Letters to the Editor - Sept. 27, 2004

Pay for e-mail consults? Consider insurers' history on dodging reimbursement for phone calls - EMRs are yet another unfunded mandate aimed at physicians - Gingrich's vision for electronic medical records spells trouble for physicians - FPs interested in sleep medicine subspecialty should speak out

Pay for e-mail consults? Consider insurers' history on dodging reimbursement for phone calls

Regarding "Online consultation slow to grow" (Article, July 12): Physician-patient e-mail has been slow to take off despite availability of e-mail to the general consumer for more than 10 years now. Some have questioned the reluctance of third-party payers to reimburse for virtual office visits and e-consults. Consider the following hypothetical news report:

"An exciting new innovation in telecommunications is about to revolutionize the physician's office. This new technology for the first time offers the patient access to his or her physician nearly instantaneously without ever leaving the house. Using this technological marvel, the patient can quickly and easily notify the physician of a new medical problem, follow up from a recent office visit, or simply ask the physician a question related to a specific disease or health care issue. The patient never has to make an appointment or wait as a walk-in patient in a crowded waiting room. Likewise, the physician does not have to tie up valuable office staff. This innovative technology will certainly improve the so-called turnaround time for information flow of vital health care information between physician and patient, and in so doing has all the potential for making significant contributions to improved quality of care.

"One potential stumbling block was raised by the physician community. Most physicians we spoke with said they have encountered difficulty obtaining reimbursement from a number of health insurance companies for providing this new service for their patients. In fact, claims specialists from several of the larger health insurance companies questioned whether this sort of physician-patient interaction represented a genuine physician visit and should even be reimbursed at all.

"It remains to be seen, at this juncture, whether or not the telephone will ever take its place alongside the stethoscope as a routine tool in the delivery of health care in America."

Although this "news report" itself is of course fictional, the descriptive facts and historical context are not. The first commercial telephone line was installed in Boston in 1877. E-mail arrived on the scene approximately a hundred years later.

To the dismay of the physician community, it has been the policy of most health insurers for the past 50 years to deny direct reimbursement for telephone calls with patients. Now, whether physicians will be successful in their attempts to convince health insurance companies to pay for e-mail and virtual office visits (e-visits and e-consults) remains to be seen.

What is not disputed is the glitz, glitter, dazzle and hoopla of this new high-tech form of physician-patient communication has as yet failed to demonstrate any purported improvement over the tried and proven, user-friendly and less expensive telephone that has served both physicians and patients quite nicely in three different centuries.

In the excitement of new technology, we sometimes lose sight of the e-elephant in the center of the clinic.

--Jim Bowman, MD, Raleigh, N.C.

EMRs are yet another unfunded mandate aimed at physicians

Regarding "Gingrich's grand vision" (Article, Aug. 9): Newt Gingrich claims he doesn't believe that electronic medical record systems cost $20,000 to $50,000 [per doctor, per year]. In the last six months my practice has priced several EMR systems, and we have had no quote below $120,000 for our four-physician, one-location practice. Then there are the annual, everlasting, parasitic maintenance contract and technical support fees.

I also note that he expects the doctors to pay for the system he wishes to foist upon us, saying that we "can borrow against the float ... something every business in America is doing." What float? Doctors' offices are not "every business in America." As far as I know, we are the only "business" that cannot set its own prices.

So physicians are yet again going to be expected to support an unfunded mandate, while Mr. Gingrich gets richer off the feeding frenzy of the vendors of EMR packages.

--Gary Cowan, MD, Fort Worth, Texas

Gingrich's vision for electronic medical records spells trouble for physicians

Regarding "Gingrich's grand vision" (Article, Aug. 9): Before Newt Gingrich's inane interview, I was a believer in the necessity of an EMR; after reading it, I am convinced that he needs to stay as far away from the process as possible.

His "facts" are fractured.

No physician could pay for the conversion to an EMR upfront, then "borrow against the float," as he so self-righteously enunciates.

And since when do pharmacists call back on "40% of all prescriptions?" I must write or call in 5,000 prescriptions annually and average 10 callbacks from pharmacists per year.

I could keep quoting, but it isn't worth the effort.

Frankly, I suspect that Gingrich and his organization are in this to get filthy rich at the expense of primary care physicians and the unsuspecting public.

--Jerry L. Haag, MD, Elmer, N.J.

FPs interested in sleep medicine subspecialty should speak out

This October, the American Board of Family Practice will be meeting to discuss the development of a certificate of added qualifications in sleep medicine. The ABFP has been kind enough to consider this issue for a second time.

Sleep medicine is a subspecialty that lends itself well to the practicing family physician. The breadth of problems confronted in the sleep clinic, ranging from the psychosocial/psychiatric to the medicine-intensive cardiovascular patients, and the wide range of skills involved in the proper clinical assessment, diagnosis and management of these patients is entirely within the realm of the family practitioner.

In fact, the family physician is uniquely poised to understand and handle the full breadth of problems encountered in the sleep-disordered patient because of the wide scope of our training. Further, sleep medicine is a subspecialty that is almost entirely outpatient-based, an area of medicine where family physicians are trained and expected to excel.

We know that there are many forces at play that have caused the current national downtrends in the appeal of family medicine. These forces may at least partially be addressed by adding additional opportunities to obtain CAQs in other subspecialty areas.

This will serve to diversify our training and practice opportunities and will increase the respectability of our specialty.

If consideration of a CAQ in sleep medicine by the ABFP is important to you, or more appropriately, if you would then consider additional training in order to obtain a CAQ, please make efforts to communicate your position to the American Board of Family Practice.

--Daniel Clerc, MD, Seattle