Convenient Care and Telemedicine

Studies | Health

No. 305
Wednesday, November 28, 2007
by Devon M. Herrick


Notes

  1. Overuse of Emergency Department among Insured Californians,” California HealthCare Foundation, October 2006.
  2. Bradley C. Strunk and Peter J. Cunningham, “Treading Water: Americans' Access to Needed Medical Care, 1997-2001,” Center for Studying Health System Change, Tracking Report, Vol. 1, March 2002.
  3. Allison Liebhaber and Joy M. Grossman, “Physicians Slow to Adopt Patient E-mail,” Center for Studying Health System Change, Data Bulletin No. 32, September 21, 2006.
  4. “Patients Want Online Communication With Their Doctors,” Medscape Medical News , April 17, 2002; and “Patient/Physician Online Communication: Many Patients Want It, Would Pay for It, and It Would Influence Their Choice of Doctors and Health Plans,” Harris Interactive Healthcare News , Vol. 2, No. 8, April 10, 2002.
  5. Sandra G. Boodman, “Calling Doctor Dappen,” Washington Post , September 9, 2003. Also see Mike Norbut, “Doctor Redefines Visits with Phone, E-mail,” American Medical News , October 20, 2003; and Christine Wiebe, “Doctors Still Slow to Adopt E-mail Communication,” Medscape Money & Medicine, Vol. 2, No. 2, 2001.
  6. Wiebe, “Doctors Still Slow to Adopt Email Communication.” Among health plans that do pay, some will not compensate doctors for e-mail exchanges unless the patient has first been examined in an office.  Other insurers reimburse less for e-mail exchanges than for in-person visits.  See Milt Freudenheim, “Digital Rx: Take Two Aspirins and E-Mail Me in the Morning,” New York Times , March 2, 2005.  An exception is Blue Shield of California, which pays physicians the same for an e-mail consultation ($25) as it does for an office visit.  David Koenig (Associated Press), “A Few Doctors Seeing Patients Online,” Akron Beacon Journal , December 21, 2003.  The American Medical Association has created a reimbursement code for online consultation patients, making it easier for physicians to get paid.
  7. Chris Talbott (Associated Press), “Shortage of Doctors Affects Rural U.S.,” Boston Globe , July 21, 2007.
  8. Dennis Cauchon, “Medical Miscalculation Creates Doctor Shortage,” USA Today , March 25, 1005.
  9. Janet Coffman, Brian Quinn, Timothy T. Brown and Richard Scheffler, “Is There a Doctor in the House? An Examination of the Physician Workforce in California over the Past 25 Years,” Nicholas C. Petris Center on Health Care Markets and Consumer Welfare, School of Public Health, University of California-Berkley, June 2004.  Available: http://www.petris.org/Docs/CADocs.pdf. Accessed October 23, 2007.
  10. “Addressing the Problem of Low Acuity Non-Emergent ER Visits,” Mercer Human Resources Consulting, January 2006.
  11. “Overuse of Emergency Department among Insured Californians.”
  12. Mercer pegs the average cost per emergency room visit at $383, or about two to three times as costly as a traditional physician office visit.  “Addressing the Problem of Low Acuity Non-Emergent ER Visits,” Mercer Human Resources Consulting, January 2006.
  13. See Occupational Health Management, “Self-Care Can Save Millions in Health Costs: Unnecessary Visits to ED, other Costs Avoided,” Occupational Health Management , November 2001.
  14. Sally Trude, “So Much to Do, So Little Time: Physician Capacity Constraints, 1997-2001,” Center for Studying Health System Change, Tracking Report No. 8, May 2003.
  15. For examination of the literature on doctor-patient communication, see Ronald M. Epstein, Brian S. Alper and Timothy E. Quill, “Communicating Evidence for Participatory Decision-Making,” Journal of the American Medical Association , Vol. 291, No. 19, May 19, 2004.
  16. K. Binns and Q. Homan, “Consumers Demand Personalized Services to Manage Their Health,” ADVANCE for Health Information Executives , Vol. 5, 2001, page 88.
  17. See Epstein, Alper and Quill, “Communicating Evidence for Participatory Decision-Making.”
  18. Robert J. Blendon et al., “Views of Practicing Physicians and the Public on Medical Errors,” New England Journal of Medicine, Vol. 347, No. 24, December 12, 2002, pages 1,933-40.
  19. “Quality Matters: Care Coordination,” Commonwealth Fund, Vol. 24, May/June 2007.
  20. Ross DeVol and Armen Bedroussian, “ An Unhealthy America: The Economic Burden of Chronic Disease — Charting a New Course to Save Lives and Increase Productivity and Economic Growth,” Milken Institute, October 2007.
  21. “Disease Management: The New Tool for Cost Containment and Quality Care,” Health Policy Studies Division, National Governors Association, Issue Brief, February 2003.
  22. Thomas Bodenheimer, “Disease Management — Promises and Pitfalls,” New England Journal of Medicine , Vol. 340, No. 15, April 15, 1999, pages 1,202-05.
  23. Ibid.
  24. “Disease Management: The New Tool for Cost Containment and Quality Care.”
  25. For instance, see Gina Kolata, “Looking Past Blood Sugar to Survive with Diabetes,” New York Times , August 20, 2007.
  26. Information obtained from Solantic.com Web site. See also Milt Freudenheim, “Attention Shoppers: Low Prices on Shots in Clinic,” New York Times , May 14, 2006.
  27. Ibid.
  28. Maureen Glabman, “What Doctors Don't Know About the New Plan Designs,” Managed Care Magazine , January 2006.
  29. See Jason Robertson, “Doctor Taking Care of Small Business,” Dallas Morning News , April 30, 2007.
  30. Laurance Baker, Jeffery Rideout, Paul Gertler and Kristina Raube, “Effect of an Internet-Based System for Doctor-Patient Communication on Health Care Spending,” Journal of the American Medical Informatics Association , Vol. 12, No. 5, May 19, 2005, pages 530-36.
  31. Office visits were 7 percent to 10 percent lower than for a control group.  See Yi Yvonne Zhou et al.,  “Patient Access to an Electronic Health Record with Secure Messaging: Impact on Primary Care Utilization,” American Journal of Managed Care , Vol. 13, No. 7, July 2007.  A study from Norway also found patients able to e-mail their doctor had fewer office visits.  See Trine Strand Bergmo et al.,  “Electronic Patient-Provider Communication: Will It Offset Office Visits and Telephone Consultations in Primary Care?” International Journal Medical Informatics , Vol. 74, No. 9, 2005, September 2005, pages 705-10.
  32. April W. Armstrong et al., “Economic Evaluation of Interactive Teledermatology Compared with Conventional Care,” Telemedicine and e-Health , Vol. 13, No. 2, April 2007, pages 91-99.
  33. Abrar A. Qureshi et al., “Willingness to Pay Stated Preferences for Telemedicine Versus In-Person Visits in Patients with a History of Psoriasis or Melanoma,” Telemedicine and e-Health , Vol. 12, No. 6, December 2006, pages 639-40.
  34. “PPO to Pay Physicians for Web Consultations - First Health Group - Company Operations,” Health Management Technology , July 2000.
  35. Warner V. Slack, “A 67-Year-Old Man Who E-Mails His Physician,” Journal of the American Medical Association , Vol. 292, No. 18, November 10, 2004, pages 2,255-61.
  36. Zhou et al., “Patient Access to an Electronic Health Record with Secure Messaging: Impact on Primary Care Utilization.”
  37. For an example of a similar service where physicians make costly house calls to a hotel room, see Jennifer Alsever, “Retro Medicine: Doctors Making House Calls (for a Price),” New York Times , September 23, 2007.
  38. “Addressing the Problem of Low Acuity Non-Emergent ER Visits,” Mercer Human Resources Consulting, January 2006.
  39. Information obtained from conversations with TelaDoc executives in addition to the TelaDoc Web site.
  40. TelaDoc customer surveys from January 1, 2007, through May 30, 2007.  If a call is not returned in under three hours the consultation is free — something that happens less than 3 percent of the time.
  41. Ibid.
  42. Ibid.  Sixty-nine percent rate the TelaDoc service as excellent.  Nearly 22 percent rate it as good.
  43. See Epstein, Alper and Quill, “Communicating Evidence for Participatory Decision-Making.”
  44. TelaDoc customer surveys from January 1, 2007, through May 30, 2007.
  45. For a brief literature review of the history of telemedicine, see Nancy Brown, “A Brief History of Telemedicine,” Telemedicine Information Exchange, May 30, 1995. Available at http://tie.telemed.org/articles/article.asp?path=articles&article=tmhistory_nb_tie95.xml.  Accessed September 19, 2007.
  46. At the time, there was no way to estimate the cost of the telemedicine network and therefore no way to calculate net gains.  However, this technology is now readily available and relatively inexpensive.  See D. S. Watson, “Telemedicine,” Medical Journal of Australia , Vol. 151, No. 2, 1989, pages 62-71.
  47. Conversations with Arthur Stern, corporate marketing specialist at Doctor On Call and the Doctor On Call Web site.
  48. See McKesson Web site at http://www.mckesson.com/en_us/McKesson.com/For+Healthcare+Providers/Hospitals/Contact+Center+Management/ASK-A-NURSE.html.
  49. See Fonemed Web site at http://www.fonemed.com.
  50. See Carenet Web site at http://www.Carenet.com.
  51. Cristiano Antonelli, Aldo Geuna and W. Edward Steinmueller, “Information and Communication Technologies and the Production, Distribution and Use of Knowledge,” International Journal of Technology Management, Vol. 20, No. 1/2, 2000, pages 72-94.
  52. In 1999, Bob Pringle, president of health content provider Inteli-health, estimated there were 15,000 to 20,000 Web sites dedicated to health-related content. See Robert McGarvey, “Online Health's Plague of Riches,” Tech Insider , September 29, 1999. The Internet Healthcare Coalition claims more than 20,000 Web sites dedicated to health care. See “Tips for Healthy Surfing Online,” Internet Healthcare Coalition, 2002. This is consistent with estimates from the Journal of Medical Internet Research . See Roberto J. Rodrigues, “Ethical and Legal Issues in Interactive Health Communications: A Call for International Cooperation,” Journal of Medical Internet Research , Vol. 2, No. 1, 2001.
  53. Susannah Fox, “Online Health Search 2006,” Pew Charitable Trusts, Pew Internet and American Life Project, October 29, 2006.
  54. Devon M. Herrick and John C. Goodman, “ The Market for Medical Care: Why You Don't Know the Price; Why You Don't Know about Quality; And What Can Be Done about It,” National Center for Policy Analysis, Policy Report No. 296, March 2007.  Available at http://www.ncpa.org/pub/st/st296/.
  55. J. Finkelstein and Robert Friedman, “Telecommunication Offers Solution to Chronic Pulmonary Disease Management,” Advance Managers Respiratory Care , Vol. 9, No. 5, 2000, pages 12-14.
  56. Richard Hillestad et al., “Can Electronic Medical Record Systems Transform Health Care? Potential Health Benefits, Savings, and Costs,” Health Affairs , Vol. 24, No. 5, September/October 2005, pages 1,103-17.
  57. For instance, a doctor and nurse practitioner working as a team were better able to manage chronic conditions than a physician working alone.  See David Litaker, “Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care,” Journal of Interprofessional Care , Vol. 17, No. 3 August 2003, pages 223–37.
  58. Jane Anderson (editor), “Use of Telemedicine Tools Grows within DM,” Disease Management News , Vol. 12, No. 8, 2007.
  59. For instance, children assigned to interactive disease management for asthma fared better than those in a control group with traditional disease management.  See Ren-Long Jan et al., “An Internet-Based Interactive Telemonitoring System for Improving Childhood Asthma Outcomes in Taiwan,” Telemedicine and e-Health , Vol. 13, No. 3, June 2007, pages 257-68.
  60. Paula de Toledo et al., “Telemedicine Experience for Chronic Care in COPD,” IEEE Transactions on Information Technology in Biomedicine , Vol. 10, No. 3, July 28, 2006, pages 567-73.
  61. Craig Lehmann and Jean Marie Giacini, “Pilot Study: The Impact of Technology on Home Bound Congestive Heart Failure Patients,” Home Health Care Technology Report , Vol. 1, No. 4, May/June 2004, pages 50, 59-60.
  62. Ren-Long Jan et al., “An Internet-Based Interactive Telemonitoring System for Improving Childhood Asthma Outcomes in Taiwan.”
  63. Diabetics in the treatment group had blood glucose readings (HbA1c) of 6.38 percent compared to the control group readings of 6.99 percent.  See Hyuk-Sang Kwon et al., “Establishment of Blood Glucose Monitoring System Using the Internet,” Diabetes Care , Vol. 27, No. 2, 2004, pages 478-83.
  64. Robert M. Wachter, “International Teleradiology,” New England Journal of Medicine , Vol. 354, No. 7, February 16, 2006, pages 662–63; and Arnold Milstein and Mark Smith, “Will the Surgical World Become Flat?” Health Affairs , Vol. 26, No. 1, January/February 2007.
  65. Robert M. Wachter, “The ‘Dis-location' of U.S. Medicine — The Implications of Medical Outsourcing,” New England Journal of Medicine , Vol. 354, No. 7, February 16, 2006.  For a layman's view of outsourcing radiology, see Associated Press, “Some U.S. Hospitals Outsourcing Work,” MSNBC.com, December 6, 2004. Available at www.msnbc.msn.com/id/6621014/.  Accessed April 27, 2007.
  66. Associated Press, “Some U.S. Hospitals Outsourcing Work,” MSNBC.com, December 6, 2004.  Available at www.msnbc.msn.com/id/6621014/.  Accessed April 27, 2007.  See Nighthawk Radiology Services Web site: www.nighthawkrad.net/.
  67. Rob Stein, “Hospital Services Performed Overseas,” Washington Post , April 24, 2005.
  68. Nearly 160 million Americans are covered through employer-sponsored health plans. See David Blumenthal, “Employer-Sponsored Health Insurance in the United States — Origins and Implications,” New England Journal of Medicine , Vol. 355, No. 1, July 6, 2006, pages 82-88.
  69. For a discussion, see John C. Goodman and Gerald L. Musgrave, Patient Power: Solving America's Health Care Crisis (Washington, D.C.: Cato Institute, 1992).
  70. Centers for Medicare and Medicaid Services, “National Health Expenditures by Type of Service and Source of Funds: Calendar Years 2005-1960,” U.S. Department of Health and Human Services, 2006. Available at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/nhe2005.zip. Accessed January 2006. Also see Katharine Levit et al., “Trends in U.S. Health Care Spending, 2001,” Health Affairs , Vol. 22, No. 1, February 2003, pages 154-64.
  71. However, Alissa R. Spielberg argues that within a few years after the telephone was invented, physicians felt obligated to accept calls from patients by phone — although physicians had worries about getting paid for phone consultations.  See Alissa R. Spielberg, “On Call and Online: Sociohistoric, Legal, and Ethical Implications of E-mail for the Patient-Physician Relationship,” Journal of the American Medical Association , Vol. 280, No. 15, October 21, 2998, pages 1,353-59.
  72. Many physicians felt practicing telemedicine promoted substandard care and hurt the integrity of the medical profession.  See Claude S. Fischer, America Calling: The Social History of the Telephone to 1940 (Los Angeles: University of California Press, 1992), page 176; and Stanley Joel Reiser, Medicine and the Reign of Technology (New York: Cambridge University Press, 1978), page 199.  
  73. See John W. Jones, “Legal Obstacles to Internet Prescribing,” Physician's News Digest , June 2004. 
  74. Mary Schmeida, Ramona McNeal and Karen Mossberger, “Policy Determinants Affect Telehealth Implementation,” Telemedicine and e-Health , Vol. 13, No. 2, April 2007, pages 100-107.
  75. Reuben A. Kessel, “Price Discrimination in Medicine,” Journal of Law and Economics , Vol. 1, October 1958, pages 43-44. The theory is that price-cutting would lead to a situation where fees would be too low for a physician to render quality services.  For a review of health insurance regulation, see John C. Goodman, The Regulation of Medical Care: Is the Price Too High? (San Francisco, Calif.: Cato Institute, 1980).  Also see Greg Scandlen, “100 Years of Market Distortions,” Consumers for Health Care Choices, May 22, 2007.
  76. The states have long licensed and regulated physicians with the ostensible goal of maintaining the quality of medical care.  See Paul B. Ginsburg and Ernest Moy, “Physician Licensure and the Quality of Care: The Role of New Information Technologies,” Regulation , Cato Institute, Vol. 15, No. 4, Fall 1992.  For a literature review of the history of medical licensure, see Goodman and Musgrave, Patient Power: Solving America's Health Care Crisis.
  77. Reuben A. Kessel, “Price Discrimination in Medicine,” Journal of Law and Economics , Vol. 1, October 1958, pages 43-44.  For a review of health insurance regulation, see Goodman, The Regulation of Medical Care: Is the Price Too High?
  78. Ginsburg and Moy, “Physician Licensure and the Quality of Care: The Role of New Information Technologies.” 
  79. Mark A. Cwiek et al., “Telemedicine Licensure in the United States: The Need for a Cooperative Regional Approach,” Telemedicine and e-Health , Vol. 13, No. 2, April 2007, pages 141-47.
  80. Specifically, some state medical boards consider it unethical for physicians to prescribe treatments online (and therefore prohibit them from doing so through regulation), unless there is a bona fide doctor/patient relationship that begins with a face-to-face meeting and physical examination.  See John W. Jones, “Legal Obstacles to Internet Prescribing,” Physician's News Digest , June 2004.
  81. For a discussion, see Devon M. Herrick, “Demand Growing for Corporate Practice of Medicine,” Health Care News , Heartland Institute, January 1, 2006.
  82. Nicole Huberfeld, “Be Not Afraid of Change: Time to Eliminate the Corporate Practice of Medicine Doctrine,” Health Matrix , Vol. 14, No. 2, 2004, pages 243-91.
  83. For example, Harvard Business School professor Regina Herzlinger, a strong proponent of consumer-driven health care, has proposed a regulatory body modeled on the U.S. Securities and Exchange Commission to oversee transparency in health care.  See Regina E. Herzlinger, “Testimony Before the Subcommittee on Health of the House Committee on Ways and Means,” July 18, 2006.  Available at http://waysandmeans.house.gov/hearings.asp?formmode=view&id=5139.  Accessed July 21, 2006.
  84. John C. Goodman, President, National Center for Policy Analysis, “Health Savings Accounts,” Testimony Before the U.S. Senate Special Committee on Aging, May 19, 2004.
  85. Ibid.
  86. John Irwin and Edwin Parker, “Benefits of Telemedicine,” Telemedicine Association of Oregon, January 16, 2004.  Available at: http://www.ortcc.org/PDF/BenefitsofTelemedicine.pdf.  Accessed September 26, 2007.
  87. Cwiek et al., “Telemedicine Licensure in the United States: The Need for a Cooperative Regional Approach.”
  88. John C. Goodman, “Making HSAs Better,” National Center for Policy Analysis, Brief Analysis No. 518, June 30, 2005.
  89. Huberfeld, “Be Not Afraid of Change: Time to Eliminate the Corporate Practice of Medicine Doctrine.”
  90. Kate Murphy, “What Pilots Can Teach Hospitals about Patient Safety,” New York Times , October 31, 2006.
  91. Research at NASA found most aviation accidents were caused by human error and often could have been prevented by better communication among the flight crew. A protocol called “crew resource management” is now standard training for all flight crews. See “New Surgeon-In-Chief Adapts Airline Safety Program to Improve Patient Safety,” Medical News Today , November 13, 2006. Available at http://www.medicalnewstoday.com/medicalnews.php?newsid=56496. Accessed December 14, 2006. Also see Eric J. Thomas and Robert L. Helmreich, “Will Airline Safety Models Work in Medicine?” in Marilynn M. Rosenthal and Kathleen M. Sutcliffe, eds., Medical Error: What Do We Know? What Do We Do? (San Francisco, Calif.: Jossey-Bass, 2002), pages 217-34.

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