BUSINESSOnline consultation: What's it worth?Rather than wait for insurers to set a price on communicating with patients online, some doctors are establishing their own fees.By Tyler Chin, amednews staff. June 10, 2002. A couple of years ago, after some patients asked him to help evaluate health information they had found online, Dean Tomasello, MD, got the idea to start a Web site at which people could ask him questions and receive answers via e-mail. The service didn't cost anything at first. But the Walworth, Wis., family physician last year started charging a fee after the volume of questions rose so much that he no longer could afford to answer them for free. Despite the change, consumers have been more than willing to pay $25 out of pocket to get their questions answered, Dr. Tomasello said. "People are looking for health and medical information online, but they are a little overwhelmed, confused and anxious about what they find," he said. "They need a little bit more guidance, and we're here to help them sort through it and give them what they need as it applies to their or their family member's specific case." Dr. Tomasello is part of an early wave of physicians who are finding that people are willing to pay for online consultations, though health insurers do not pay for them.
90% of patients want to communicate online with their physicians.
This month, for example, about 1,000 doctors, will begin offering fee-based online consultation service to established patients through a Web site operated by Medem Inc., which is partly owned by the AMA. Online consultations are fraught with uncertainty and controversy because they are such a new development that medical organizations, professionals and others have divided opinions about what constitutes an appropriate, professional and ethical online consultation. The AMA's policy says that physicians shouldn't do online consultations with patients they have never met, but others, such as Dr. Tomasello, don't see anything wrong in performing online consultations with strangers. Demand and supplyRecent surveys confirm that there is patient demand for patient-physician online communication. According to a survey by Harris Interactive, 90% of adults want to communicate online with their physicians. About 37% say that they would pay out of pocket to communicate online with their doctor. AMA policy is that physicians should be compensated a fair fee of their choosing for consultation services rendered to established patients regardless of whether the consultation is rendered by electronic mail or other form of communication. A few insurers have said they would reimburse physicians for online consultations, but most major HMOs don't. Medicare reimburses for telemedicine consultations involving underserved rural areas but doesn't pay a flat fee for e-mail communication between individual physicians and patients.
37% of patients are willing to pay to communicate online with their doctor.
The eRisk Working Group for Healthcare, a consortium of national medical societies and malpractice insurance firms that Medem helped create, defines an online consultation as a clinical consultation that is provided by a physician to a patient via an electronic communication network, such as the Internet, for which the physician expects to be paid. But that definition is simply a guideline, meaning that what constitutes an online consultation is left up to each physician. Many physicians who have signed up to deliver online consultations via Medem's network appear to be charging $20 or $25 per consultation, said Edward Fotsch, MD, CEO of Medem. Physicians and patients who want to do online consultations must register with Medem and give their credit card information with their question. They are charged only after a doctor deems their request appropriate and responds to it. Physicians can waive their fee or decline to answer if they deem the topic to be inappropriate, Medem said. The company charges physicians $2.50 per transaction, but only if the physician charges the patient for the consultation. J. Allen Meadows, MD, an allergist in Montgomery, Ala., who has signed up with Medem, is leaning toward charging $20 for an online consultation, which would put his fee within the $15 to $30 co-pay his patients typically pay for an office visit. "If we're going to get people to use this, then it needs to be a reasonable fee," he said. The main reason Dr. Meadows is offering online consultations is that he wants to replace the phone with the Internet because he says it will improve his overhead and practice efficiency.
Medicare reimburses for telemedicine, but not for e-mail.
"The biggest burden on my practice is the time my employees have to spend on the phone," Dr. Meadows said. "At this point, I pay a registered nurse full-time just to answer questions on the phone, and there's absolutely no reimbursement whatsoever for it. It's very time-consuming and expensive." Although he won't be able to charge patients for every online communication, he will still save time and money if he can communicate online with patients, because the Internet doesn't disrupt office routine as much as the telephone, Dr. Meadows said. For example, the Internet will make it easier for his office to contact teachers and other patients who are difficult to reach because they have a small window during which they are available. When teachers call, his employees have to choose between dropping whatever they are doing to take the call or playing phone tag later if they don't. "Instead of playing phone tag, a teacher can ask a question and fill out an online consultation," said Dr. Meadows, who will make the online service available only to current patients. "We can get that instantly at our office, and a nurse will be able to read and reply with additional questions. It doesn't have to be done immediately like it has to be done with a phone call." To encourage patients to switch to the Internet, Dr. Meadows plans to tell them online consultations will have priority over phone calls. While he hadn't registered with Medem yet, he already has scheduled a fee-based online consultation with a patient who attends college outside Alabama and wants a refill. He normally doesn't charge patients for refills, but this case is an exception because he has not seen the patient for a year, Dr. Meadows said. Like Dr. Tomasello, Dr. Meadows said he would not charge those who request appointments or ask questions about a previous office visit. Just informationBy contrast, Dr. Tomasello provides the online service primarily to people he has never seen, saying he doesn't technically diagnose conditions. He also doesn't treat or prescribe online, he said, explaining that he offers general information specific to the online questioner. "We don't really diagnose," Dr. Tomasello said. "We don't say, 'You have this; you should do this.' We say, 'The symptoms [you have] could represent several possibilities. Here are the common ones, here are the tests that may be run [by your physician] and here is what these tests are intended to find.' " Consumers who want to use his service, NetLiveMD.com, can pay either $25 per question or a $49 annual membership fee. Those choosing the latter option receive an online health assessment after they fill out an extensive medical history online, preventive care reminders and a free online consultation from Dr. Tomasello. Additional consultations cost $19 each. Dr. Tomasello, who spends about four hours a day on NetLiveMD.com, is making $200 a day from membership and online consultation fees, he said. So far, he has more than 280 members. The site, which promises to respond within 24 hours, receives about 20 questions a day, Dr. Tomasello said. He answers about two-thirds of the questions. The remainder are answered by three doctors he recently hired, paying them $15 per question. Dr. Tomasello said his customers must pay first before he answers their question. If they are uneasy about providing their credit card information, he answers their questions and asks them to mail the payment, he said. During the past year, Dr. Tomasello said he has answered more than 1,000 questions from people who aren't getting what they need from their physicians. "If doctors could communicate well with their patients and patients could get access to their doctor and get their questions answered in a timely manner, they wouldn't need us at all," he said. He tells online questioners to visit their own physicians. "We're filling a need," he said. "We're not about replacing the physician. We're trying to empower the patient, and we're trying to improve the patient-physician interaction." Liability riskFor different reasons, both Dr. Meadows and Dr. Tomasello are not concerned about any medical liability risk from online consultations. Dr. Meadows said his liability insurance covers online consultations because the interaction involves established patients. He also recently informed his insurance carrier about his online plans when he renewed his policy and did not hear anything back from the carrier. The cost of the policy rose slightly, but the hike was not caused by his move toward online consultations. Dr. Tomasello said he is not at risk because he is not diagnosing, treating or prescribing online. He also has posted a disclaimer on his site, clearly stating that he provides information, not medical advice, he said. But others aren't so sure that such disclaimers would shield physicians from potential liability. That's because the medical liability risk associated with any online consultation won't be known until a lawsuit is filed and there is a court ruling, said Paul J. Breaux, a health care attorney in Lafayette, La. "It's just a matter of time before a suit comes along. A lot of lawyers are waiting for that to come," he said. Until that day arrives, members of the eRisk consortium, including the AMA, have developed guidelines to help physicians minimize potential liability risks associated with online consultations. In addition to consulting online with established patients, these guidelines also include obtaining the patient's informed consent for a fee-based online consultation and telling them exactly what the cost is. "If you follow these guidelines, you're probably a lot less likely to get into trouble, though it won't guarantee that you won't," said Mark Gorney, MD, medical director of The Doctors Company, a Napa, Calif., physician-owned professional liability insurer that is a member of eRisk. "What we're trying to do is help [physicians] stay out of trouble in an area where little is known and much is guessed." ADDITIONAL INFORMATION:Risk reductionIf you are considering doing online consultations for a fee and want to minimize your legal or liability exposure, you should:
Source: eRisk Working Group for Healthcare Ask awayDean Tomasello, MD, a family physician in Walworth, Wis., said most online consultations have this typical line of questioning: "What can you tell me about it, what is it, what is causing it, what do I have to do, what are the effective treatments and what tests need to be done?" Most questions fall under the following categories:
Here is a sampling of questions:
Copyright 2002 American Medical Association. All rights reserved.
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