RE: Re Email and Phone visits: question from Drain

[Guest guest]

So, for all of you working on the use of phone and e-mail MD visits: what is to stop a corporation that wants to save money from getting that privilege, and outsourcing the work to an unemployed Egyptian or Indian MD? If you think that can not happen, look at the management of social services in Wisconsin. The Governor in that state got permission to outsource the management of their chronically mentally ill patients to a Chicago company, and now when they call in because they are having problems, including problems with their medications, they talk to someone...in India. Are we sure we want to be a part of outsourcing our own jobs? Joanne,

the MD in Drain, Oregon

Never miss an email again!Yahoo! Toolbar alerts you the instant new Mail arrives. Check it out.

[Guest guest]

I recently had someone contact me regarding supervising physician assistants who work in a rural area. I would not be required to go there, but just review charts (they would be brought to me) and talk to them on the phone or email.

Any thoughts??AOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com.

[Guest guest]

Thanks!

MalaAOL now offers free email to everyone. Find out more about what's free from AOL at AOL.com.

[Guest guest]

Joann,

I suspect you are playing Devil’s

advocate here

In addition to what said, I would

offer my thoughts.

I would argue that, although they (the

corporations) may do that, it wouldn’t be a good idea because the

essential patient-physician relationship (in person) would be lacking. It

is an accepted standard for e-visits that the patient and physician doing the

e-visit already have established a therapeutic relationship. To me, that

requires prior face-to-face contact.

I have heard that there is a company out

there that is trying to align primary care docs with patients whom they have

never (and will never be) seen and conduct e-visits. I would not support

this, even when webcams or whatever else technology brings us are employed –

you just can’t beat that person-to-person, living, real-time, eye-to-eye,

reach out and touch someone interaction. Some things you won’t know

about a person until you are physically in their presence for some time.

A. Eads, M.D.

Pinnacle Family Medicine, PLLC

phone fax

P.O.

Box 7275

Woodland

Park, CO 80863

From: [mailto: ] On Behalf Of joanne holland

Sent: Monday, February 26, 2007

12:10 PM

To:

Subject: Re:

Re Email and Phone visits: question from Drain

So, for all of you working on the use of phone

and e-mail MD visits: what is to stop a corporation that wants to save

money from getting that privilege, and outsourcing the work to an unemployed Egyptian

or Indian MD?

If you think that can not happen, look at the

management of social services in Wisconsin.

The Governor in that state got permission to outsource the management of their

chronically mentally ill patients to a Chicago

company, and now when they call in because they are having problems, including

problems with their medications, they talk to someone...in India.

Are we sure we want to be a part of

outsourcing our own jobs?

Joanne, the MD in Drain, Oregon

Never

miss an email again!

Yahoo! Toolbar alerts you the instant new Mail arrives.

Check it out.

[Guest guest]

Joanne,

I think you are right on. I have

been saying for 5 years now, “be careful what you wish for” If care

can truly be adequately provided “remotely” why wouldn’t every third party

payer in the country jump on it?

Back in about 2003 I had occasion to fill

in for a rural doc hereabouts and got to see his transcription service. Well, saw the outcome, but not the

service itself, because it was in Bombay! He had a cool little

digital Dictaphone, and every couple hours the staff would come steal it from

me for about 5 minutes, plug it into the USB port

and send my dictations via the internet to someplace on the other side of the

world. About 3 hours later they

would bring me the transcripts to sign off. They were GORGEOUS! Not a single typo,

or misspelling. When I commented on this, I was told that the transcriptionists were MDs! They can get paid better to transcribe US docs dictations than they can to actually

care for patients where they are.

After I pondered that for

a while, I thought “Why would anthem pay me $20 for a ‘virtual

visit” if they can pay a CT surgeon in India 60 cents for the same service?” I still wonder the

same thing….

Annie

Re:

Re Email and Phone visits: question from Drain

So, for all of you working on

the use of phone and e-mail MD visits: what is to stop a corporation that

wants to save money from getting that privilege, and outsourcing the work to an

unemployed Egyptian or Indian MD?

If you think that can not

happen, look at the management of social services in Wisconsin. The

Governor in that state got permission to outsource the management of their

chronically mentally ill patients to a Chicago company, and now when they call

in because they are having problems, including problems with their medications,

they talk to someone...in India.

Are we sure we want to be a

part of outsourcing our own jobs?

Joanne, the MD in Drain, Oregon

Never

miss an email again!

Yahoo! Toolbar alerts you the instant new Mail arrives.

Check it out.

[Guest guest]

You are liable for their work, at least according to my malpractice company - so be careful.I recently had someone contact me regarding supervising physician assistants who work in a rural area.  I would not be required to go there, but just review charts (they would be brought to me) and talk to them on the phone or email.Any thoughts??AOL now offers free email to everyone. Find out more about what's free from AOL atAOL.com.

[Guest guest]

Will you be paid for this?

I supervised FOUR PA’s in a previous

practice and it had its rewards, eventually. If you are someone who feels

uncomfortable signing off charts (without commenting or teaching) it can be “easy”.

I guess I am a control freak, but I could not just sign off the PA charts

without commenting on things like antibiotics for URI’s or MRI scans for

every headache coming through the door. Lots of doctors I know around

here just sign without actually reading what they are co-signing. SO,

depending on how much time you want to put into this and how much they will pay

you, it can be a good experience. I spent many non-compensated hours

mentoring “my” PA’s. The benefits: Teaching

better medical care to mid-levels and developing lifelong friendships with

these wonderful people. The drawbacks (at least in my situation):

Too much sweat equity in an organization where I would never really have any

decision-making power. (SO, I left to do this IMP thing and it gets

better every day… J!)

I would do it if I were to be

well-compensated and also had the chance to meet these PA’s ahead of

time! Talk about practice styles, expectations, etc.

Ramona

Ramona G. Seidel, MD

www.baycrossingfamilymedicine.com

Your Bridge to Health

410 349-2250

polis, MD

From: [mailto: ] On Behalf Of DocSingh760@...

Sent: Monday, February 26, 2007

9:42 PM

To:

Subject: Re:

Re Email and Phone visits: question from Drain

I recently had someone contact me

regarding supervising physician assistants who work in a rural area. I

would not be required to go there, but just review charts (they would be

brought to me) and talk to them on the phone or email.

Any thoughts??

AOL now offers free email to everyone. Find out more about what's free

from AOL at AOL.com.

[Guest guest]

I too have a strong feeling of " unease " with virtual visits and other non

face-to-face medicine. I strongly rely on the nonverbal cues that patients

bring with them to face-to-face encounters.

I really respect Eads and her impressive work on IMP style thinking

and practicing, but I have become slightly concerned about the path that

receiving reimbursement for virtual visits might take.

I think this feeling of unease is due to the fact that I have become so jaded

against the whole insurance industry that I can not believe they would truly

support something (especially by paying for it) that is in the best interest

of patients, and NOT just moving towards the best interest of their bottom

line...

Please help me shake this uneasy feeling regarding this portion of our " brave

new world. "

, MD

Durango, CO

On Mon, 26 Feb 2007 21:35:37 -0500

" Annie Skaggs " wrote:

> Joanne, I think you are right on. I have been saying for 5 years now,

> " be careful what you wish for " If care can truly be adequately provided

> " remotely " why wouldn't every third party payer in the country jump on

> it?

>

> Back in about 2003 I had occasion to fill in for a rural doc hereabouts

> and got to see his transcription service. Well, saw the outcome, but

> not the service itself, because it was in Bombay! He had a cool little

> digital Dictaphone, and every couple hours the staff would come steal it

> from me for about 5 minutes, plug it into the USB port and send my

> dictations via the internet to someplace on the other side of the world.

> About 3 hours later they would bring me the transcripts to sign off.

> They were GORGEOUS! Not a single typo, or misspelling. When I commented

> on this, I was told that the transcriptionists were MDs! They can get

> paid better to transcribe US docs dictations than they can to actually

> care for patients where they are.

> After I pondered that for a while, I thought " Why would anthem pay me

> $20 for a 'virtual visit " if they can pay a CT surgeon in India 60 cents

> for the same service? " I still wonder the same thing..

> Annie

>

>

> Re: Re Email and Phone visits: question

> from Drain

>

> So, for all of you working on the use of phone and e-mail MD

> visits: what is to stop a corporation that wants to save money from

> getting that privilege, and outsourcing the work to an unemployed

> Egyptian or Indian MD?

> If you think that can not happen, look at the management of social

> services in Wisconsin. The Governor in that state got permission to

> outsource the management of their chronically mentally ill patients to a

> Chicago company, and now when they call in because they are having

> problems, including problems with their medications, they talk to

> someone...in India.

> Are we sure we want to be a part of outsourcing our own jobs?

>

> Joanne, the MD in Drain, Oregon

>

> _____

>

> Never

> <http://us.rd.yahoo.com/evt=49938/*http:/tools.search.yahoo.com/toolbar/

> features/mail/> miss an email again!

> Yahoo! Toolbar alerts you the instant new Mail arrives. Check it out.

>

[Guest guest]

,

I'm doing a retainer practice (monthly or annual fee) and my patients

absolutely love e-mail for appropriate things, even though they could

come in for " free " (phone, email, visits are all included up to

a limit). Of course, these are well established, known

patients. They send me info they forget to bring, questions about

whether they should be seen for a new issue, simple problems, follow up

on how they are doing after the changes we discussed at a prior

visit. I am completely convinced that in this type of practice, it

is good for them, me, and the quality of medical care. Actually, it

is great for all of these.

Sharon

At 08:44 PM 2/26/2007, you wrote:

I too have a strong feeling of

" unease " with virtual visits and other non

face-to-face medicine. I strongly rely on the nonverbal cues that

patients

bring with them to face-to-face encounters.

I really respect Eads and her impressive work on IMP style

thinking

and practicing, but I have become slightly concerned about the path that

receiving reimbursement for virtual visits might take.

I think this feeling of unease is due to the fact that I have become so

jaded

against the whole insurance industry that I can not believe they would

truly

support something (especially by paying for it) that is in the best

interest

of patients, and NOT just moving towards the best interest of their

bottom

line...

Please help me shake this uneasy feeling regarding this portion of our

" brave

new world. "

, MD

Durango, CO

On Mon, 26 Feb 2007 21:35:37 -0500

" Annie Skaggs "

<

askaggs@...> wrote:

> Joanne, I think you are right on. I have been saying for 5 years

now,

> " be careful what you wish for " If care can truly be

adequately provided

> " remotely " why wouldn't every third party payer in the

country jump on

> it?

>

> Back in about 2003 I had occasion to fill in for a rural doc

hereabouts

> and got to see his transcription service. Well, saw the outcome,

but

> not the service itself, because it was in Bombay! He had a cool

little

> digital Dictaphone, and every couple hours the staff would come

steal it

> from me for about 5 minutes, plug it into the USB port and send

my

> dictations via the internet to someplace on the other side of the

world.

> About 3 hours later they would bring me the transcripts to sign

off.

> They were GORGEOUS! Not a single typo, or misspelling. When I

commented

> on this, I was told that the transcriptionists were MDs! They can

get

> paid better to transcribe US docs dictations than they can to

actually

> care for patients where they are.

> After I pondered that for a while, I thought " Why would anthem

pay me

> $20 for a 'virtual visit " if they can pay a CT surgeon in India

60 cents

> for the same service? " I still wonder the same thing..

> Annie

>

>

> Re: Re Email and Phone visits:

question

> from Drain

>

> So, for all of you working on the use of phone and e-mail MD

> visits: what is to stop a corporation that wants to save money

from

> getting that privilege, and outsourcing the work to an

unemployed

> Egyptian or Indian MD?

> If you think that can not happen, look at the management of

social

> services in Wisconsin. The Governor in that state got permission

to

> outsource the management of their chronically mentally ill patients

to a

> Chicago company, and now when they call in because they are

having

> problems, including problems with their medications, they talk

to

> someone...in India.

> Are we sure we want to be a part of outsourcing our own jobs?

>

> Joanne, the MD in Drain, Oregon

>

> _____

>

> Never

>

<

http://us.rd.yahoo.com/evt=49938/*http:/tools.search.yahoo.com/toolbar/

> features/mail/> miss an email again!

> Yahoo! Toolbar alerts you the instant new Mail arrives. Check it

out.

>

[Guest guest]

Dear Joanne et al.,

We do a fair bit of phone and e-visit in the retainer-based Robin

Hood model with our paying (Benefactor) and sometimes with our non-

paying (Recipient) patients. Like most IMP's, we have close

relationships with our patients and find phone and e-visits VERY

helpful. The whole issue is service. It avoids a lot of wasted time

for the patient and unecessary office visits for us. And because our

reimbursement is unhooked from the need to see the patient face-to-

face it makes more sense than in a more conventional practice.

One novel practice I would like to mention in this regard is

www.doctokr.com, established by a fellow Modesto Family Practice

Residency graduate Alan Dappen, MD in Vienna, Virginia. Alan does

almost 2/3 of his visits by phone or email. He only allows patients

to sign up if they reside within a certain distance of his office.

He charges for his time like an attorney. Patients get a discount on

his hourly rate if they use a pre-paid account. His contract states

up front that their doctor:patient relationship is based on the

premise that if he says it is time for an office visit -- they must

come in. If they refuse, they are in defualt of their agreement and

can be discharged. The patient may always opt for an office visit,

but the hourly charge is a bit higher.

Though I don't think I could handle 2/3 of my office visits like he

does, I do find that I spend A LOT of time on the phone in my

current model -- and it is largely time well spent.

One comment about out-sourcing. I don't think the issue is where the

care comes from (India was a frequently used example) but rather the

quality of the service delivered to the patient. If an Egyptian

advice doctor gives good advice -- wonderful! If we have to compete

with her, maybe we should consider enhancing the quality, breadth or

intimacy of the services we are providing (the " Basket of Services "

in the New Model of Family Medicine.)

Bob Forester

St. Luke's Family Practice

Modesto, CA

>

> So, for all of you working on the use of phone and e-mail MD

visits: what is to stop a corporation that wants to save money from

getting that privilege, and outsourcing the work to an unemployed

Egyptian or Indian MD?

> If you think that can not happen, look at the management of

social services in Wisconsin. The Governor in that state got

permission to outsource the management of their chronically mentally

ill patients to a Chicago company, and now when they call in because

they are having problems, including problems with their medications,

they talk to someone...in India.

> Are we sure we want to be a part of outsourcing our own

jobs?

>

> Joanne, the MD in Drain, Oregon

>

>

>

> ---------------------------------

> Never miss an email again!

> Yahoo! Toolbar alerts you the instant new Mail arrives. Check it

out.

>

[Guest guest]

Dear , Of course I am playing devil's advocate here. However, I really hope we all know what the direction is when we turn somewhere new. Unless all this distance medical management is certainly attached to the Dr/Patient relationship, we are setting ourselves up for a very sad fall. Note that the MD in Egypt is not here to be sued, that her malpractice costs do not exist like ours, and that her overhead is less...of course her advice is desirable to someone who only notes the cost. Every day I see patient who are coming to me (from increasingly long distances...it troubles me) who have been lost in the medical management shuffle. If all the information about their conditions comes only from "hamster wheel" medical systems, and the decision making is done according to a paradigm found in a medical manual in Egypt, and there is little or no feedback

from the patient...surely there will be terrible consequences for people with difficult diagnostic problems. Speaking of difficult problems; the very thin young lady with the myxomatous mitral valve has had her surgery, and is getting stronger every day. Her only bad event in the surgery process was with the CNA who took out her endotracheal tube and decided that just before taking it out was the proper moment to give her a lecture about how she almost died and was neglecting her health which put everyone in a terrible position....etc, etc. Of course, that is the kind of thing we need in our ICUs. Burned out personelle do the most peculular Eads wrote: Joann, I suspect you are playing Devil’s advocate here In addition to what said, I would offer my thoughts. I would argue that, although they (the corporations) may do that, it wouldn’t be a good idea because the essential patient-physician relationship (in person) would be lacking. It is an accepted standard for e-visits that the patient and physician doing the e-visit already have established a therapeutic relationship. To me, that requires prior face-to-face contact. I have heard that there is a company out there that is trying to align primary care docs with patients whom they have never (and will never be) seen and conduct e-visits. I would not support this, even when webcams or whatever else technology brings us are employed – you just can’t beat that person-to-person, living, real-time, eye-to-eye, reach out and touch someone interaction. Some things you won’t know about a person until you are physically in their presence for some time. A. Eads, M.D. Pinnacle Family Medicine, PLLC phone fax P.O. Box 7275 Woodland Park, CO 80863 From: [mailto: ] On Behalf Of joanne hollandSent: Monday, February 26, 2007 12:10 PMTo:

Subject: Re: Re Email and Phone visits: question from Drain So, for all of you working on the use of phone and e-mail MD visits: what is to stop a corporation that wants to save money from getting that privilege, and outsourcing the work to an unemployed Egyptian or Indian MD? If you think that can not happen, look at the management of social

services in Wisconsin. The Governor in that state got permission to outsource the management of their chronically mentally ill patients to a Chicago company, and now when they call in because they are having problems, including problems with their medications, they talk to someone...in India. Are we sure we want to be a part of outsourcing our own jobs? Joanne, the MD in Drain, Oregon Never miss an email again!Yahoo! Toolbar alerts you the instant new Mail arrives. Check it

out.

Need a quick answer? Get one in minutes from people who know. Ask your question on

Yahoo! Answers.

[Guest guest]

Ditto to scope of Sharon's services below, except currently I do it all for

free. There are lots of simple visits that I do that I could easily do over

the phone, but I don't because the visit is tied to the reimbursement. I

do give in to some of the requests sometimes and don't require a visit,

because it certainly is convenient for the the patient. The saying about

90% of your diagnoses coming from history rings true to me, and coupled with

knowing your patient beforehand makes it much less likely that you will miss

some devastating illness.

I gave some free advice about her coccydynia to patient who is an architect,

and she asked me how she should pay me. She was shocked when I told her it

was 'included " in the amazing reimbursement her insurance company pays me

every time I see her in the office. She said in architecture, they all bill

by the minute for phone or email issues and round the minutes up to the

nearest 30 minutes. She says everything that might take her 5-10 minutes on

the phone interrupts her work flow and generates post call work. She did

drop off a few bottles of really expensive wine around Christmas (although I

don't drink, and I am a heathen...)

Lynn

>

>Reply-To:

>To:

>Subject: Re: Re Email and Phone visits: question

>from Drain

>Date: Mon, 26 Feb 2007 21:33:47 -0800

>

>,

>I'm doing a retainer practice (monthly or annual fee) and my patients

>absolutely love e-mail for appropriate things, even though they could come

>in for " free " (phone, email, visits are all included up to a limit). Of

>course, these are well established, known patients. They send me info they

>forget to bring, questions about whether they should be seen for a new

>issue, simple problems, follow up on how they are doing after the changes

>we discussed at a prior visit. I am completely convinced that in this type

>of practice, it is good for them, me, and the quality of medical care.

>Actually, it is great for all of these.

>Sharon

>

>

>At 08:44 PM 2/26/2007, you wrote:

>

>>I too have a strong feeling of " unease " with virtual visits and other non

>>face-to-face medicine. I strongly rely on the nonverbal cues that patients

>>bring with them to face-to-face encounters.

>>

>>I really respect Eads and her impressive work on IMP style

>>thinking

>>and practicing, but I have become slightly concerned about the path that

>>receiving reimbursement for virtual visits might take.

>>

>>I think this feeling of unease is due to the fact that I have become so

>>jaded

>>against the whole insurance industry that I can not believe they would

>>truly

>>support something (especially by paying for it) that is in the best

>>interest

>>of patients, and NOT just moving towards the best interest of their bottom

>>line...

>>

>>Please help me shake this uneasy feeling regarding this portion of our

>> " brave

>>new world. "

>>

>> , MD

>>Durango, CO

>>

>>On Mon, 26 Feb 2007 21:35:37 -0500

>> " Annie Skaggs "

>><<mailto:askaggs%40fayettefamilymed.com>askaggs@...>

>>wrote:

>> > Joanne, I think you are right on. I have been saying for 5 years now,

>> > " be careful what you wish for " If care can truly be adequately provided

>> > " remotely " why wouldn't every third party payer in the country jump on

>> > it?

>> >

>> > Back in about 2003 I had occasion to fill in for a rural doc hereabouts

>> > and got to see his transcription service. Well, saw the outcome, but

>> > not the service itself, because it was in Bombay! He had a cool little

>> > digital Dictaphone, and every couple hours the staff would come steal

>>it

>> > from me for about 5 minutes, plug it into the USB port and send my

>> > dictations via the internet to someplace on the other side of the

>>world.

>> > About 3 hours later they would bring me the transcripts to sign off.

>> > They were GORGEOUS! Not a single typo, or misspelling. When I commented

>> > on this, I was told that the transcriptionists were MDs! They can get

>> > paid better to transcribe US docs dictations than they can to actually

>> > care for patients where they are.

>> > After I pondered that for a while, I thought " Why would anthem pay me

>> > $20 for a 'virtual visit " if they can pay a CT surgeon in India 60

>>cents

>> > for the same service? " I still wonder the same thing..

>> > Annie

>> >

>> >

>> > Re: Re Email and Phone visits: question

>> > from Drain

>> >

>> > So, for all of you working on the use of phone and e-mail MD

>> > visits: what is to stop a corporation that wants to save money from

>> > getting that privilege, and outsourcing the work to an unemployed

>> > Egyptian or Indian MD?

>> > If you think that can not happen, look at the management of social

>> > services in Wisconsin. The Governor in that state got permission to

>> > outsource the management of their chronically mentally ill patients to

>>a

>> > Chicago company, and now when they call in because they are having

>> > problems, including problems with their medications, they talk to

>> > someone...in India.

>> > Are we sure we want to be a part of outsourcing our own jobs?

>> >

>> > Joanne, the MD in Drain, Oregon

>> >

>> > _____

>> >

>> > Never

>> >

>><<http://us.rd.yahoo.com/evt=49938/*http:/tools.search.yahoo.com/toolbar/>http\

://us.rd.yahoo.com/evt=49938/*http:/tools.search.yahoo.com/toolbar/

>> > features/mail/> miss an email again!

>> > Yahoo! Toolbar alerts you the instant new Mail arrives. Check it out.

>> >

>>

>>

_________________________________________________________________

Find a local pizza place, movie theater, and more….then map the best route!

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[Guest guest]

Yes, and there is that…but

interestingly enough, in my state NO increase in malpractice rates to

supervise! (but no reduction for low volume practice…)

Ramona

Ramona G. Seidel, M.D.

www.baycrossingfamilymedicine.com

Your Bridge to Health

polis, MD

From: [mailto: ] On Behalf Of Guinn

Sent: Monday, February 26, 2007

10:36 PM

To:

Subject: Re:

Re Email and Phone visits: question from Drain

You are

liable for their work, at least according to my malpractice company - so be

careful.

On Feb 26, 2007, at 7:42 PM, DocSingh760aol

wrote:

I

recently had someone contact me regarding supervising physician assistants who

work in a rural area. I would not be required to go there, but just review

charts (they would be brought to me) and talk to them on the phone or email.

Any

thoughts??

AOL

now offers free email to everyone. Find out more about what's free from AOL atAOL.com.