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Modern doctors’ house call: Skype chat and fast diagnosis

TACOMA, Wash. – One night, when her face turned puffy and painful from what she thought was a sinus infection, Jessica DeVisser briefly considered going to an urgent care clinic, but then decided to try something "kind of sci-fi."

She sat with her laptop on her living room couch, went online and requested a virtual consultation. She typed in her symptoms and credit card number, and within half an hour, a doctor appeared on her screen via Skype. He looked her over, asked some questions and agreed she had sinusitis. In minutes, DeVisser, a stay-at-home mother, had an antibiotics prescription called in to her pharmacy.

The same forces that have made instant messaging and video calls part of daily life for many Americans are now shaking up basic medical care. Health systems and insurers are rushing to offer video consultations for routine ailments, convinced they will save money and relieve pressure on overextended primary care systems in cities and rural areas alike. And more people like DeVisser, fluent in Skype and FaceTime and eager for cheaper, more convenient medical care, are trying them out.

"I’m terrible about going to the doctor, just because of the time it takes," DeVisser, 35, said. "This feels empowering: You just click a button and the doctor comes to you."

But telemedicine is facing pushback from some more traditional corners of the medical world. Medicare, which often sets the precedent for other insurers, strictly limits reimbursement for telemedicine services out of concern that expanding coverage would increase, not reduce, costs. Some doctors assert that hands-on exams are more effective and warn that the potential for misdiagnoses via video is great.

Legislatures and medical boards in some states are listening carefully to such criticisms, and a few, led by Texas, are trying to slow the rapid growth of virtual medicine. But many more states are embracing the new world of virtual house calls, largely by updating rules to allow doctor-patient relationships to be established and medications to be prescribed via video. Health systems, facing stiff competition from urgent care centers, retail clinics and startup companies that offer video consultations through apps for smartphones and tablets, are increasingly offering the service as well.

While telemedicine consultations have been around for decades, they have mostly connected specialists with patients in remote areas, who almost always had to visit a clinic or hospital for the videoconference. The difference now is that patients can be wherever they want and use their own smartphones or tablets for the visits, which are trending toward more basic care.

In Philadelphia, Jefferson University Hospitals now let patients have video follow-up visits with internists, urologists, and ear, nose and throat specialists. Mount Sinai Health System in New York is starting to offer video visits for primary care patients. Mercy, a health system based in St. Louis, will soon open a $54 million virtual care center to house a number of telemedicine programs, including urgent and primary care video consultations for chronically ill and other high-risk patients who need frequent assessments and advice.

Advocates say virtual visits for basic care could reduce costs over the long term. It is cheaper to operate telemedicine services than brick-and-mortar offices, allowing companies to charge as little as $40 or $50 for consultations – less than for visits to emergency rooms, urgent care centers and doctors’ offices. They also say that by letting people talk to a doctor whenever they need to, from home or work, virtual visits make for more satisfied and potentially healthier patients than traditional appointments that are available only at certain times.

Hope Sickmeier, 51, a fourth-grade teacher in Ashland, Missouri, used her Anthem insurance for a virtual urgent care visit one Saturday night, three days into a toothache that kept getting worse. A week earlier, she had gone to the emergency room with a migraine and owed a $200 co-payment.

This time she grabbed her iPad, downloaded the app for the visits and scanned a list of available doctors, choosing one with "a trustworthy face."

When the doctor appeared on her screen, she told him her symptoms and, holding her iPad close to her face, showed him her painful tooth and the swelling in her jaw.

"I was in so much pain, I didn’t care that it was weird," Sickmeier said. "He got right to the point, which was what I wanted. He prescribed antibiotics and called them into an all-night pharmacy about 20 minutes away."

Washington state gave a victory to the industry in April when Gov. Jay Inslee, a Democrat, signed legislation requiring insurers to cover a range of telemedicine services if they cover those services when provided in person. But the new law, which made Washington the 24th state to ensure reimbursement for some telemedicine services, does not cover virtual urgent care outside a medical facility.

Still, the law "opens the doors with a lot of our payers," said Matt Levi, CHI Franciscan Health’s director of virtual health services. He added that some insurers, like Molina Healthcare of Washington, the state’s largest Medicaid plan, were starting to cover virtual urgent care, though the law does not require it.

"We are jumping in with both feet on this," said Peter Adler, president of Molina Healthcare of Washington. "We think it’s the future, and it’s here now."

Some large insurers are starting to pay, too. UnitedHealthcare, the nation’s largest insurer, announced in April that it would cover virtual visits for most of its 26 million commercial members by next year, citing the shortage of primary care doctors and the cost of less than $50 per virtual visit. Anthem will cover virtual urgent care visits for 16 million members in 11 states by the end of this year, and it expects the number to reach 20 million next year. Both insurers are relying on third-party telemedicine companies to provide the doctors and the technology platform for the service, just as most health systems do for now.

Even as virtual visits multiply, researchers say it is not clear whether they really save money or provide better outcomes.

Virtual urgent care visits are undoubtedly less expensive than trips to the emergency room, said Dr. Ateev Mehrotra, a professor of health policy at Harvard Medical School, who has studied telemedicine.

"But I think it’s very plausible, and probably likely, that a lot of people who do a virtual visit would otherwise have stayed home," Mehrotra said, pointing to research that suggests most people do not end up seeking care when they feel sick. "So it could increase health care spending overall."

CHI Franciscan’s virtual urgent care program contracts with Carena, a private company in Seattle that employs 17 physicians and nurse practitioners to do virtual consultations in 11 states. Among CHI Franciscan’s patients, the most frequent users are women ages 25 to 55, and the most typical diagnoses are bladder infections, upper respiratory tract infections and pinkeye.

Users are prescribed medication about 40 percent of the time, said Beth Bacon, the company’s vice president for consumer affairs. Most visits take place on weekends or between 5 p.m. and 8 a.m., she said, when doctors’ offices are closed. Like other virtual urgent care programs, CHI Franciscan’s emphasizes that it is not for medical emergencies, advising customers on its website to "call 911 or proceed to the nearest emergency room" if they have chest pain, difficulty breathing or other potentially life-threatening symptoms.

Although Carena provides all the physicians for the program now, several CHI Franciscan doctors are training to become "virtualists." Dr. Dan Diamond, a family practitioner at one of CHI Franciscan’s urgent care centers who recently trained to conduct virtual visits, said he enjoyed the less hurried pace.

"I don’t have people knocking on the door and saying, ‘Doc, we need you in another room,’" he said. "I’m able to focus on that one patient, without all the commotion that happens in an urgent care or an emergency room."

Still, he added, "there are some times where we just can’t do it virtually and we need to lay hands on a patient."

DeVisser turned out to be one of those cases. While happy with her virtual visit last summer, she ended up going to her primary care doctor a few weeks later because the antibiotics had not fully cleared up her sinus problems. He referred her to an ear, nose and throat specialist, who found through an examination that she had nasal polyps that needed to be removed.

"At least it mitigated the problem," she said of her video consultation. "And it was much more comfortable than having to go sit with a bunch of other sick people in a waiting room."

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