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Telemedicine clinics: Could they cannibalize primary care practices?

Franciscan Health System is using Carena's doctors to provide patient care off-hours. It wasn't an easy sell at first, but so far, so good.

This is the second of a two-part story examining telemedicine clinics that support primary care practices.

Could you blame physicians for shuddering at the thought of their health system employers contracting -- no, outsourcing -- after-hours care to a telemedicine clinic provider who brought its own physicians to the table?

Despite initial pushback from physicians, that's exactly what Franciscan Health System in Tacoma, Wash., did in an effort to stave off issues with limited primary care physician bandwidth. In addition, it keeps its patients from using pricey emergency rooms for primary care in nonemergency, off-hours situations.

When Franciscan's brick-and-mortar clinics close, the phones auto-forward calls to Carena Inc.'s San Francisco office, which is staffed with reception staff and health practitioners licensed in Washington and ready to take phone and video calls to treat patients. Those practitioners also serve Carena's other clients, which comprise consumers, employer insurance plans and health systems.

How Carena's telemedicine clinics work

The patient data integration with Franciscan is tight; Carena practitioners can log into Franciscan's EHR system and look at a patient's record. The Carena practitioner treating a Franciscan patient, often within minutes of an episode of care, emails the Franciscan physician the particulars.

The next day by 10 a.m., the Franciscan physician gets a digest update on the previous night's treatments, ER referrals or appointment changes, if there were any. In some cases, such as a patient request or a special need, Carena will transfer patients to the Franciscan physician on call.

In a presentation at the American Telemedicine Association's 2013 Annual International Meeting & Trade Show -- as well as in interviews with SearchHealthIT -- IT leaders at Franciscan outlined the problems with physician buy-in they faced when they first contracted the Seattle-based Carena in early 2011. The physicians in the primary care practice didn't understand the plan to conduct off-hours clinics, they didn't know how to conduct video visits, and they were afraid it would cannibalize their income.

Telemedicine 'champions' key to achieving success

Louis Lim, M.D., Franciscan medical director of quality and care management, said in the presentation that getting physicians from primary care practices involved in defining and designing the Carena offering helped allay many fears. Identifying and engaging physician champions on the Franciscan side also helped allay fears of the rank and file doctors, added Frances Gough, M.D., Carena's chief medical officer. These champions provided a peer group that could explain things to docs who were worried that Carena was there not to support them but to poach their patients and income.

The market is massive. Consumers, more and more, are looking for access to a primary care physician. We can provide an extension of that.
Ralph DerricksonCEO, Carena Inc.

No matter how it was received, contracting with Carena was a business decision that wasn't going to be reversed, as the Pacific Northwest's healthcare environment is rapidly moving to accountable care organization (ACO) and other global-payment models more quickly than many other U.S. regions. This requires tools for population health management that can keep costs down.

While Franciscan hasn't yet entered into these risk-based contracts, Cliff Robertson, M.D., Franciscan's chief operating officer, said in the presentation that he anticipates it will soon.

Telemedicine clinics can, in theory, help control costs by cutting ER visits and helping to keep tabs on chronic care patients between office visits and keeping them healthier. But it can also relieve time pressure on overworked docs, whose weekends on call were getting hectic. During the Carena pilot implementations, patient calls dropped 44% for Franciscan on-call physicians.

"We really looked at it as a way to expand capacity for our primary care network," said Robertson. "More importantly, we saw it as a tool that was vital as we transition from a fee-for-service reimbursement model into a risk-based model. [We looked] at this virtual primary care as a tool that we would absolutely need if we were to manage a population of patients in a more cost-effective, lower-cost setting."

Carena plans to expand telemedicine clinics

Franciscan rolled out Carena services first to its own employees and their beneficiaries as a benefit called Franciscan Anytime for its self-pay employer insurance plan, a deliberate move to help the patients the health system was most financially at risk in covering with the service. Since then it's been expanded to cover area employees of its parent company, Catholic Health Initiatives.

Matt Levi, Franciscan's director of virtual health services, told SearchHealthIT that, ultimately, the telemedicine clinics will expand to offer service to any patient in the area, whether they're a Franciscan regular or not. The IT pieces to support care coordination are mostly in place for Franciscan patients. The hospital will close the loop with a coming Franciscan Epic EHR installation, which will require rethinking how Carena connects to the EHR system and how information will flow to their doctors via the medical record.

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Carena CEO Ralph Derrickson is convinced his company's services not only can aid health systems in population health management required of the coming ACO era, but their convenience will ultimately serve as a patient recruitment tool. Primary care practices are rife for telemedicine, he believes.

"The market is massive," Derrickson told SearchHealthIT. "Consumers, more and more, are looking for access to a primary care physician. We can provide an extension of that, very straightforward, and treat those day-to-day issues."

Previous: American Well's push into the payer, provider and retail markets.

Let us know what you think about the story; email Don Fluckinger, news director or contact @DonFluckinger on Twitter.

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