And, it's amazing what some organizations will pay when they are asked. I despise Penquis Cap in our area (they do a great service) but like about five other organizations, they have this knee jerk reaction that every year they need a complete medical record of the patient. So, we started charging $18.00 and damned, if they didn't pay. But, I digress here.

I think it will be very hard to get a patient to pay for a phone consultation whether on call or otherwise. And, since call goes along with being a physician, calling in Vigamox is convenient for the patient, but it is also convenient for me at times. Sure, I increase my medicolegal risk as I didn't rule out uveitis (even if I could have), but I doubt I can then ask the patient, "now that I did you that favor, can you pay me whatever?" Of course, a lawyer would charge, but they don't go through insurance, and we are USED to their charging. That is the huge issue.

But, I think email does have a place. I already use it quite extensively at no charge, and I should be able to charge for it. Like most of you, it is only with a few select people. To be honest, I would rather email them than call them back.

On the other hand, I can't imagine just having a free pipeline via email to my doctor anytime I wished.

But, I agree with Wayne. First, some patients don't want to call either. And, some don't think it is worth having to come in.

The parent that used to call and for me to call back later (at no charge) now may choose to email me, since she will get the answer sooner sometimes and because people just don't want to call and wait around for a return call.

So, she emails about a rash, goes through some of the questions, explains that her two year old now has about 15 red bumps on his trunk and neck. It looks like Chickenpox, but shouldn't there be more and a fever? You determine that he had the Varivax and so you surmise (as you would on the phone) that this is the chickenpox kids now get that have been vaccinated. You advise Benadryl AND you ask her to follow up with you tomorrow if not better. (I think there are some laws or rules maybe that if they see you within a certain amount of time you can't charge for both.

I don't think you should charge the same as an actual visit as you didn't see the patient and you probably didn't take as much time AND there is very little overhead. As far as liability goes, I don't see the difference between an email and a phone call. Actually, the email provides evidence for US that we told them to go to the ED if the fever increased or the patient got this or that. As opposed to the phone call where you may or may not write down what you told them, but they can still deny you did.

Personally, I don't really worry too much about medicolegal issues. (Please don't yell at me).

I do feel a little funny, answering the next email for $22.00.

Bert, we us the RelayHealth system. So we have some communication for free, but any questions concerning a medical problem must be an online consult (or come in). But we'll email their lab results, or they can request an updated referral say to follow up annually on their previously detached retina.

We had hoped to do just one or two a month (yeah, just that) which would actually pay for the Relay contract. But we haven't seen that many. More like one every 2-3 months.

But what made me ask about the pricing: Well, it seems that whenever the insurance companies say "Oh you can do this service, and we'll pay you a whopping $X because we know your expertise and time is valuable" well I immediately say "Oh, the FMV for that service is actually $2X". And that ends up on the fee schedule. Don't know how I started doing that. Maybe its something about GHI paying only $75 for a 99385 (Preventive on initial visit). Or only $90 for Twinrix vaccine, where the pharmacy charges $140. Anyways, the insurance companies jumped up and said they'd pay $30 for the online consult. According to my knee-jerk reaction, the FMV is $60, or maybe only $50. You get the idea. I just wanted some other opinions on the subject.

Gee Bert, you only charge $22? Oh, but you live in Maine and everyone is on Mainecare. In Manhattan, we and other private docs dont accept HealthyNY or Medicaid.