SAN JOSE, CA -- One trend in health care: A shortage of primary care physicians is driving more patients to seek primary care in emergency rooms -- and insurers don't like it. In fact, earlier this year Washington state Medicaid toyed with the idea of denying reimbursements for some ER visits -- retroactively, after the visits took place -- when the payer deemed them "unnecessary."
The state relented, but not until after docs sought a court injunction to stop the law. The situation, said the CEO of Tacoma-based Franciscan Health Systems Cliff Robertson, M.D., illustrates the problems the PCP shortage is causing. His system -- including five hospitals, 70 clinics and more than 400 physicians -- employs telemedicine services from Carena, Inc., which does video "house calls" with patients. Carena provides the physician network, and the back-end support for the calls. Presently only self-insured customers can use it but the health system is negotiating with Medicaid and other commercial payers to create reimbursement schemes so all patients will be covered. Robertson and several Carena executives discussed the program during a panel at the American Telemedicine Association's annual meeting.
The system has some shortcomings: Carena docs can't treat everything via video, and there are interoperability issues between Carena's and Franciscan's EHR that they expect will soon be solved when both parties finish an Epic EHR implementation currently in process. Issues aside, Robertson believes wholeheartedly that physician-patient video care encounters will be a service every physician will offer within five years.
Right now, while nurse call lines help insurers and providers stave off some unnecessary doctor visits by reassuring patients who don't need to come in that they should stay home and tough out whatever their present health problem is, Robertson said that patients tell Franciscan that they want more. They want some actual care advice -- not to be told either to come in or not. Telemedicine urgent care is the bridge.
Dr. Benjamin GreenMedical Director, Carena, Inc.
"Virtual care delivery models are going to extend the reach of the primary care provider," Robertson told SearchHealthIT after the panel, adding that when he was a practicing PCP, probably 60% of the care could have been handled online. "I believe that within the next five years you're going to see more and more primary care docs offering these types of services as part of their practice."
Can't treat everything with telemedicine urgent care
Carena launched with the idea of preventing ER readmissions by dispatching physicians to make house calls to check in on patients. It was costly but less costly than ER visits, which made it appealing to payers, said Carena's Medical Director Benjamin Green, M.D. The company's been gaining popularity among patients for several reasons, he added: The rise and ease of use of video technology, improving bandwidth to support it, and a general willingness for patients to learn how to use a new system in exchange for getting live care -- where they are -- instead of going through the rigmarole of making a doctor's appointment and getting in to the office.
But the technology has its limitations, Green said. While otitis media (middle ear infections) cannot be diagnosed via a video visit, for example, the common urinary tract infections can, because they use the decision tree based on common question-and-answer protocols used throughout health care during face-to-face visits. Like the nurse triage hotlines, in those cases where the patient's problem requires a visit to their PCP or a specialist, Carena refers them back to Franciscan.
"I see telemedicine doing for health care what, for banking, the ATM did," said Green, meaning reducing unnecessary bank visits and the staffing they required -- and by extension, the overhead required for running a bank. Or as Robertson put it, "the simple stuff that by default should be taken care of somewhere else, anyway."
Reimbursement issues remain for telemedicine urgent care
While getting payers to reimburse Carena's services is a work in progress, Carena has secured malpractice and liability insurance, said CEO Ralph Derrickson. Some of the same arguments that persuade liability carriers that they manage risk well may end up being the same ones that persuade health insurance payers to cover virtual visits:
- According to Carena research, most in-person visits net the patient 7 minutes with a physician; their virtual visits average 20 minutes.
- Since telemedicine providers understand the limits of remote visits, they take on simpler diagnostic challenges.
- Carena physicians make use of "much clinical decision support," which standardizes care.
"We're offering care that's both clinically appropriate and under circumstances that are pretty consistent and well known to our liability carrier," Green said.