Payment for T-visits and E-visits

In the 21st century practice of medicine, the type of physician-patient interaction should be tailored to the problem at hand. The current types of interactions include face-to-face encounters, synchronous telephonic communication, written communication and, most recently, asynchronous electronic (email) communication. Experienced physicians have been experimenting with email interactions with patients for the past 10 years. Major limitations to the expansion of this novel and potentially efficient communication method include security concerns and compensation issues. Secure web sites and encryption methods will likely handle the security concerns leaving payment for email as the remaining factor. Email is increasingly available to a wider range of patients and has the advantages of being done at times convenient to both patients and physicians, and capable of being forwarded to support staff for task completion and to the medical record for permanent documentation.

Telephone work will not be entirely replaced by email as synchronous communication will always be necessary for good patient care. With the substantial increase in physician-patient communications required to carry on the more complex case management involved in today’s medical care, additional forms of communication are desirable. There is a natural hierarchy from email to telephone calls to office visits. Each is appropriate for a certain level and kind of patient care. Physicians are seeking not only more efficient ways to perform their care tasks but also compensation for all their efforts.

Payment for telephone interactions with patients has never gained significant currency in medical care. Newer email communication has the risk of being similarly undervalued. Unlike lawyers, who do substantial work by phone and have routinely charged (by the minute) for such services, physician telephone contact with patients has been regarded as just part of the business of delivering care and has rarely been billed as a separate service. Currently, only office visits are billable in most systems. Payment for telephone and email medical services is justified for several reasons:

1. Both telephone and email interactions involve real patient care. Evaluation and management decisions are being made through these media.
2. Increased personalized communication between the physician and patient enhance the physician-patient relationship and thus can be seen as having additional value.
3. Efficient handling of questions and other communications that do not require a face-to-face visit saves the attendant overhead costs to both physician and patient.

In the 21st century medical practice, communication will expand to electronic methods including video. Face-to-face visits will be preserved for some important situations, such as initial visits, problems requiring a physical examination, complex case management issues, some patient education visits, psychosocial issues and visits requiring communication with other family members and caretakers. Other needs might be fulfilled by group visits or home visits. But a substantial number of routine types of problems can and will be handled by a combination of telephone and email interaction. These include simple diagnostic challenges where physical examination is not necessary, chronic disease management questions, some patient education requests, and many simple follow up tasks such as reporting on lab work and imaging.

Since patients will use telephone or email communication with their physicians differently, it would make sense to provide a variety of ways to charge for such services. One model might be a charge for an “e-visit” or “t-visit” (telephone consultation). This would be a patient interaction that might well replace an office visit. A patient complaint or inquiry about a specific problem that the physician would handle perhaps over a few email exchanges to get all the data needed to make an assessment and a diagnostic and/or therapeutic plan could be bundled as a single encounter. Follow up communications might be included in such an e/t-visit price. Another payment model which might better suit more mature doctor-patient relationships where the communication fluctuates from time to time, sometimes being quite intense and other times less so, would be a monthly open access charge with an intensity charge for high usage.

A key question is who should pay for email and telephone services? Patients might be willing to pay for such services if they were provided in a timely and personal fashion directly from their own personal physician(s). This would improve continuity of care, something which is highly valued by patients. Concern has been expressed about suddenly charging for services that have always been provided at no charge, such as in telephone communications. But how many patients complain about never or belatedly receiving calls back from their doctors? Perhaps this is because of the financial burdens and uncompensated effort doctors perceive about giving such “free” advice and care over the phone, preferring to provide care in a setting where they can bill. Similar concerns have been raised about paying for the new form of email communication. Perhaps patients would be willing to pay a reduce co-pay fee (compared to an office visit) if their doctor returned their email or telephone call by the end of the day and if such interactions answered their questions without the hassle of leaving work and going to the doctor’s office for a 10 minute interaction. If patients perceived that this communication channel to their physician(s) was of substantial value then they might be willing to pay for these services either at the time of use (via an electronic co-pay) or be billed monthly for the privilege of their use.

Similarly, third party payers of health care might accept responsibility for such payment if they thought that this form of service delivery would be cost saving, quality enhancing, or both. If the cost of an e-visit or t-visit was set at 1/3 to 1/2 of a face-to-face office visit, then medical costs per patient might decline and ultimately premium pricing could be decreased or at least have a lower rate of increase. Similarly, if one could prove that a patient with responsive telephone and email access to their physician(s) actually visited less often or used less health services, a favorable cost-saving argument could be made.

People in the 21st century expect to receive services more conveniently and on demand. Face-to-face visits have largely gone out of other service industries such as banking and travel. More intense use of telephone and email communication between patients and their doctors should be important continuity of care components of the new models of “high tech – high touch” care for our new century. But if we are seriously committed to providing this important patient care work by physicians, it deserves to be compensated just like the continuingly important traditional face-to-face interactions in the office.

Since 2001 Dr. Gene A. Kallenberg has been Professor and Chief of the Division of Family Medicine and Vice Chair for the Dept. of Family and Preventive Medicine. Dr. Kallenberg also serves as the Chief of the Medical Staff of the UCSD Medical Center. His interests include new models of primary care, mental health and primary care collaboration, practice-based research and both undergraduate and graduate medical education.