Some Thoughts on Telemedicine – by Robert Nelson, MD

Labtop.stethoscope.iStock_000017019201MediumThird-party free practices such as DPC, cash-only and other non-insurance-based models are a natural fit for a variety of electronic media that can be used to communicate with patients. Patients love it. I call it simply lifestyle-friendly medicine. It syncs seamlessly with how people currently live their lives and communicate with friends, family and business colleagues.

So why not utilize these same tools to communicate with your doctor?

You’ve heard the saying, “all politics are local”.  Well, all good primary medical care eventually becomes personal and local. But things happen. Medical Boards set guidelines. Malpractice policies rear their ugly head. What if patient needs to be seen in person? They are a litany of what if’s that can get in the way of a good thing.

Point of emphasis: HIPAA/HITECH still applies even if a practice does not take or bill insurance! Email, text, and non-HIPAA compliant video platforms are not secure.

Telehealth companies are springing like weeds in July; they are everywhere. They claim to be “change agents”, “disruptors” and “innovators”and are going to change healthcare; promising doctors a significant boosts in income just by sitting in front of their computer at home.

News flash! People are not buying in anywhere close to the quantities predicted based on survey interest. The video screens are not lighting up! I know, I have been on the ground floor of two well designed Telehealth platforms and I made myself reasonably available. AND, in a 9 month period of experience between the two I DID NOT HAVE ONE VIDEO CONSULTATION FROM A PATIENT THAT WAS NOT ALREADY MY PRIVATE PATIENT. To be fair, the potential patient base was only the whole state of Georgia, though!

So what going on? Do patient-consumers not use electronic communications as much as we thought? No, they use them plenty.  The problem is, we are not using electronic platforms in the right way and when we do, we are not educating patients on the advantages and proper use.

There are some systemic roadblocks as well. Insurance-based practices rarely use e-platforms because they can’t get paid for it and don’t have time due to schedule being packed with co-pay patients. Some DPC and concierge practices still believe they can use any platform (Skype, non-secure texting, etc…) and don’t have to worry about HIPAA violations – Not so.

Also, we’ve anointed Telehealth as unwitting surrogate for personalized, convenient care. While it is convenient, and much like walking into a local urgent care or ER, it can be a potpourri of unpleasant surprises and disappointments.  Like Forrest Gump would say, “you never know what you’re gonna get.”

Patients are not unsophisticated and they tune their shopping radar to match the services they seek. In this case it is medical care – not widgets or apps or data plans.

Telehealth is not a YouTube video or the latest smartphone app. It is about leveraging convenient communication platforms with OUR patients so we are rarely ever out of touch. Patients will and do use Telehealth liberally when the person on the other end of the transmission is a doctor or provider they know, like and trust.

This is why it is critical that private practices, especially the small ones that can adapt quickly, start to use a variety of secure (think HIPAA) e-platforms and secure messaging services to stay in touch with patients.

Someone is eventually going to do this right. Shouldn’t it be the doctors who are already providing great in-person care for their patients?  Let’s just extend that beyond the office walls. As primary care doctors, we take pride in the fact that we can take care of most of our patient’s needs. Let’s start by being available for them in a lifestyle-friendly way. Our patients deserve that.


  1. I think the only “safe” medicine to do online is psychiatry. The doctor does not do a physical examination, just talks to the patient. Mental health practices are already being executed on the internet, there are a few websites for “webtherapy”. I’m not a doctor, a virtual assistant in fact, so I am not well versed in the vehicles that can be used for treating patients, but I don’t think patients should be seen through a screen.

    Sara Kesler, Virtual Assistant


  2. Sara,

    I think psychiatry is a perfect example of a truly meaningful use of Telemedicine. Even so, your point about in-person care even applies to mental health. Even when no “physical exam” is performed, there is a lot of body language and nuance that can be missed on video compared to face-to-face.

    There are many legitimate uses of Telemedicine (secure text, video, telephone, instant message) for patients that have an established relationship with their doctor; or even if they don’t such as when on vacation, or just in need of quick advice. Estimates from primary care docs indicate that about 35 – 40% of problems in primary care probably don’t need a face to face encounter. They can be solved by exchanging information or viewing a photo. Doctors mostly know, as do patients, what needs a face to face encounter for an exam.

    Remember, when most doctors insist on an office visit to refill a routine, relatively benign medication it is mainly because the only way for third-party reimbursed practices to generate revenue is to file an insurance claim based on visit, with approved code and charting to support it.

    The great thing about direct-pay and membership primary care, is that when telemedicine IS appropriate it can be used without compromising revenue because the service is embedded in the price or there is a mechanism to charge for it based on the complexity of the encounter.

    Thanks for reading! Please consider joining the discussion regularly by subscribing to The Sovereign Patient via email. I value the input of my readers.

    Bob Nelson, MD


  3. I’ve done telemedicine visits. In our small healthcare organization we have used it for simple skilled nursing facilities visits and even urgent care (we were a Beacon site where telemedicine project was first initiated). I would say that many more of my patients could take advantage of video visits… Dr. Nelson is correct about the reimbursement. I will not be paid when the patient is not at a site where I am credentialed (like in their home). For a telemedicine visit like this, it’s “cash only” (no insurance reimbursement). I feel this has been the real rate-limiter for adoption of these visits. Many of my patients have negligible copay for in-office visit, so they would never pay $45 for telemedicine visit. I think many more patient would happily do a telemedicine visit, but without getting paid more than the negligible about patients would be willing to pay, they wouldn’t be able to keep the lights on at their “regular” practice. I could easily do chronic condition management from my computer at work (or home); I usually need some vitals (that patients could get with home equipment) or need their lab results (metabolic panels, TSH, A1C, etc.), I don’t need any “laying on of hands” to make treatment decisions for most patients. We cannot pursue the telemedicine in earnest until the reimbursement models change.

    Dirk Thompson, MS, MD


  4. Dr. Thompson: Thanks for your comments and contribution to the discussion.

    You raise an interesting issue about copay vs. cost of a Telemedicine video consult. When you think about it, it’s a win-win for the payers to continue this stalemate because it continues and perpetuates the status quo of the perverse billing cycle.

    If payers start reimbursing for videoconferencing or smart phone consult, then we have ceded one more area to them and it will end up costing more than it needs to and we lose control as they set guidelines and regulations, etc. If on the other hand, it stays outside of the billing cycle, patients are reluctant to utilize if it is substantially higher than their co-pay.

    This is just one of many examples why it is important to pull routine primary care from out from under the payers umbrella so that prices will normalize as normal market forces exert their desired effect.

    One strategy to consider that may give physicians the upper hand in this area is to charge a fee for consultations that is equal to the co-pay. The convenience of remote consults compared to an office visit would tip the scales towards utilization of the remote encounter. If it turns out they need to be seen, then the fee could be counted as their co-pay. In this case, everyone wins and the cost is budget neutral. If no claim is generated, and the consultation is a “non-covered service” then there is no violation of the contractual relationship that the physician has with the payer.


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