Tag Archives: Med Group

For the First Time, Employed Docs Outnumber Self-employed Docs

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https://www.healthleadersmedia.com/first-time-employed-docs-outnumber-self-employed-docs

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The milestone continues a long-term trend that has shifted the distribution of physicians away from ownership of private practices.

KEY TAKEAWAYS

Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012.

Self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012.

In the aggregate, 34.7% of physicians worked either directly for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29.0% in 2012.

Employed physicians outnumber self-employed physicians for the first time in the United States, according to an updated study on physician practices by the American Medical Association.

“Transformational change continues in the delivery of healthcare and physicians are responding by reevaluating their practice arrangements,” AMA President Barbara L. McAneny, MD, said in a media release.

Employed physicians were 47.4% of all patient care physicians in 2018, up 6% points since 2012.

Self-employed physicians were 45.9% of all patient care physicians in 2018, down 7% points since 2012.

Such a dramatic shift is not unprecendented. Older AMA surveys show the share of self-employed physicians fell 14% points during a six-year span between 1988 and 1994.

Given the rate of change in the early 1990s, it appeared a point was imminent when employed physicians would outnumber self-employed physicians, but the shift took much longer than anticipated.

The AMA’s researchers said that history suggests that “caution should be taken in assuming current trends will continue indefinitely.”

The majority of patient care physicians (54%) worked in physician-owned practices in 2018 either as an owner, employee, or contractor. Although this share fell from 60% in 2012, the trend away from physician-owned practice appears to be slowing since more than half of the shift occurred between 2012 and 2014, the study said.

At the same time, there was an increase in the share of physicians working directly for a hospital or in a practice at least partly owned by a hospital.

Physicians working directly for a hospital were 8% of all patient care physicians, an increase from 5.6% in 2012. Physicians in hospital-owned practices were 26.7% of all patient care physicians, an increase from 23.4% in 2012.

In the aggregate, 34.7% of physicians worked either for a hospital or in a practice at least partly owned by a hospital in 2018, up from 29.0% in 2012.

Younger physicians and women physicians are more likely to be employed. Nearly 70% of physicians under age 40 were employees in 2018, compared to 38.2% of physicians age 55 and over.

Among female physicians, more were employees than practice owners (57.6% vs. 34.3%). The reverse is true for male physicians, more were practice owners than employees (52.1% vs. 41.9%).

As in past AMA studies, physicians’ employment status varied widely across medical specialties in 2018.

The surgical subspecialties had the highest share of owners (64.5%) followed by obstetrics/gynecology (53.8%) and internal medicine subspecialties (51.7%).

Emergency medicine had the lowest share of owners (26.2%) and the highest share of independent contractors (27.3%). Family practice was the specialty with the highest share of employed physicians (57.4%).

Most physicians still work in small practices, but this share has fallen slowly but steadily since 2012. In 2018, 56.5% of physicians worked in practices with 10 or fewer physicians compared to 61.4% in 2012.

The AMA report said the transition has been driven primarily by the shift away from very small practices, especially solo practices, in favor of very large practices of 50 or more physicians.

The new study is the latest addition to the AMA’s Policy Research Perspective series that examines long term changes in practice arrangements and payment methodologies.

“Transformational change continues in the delivery of healthcare and physicians are responding by reevaluating their practice arrangements. ”

 

 

 

 

Healthcare Triage: Doctors’ White Coats Can Host a Lot of Bacteria

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Healthcare Triage: Doctors’ White Coats Can Host a Lot of Bacteria

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For a lot of doctors and patients, the physician’s traditional white coat is a big part of a doctor’s identity, and contributes to their authority. Those white coats can also spread disease! It turns out, fabrics in doctors coats can be a breeding ground for bacteria, and they probably don’t get cleaned often enough.

 

 

Why Your Doctor’s White Coat Can Be a Threat to Your Health

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A defining symbol of a profession may also be teeming with harmful bacteria and not washed as often as patients might hope.

A recent study of patients at 10 academic hospitals in the United States found that just over half care about what their doctors wear, most of them preferring the traditional white coat.

Some doctors prefer the white coat, too, viewing it as a defining symbol of the profession.

What many might not realize, though, is that health care workers’ attire — including that seemingly “clean” white coat that many prefer — can harbor dangerous bacteria and pathogens.

A systematic review of studies found that white coats are frequently contaminated with strains of harmful and sometimes drug-resistant bacteria associated with hospital-acquired infections. As many as 16 percent of white coats tested positive for MRSA, and up to 42 percent for the bacterial class Gram-negative rods.

Both types of bacteria can cause serious problems, including skin and bloodstream infections, sepsis and pneumonia.

It isn’t just white coats that can be problematic. The review also found that stethoscopes, phones and tablets can be contaminated with harmful bacteria. One study of orthopedic surgeons showed a 45 percent match between the species of bacteria found on their ties and in the wounds of patients they had treated. Nurses’ uniforms have also been found to be contaminated.

Among possible remedies, antimicrobial textiles can help reduce the presence of certain kinds of bacteria, according to a randomized study. Daily laundering of health care workers’ attire can help somewhat, though studies show that bacteria can contaminate them within hours.

Several studies of American physicians found that a majority go more than a week before washing white coats. Seventeen percent go more than a month. Several London-focused studies had similar findings pertaining both to coats and ties.

A randomized trial published last year tested whether wearing short- or- long-sleeved white coats made a difference in the transmission of pathogens. Consistent with previous work, the study found short sleeves led to lower rates of transmission of viral D.N.A. It may be easier to keep hands and wrists clean when they’re not in contact with sleeves, which themselves can easily brush against other contaminated objects. For this reason, the Society for Healthcare Epidemiology of America suggests clinicians consider an approach of “bare below the elbows.”

With the use of alcohol-based hand sanitizer — often more effective and convenient than soap and water — it’s far easier to keep hands clean than clothing.

But the placement of alcohol-based hand sanitizer for health workers isn’t as convenient as it could be, reducing its use. The reason? In the early 2000s, fire marshals began requiring hospitals to remove or relocate dispensers because hand sanitizers contain at least 60 percent alcohol, making them flammable.

Fire codes now limit where they can be placed — a minimum distance from electrical outlets, for example — or how much can be kept on site.

Hand sanitizers are most often used in hallways, though greater use closer to patients (like immediately before or after touching a patient) could be more effective.

One creative team of researchers studied what would happen if dispensers were hung over patients’ beds on a trapeze-bar apparatus. This put the sanitizer in obvious, plain view as clinicians tended to patients. The result? Over 50 percent more hand sanitizer was used.

Although there have been fires in hospitals traced to alcohol-based hand sanitizer, they are rare. Across nearly 800 American health care facilities that used alcohol-based hand sanitizer, one study found, no fires had occurred. The World Health Organization puts the fire risk of hand sanitizers as “very low.”

An article in The New York Times 10 years ago said the American Medical Association, concerned about bacteria transmission, was studying a proposal “that doctors hang up their lab coats — for good.” Maybe one reason the idea hasn’t taken hold in the past decade is reflected in a doctor’s comment in the article that “the coat is part of what defines me, and I couldn’t function without it.”

It’s a powerful symbol. But maybe tradition doesn’t have to be abandoned, just modified. Combining bare-below-the-elbows white attire, more frequently washed, and with more conveniently placed hand sanitizers — including wearable sanitizer dispensers — could help reduce the spread of harmful bacteria.

Until these ideas or others are fully rolled out, one thing we can all do right now is ask our doctors about hand sanitizing before they make physical contact with us (including handshakes). A little reminder could go a long way.

 

 

Doctors Are Fed Up With Being Turned Into Debt Collectors

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https://www.bloomberg.com/news/articles/2018-11-15/doctors-are-fed-up-with-being-turned-into-debt-collectors

Highlighting a key implication of the rise in high-deductible health plans, both on the ACA exchanges and in employer-sponsored insurance, the article describes a question now commonly faced by doctors and hospitals—how best to collect their patients’ portion of the fees they charge? As one Texas doctor tells Bloomberg, reflecting the experience of the Maldonados from the other side of the equation, “If [patients] have to decide if they’re going to pay their rent or the rest of our bill, they’re definitely paying their rent.” He reports that the number of people dodging his calls to discuss payment has increased “tremendously” since the passage of the ACA. Another Texas doctor reports that his small practice had to add an additional full-time staff member just to collect money owed by patients, adding further overhead to his practice’s costs and making it more likely that he, like many other doctors, will eventually seek shelter by being employed by a larger delivery organization. That trend, as has been repeatedly shown, further increases the cost of care, exacerbating the increase in insurance costs for families like the Maldonados. This Gordian knot of increasing costs, rising deductibles, and growing premiums has left us with a healthcare system that’s forcing difficult decisions at every turn, for patients and providers.

Physicians, hospitals and medical labs are grappling with the rise in high-deductible insurance.

Doctors, hospitals and medical labs used to be concerned about patients who didn’t have insurance not paying their bills. Now they’re scrambling to get paid by the ones who do have insurance.

For more than a decade, insurers and employers have been shifting the cost of care onto their workers and customers, tamping down premiums by raising patients’ out-of-pocket costs. Last year, almost half of privately insured Americans under age 65 had annual deductibles ranging from $1,300 to as high as $6,550, government data show.

Now, instead of getting paid by insurance companies on a predictable schedule, health-care providers have to engage in an awkward dance. One moment they’re removing a pre-cancerous skin mole. The next, they’re haranguing patients to pay what’s become a growing portion of the total medical bill.

“It’s harder to collect from the patient than it is from the insurance,” said Amy Derick, a doctor who heads a dermatology practice outside Chicago. “If the plans change to a higher deductible, it’s harder to get the patients to pay.”

Independent physicians cited reimbursement pressures as their biggest concern for staying in business, according to a report by Accenture Plc in 2015.

“If they have to decide if they’re going to pay their rent or the rest of our bill, they’re definitely paying their rent,” said Gerald “Ray” Callas, president of the Texas Society of Anesthesiologists, whose Beaumont, Texas, practice treats about 40,000 people annually. “We try to work with the patient, but on the other hand, we can’t do it for free because we still maintain a small business.”

Accenture

In 2016, Callas introduced payment options that allow patients with expensive plans to pay a portion of the bill upfront or on a monthly basis over several years. Even so, Callas said the number of people avoiding his calls after surgery has increased “tremendously” each year since the Affordable Care Act passed in 2010.

Derick instituted a “time-out” option a few years back that gives patients the billing codes before a procedure, allowing them to call their insurance companies for estimates. Even with the program, collection rates are slower, especially at the beginning of the year when insurance plan deductibles reset.

Even large medical companies with national operations are facing the problem. Quest Diagnostics Inc., the lab-testing giant, said 20 percent of services billed to patients in the third quarter of this year went unpaid, costing the company about $80 million in lost revenue.

“We certainly have a high bad-debt rate for the uninsured,” Chief Financial Officer Mark Guinan said in a telephone interview. “But really the biggest driver is people with insurance. It’s their coinsurance and their high deductibles, and they don’t always pay their bills.”

Another testing company, Laboratory Corp. of America Holdings, reported its first year-over-year uptick in unpaid bills in the first quarter of 2016. At the time, Chief Executive Officer David King said high-deductible plans, higher copays and greater incidences of non-covered services led to more dollars being shifted to patients. LabCorp declined requests for comment.

Northwell Healthcare Inc., a network of more than 700 hospitals and outpatient facilities, lost $106.9 million to unpaid services in 2015. Others have reported the same: Acute-care and critical-access hospitals reported$55.9 billion in bad debt for 2015, according to data compiled by the American Hospital Directory Inc. 

“High-deductible plans have had a very big impact,” said Richard Miller, Northwell’s chief business strategy officer.

Kaiser Family Foundation, American Hospital Association

When it comes to reimbursement, a common denominator across the health-care industry is the archaic process through which bills are processed — a web of medical records, billing systems, health insurers and contractors.

High deductibles only add to the red tape. Providers don’t have real-time, fully accurate information on patient deductibles, which fluctuate based on how much has already been paid. That forces providers to constantly reach out to insurance companies for estimates.

Tarek Fakhouri, a Texas surgeon specializing in skin cancer, had to hire an additional staff member just to reason through bills with patients and their insurers, a big expense for an office of six or seven employees. About 10 percent of Fakhouri’s patients need payment plans, delay their skin-cancer surgeries until they’ve met their deductibles, or have to choose an alternative treatment.

According to a study earlier this year by the Journal of American Medical Association, primary-care physicians at academic health-care systems lose about 15 percent of their revenue to billing activities like calling insurance companies for estimates.

“It’s an unnecessary added cost to the health-care system to have to hire staff just to sit there on hold with insurance companies to find out what a patient’s deductible status is,” said Fakhouri.

Callas, Derick, and Fakhouri said they all know physicians who have left private practice altogether, some for the sole purpose of ending their dual roles as bill collectors. According to a study by the American Medical Association, less than half of doctors were self-employed as of 2016 — the lowest total ever. Many left their own practices in favor of hospitals and large physician groups with more resources.

To cope with the challenge, labs and hospitals are investing millions in programs designed to help patients understand what they owe at the point of care. Northwell has been implementing call centers and facilities where patients can ask questions about their bills.

“There’s a burden on both sides,” said Callas. “But health-care providers get caught in the middle.”

 

Doctors Leaving Atrium Buck The National Trend Of Groups Joining Hospitals

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http://www.wfae.org/post/doctors-leaving-atrium-buck-national-trend-groups-joining-hospitals#stream/0

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Hospital systems have been on a buying binge the last few years, gobbling up doctors’ practices. By one estimate, nearly a third of medical practices nationwide are now part of a large hospital network.

But one large group of physicians is going in another direction – it’s breaking away from Atrium Health and opening an independent practice next month.
A whiteboard at the temporary Tryon Medical Partners office counts down the number of days till the practice opens. It’s made up of 88 primary care and specialty doctors who are leaving Atrium Health, formerly Carolinas HealthCare System. One of them is Dr. Dale Owen.

“Just because everybody else may be selling that doesn’t mean that we are not at the peak and it’s going to start the other direction,” he said. “Because I really think that’s what’s happening. Because we cannot keep doing the same thing. We can’t just keep buying up groups and then doctors not have any say and then expect a different outcome from the very same process each time.”

Owen is a cardiologist and CEO of the practice, called Tryon Medical Partners. The mood is different now than it was five months ago. Owen and the rest of the doctors sued Atrium so they could leave and start this practice. The hospital relented.

The doctors’ lawsuit said Atrium was making changes like cutting the number of registered nurses assisting doctors, and moving nurses from individual doctors’ offices and to a central a call center.

In preparation for the opening next month, rows of nurses are in a South Park office building taking calls from patients.

They answer questions from patients and schedule appointments. The practice will stagger the opening of eight locations in the Charlotte metro area throughout the next several months, roughly mirroring the locations of the Atrium affiliated Mecklenburg Medical Group’s offices.

What the doctors are doing is unusual. The national trend for the past several years has been practices joining hospital systems. As of 2016, about a third of doctors’ practices were owned by a hospital – a more than 100 percent increase in just four years, according to a study for the Physicians Advocacy Institute and Avalere Health. Hospitals bought 5,000 practices between July 2015 and 2016 alone.

Lisa Bielamowicz is a doctor and president of Gist Healthcare, a Washington D.C. based consulting company. She said hospitals are buying up these practices to grow their networks and keep patients in the system. Physicians sought stability and help with increasing administrative tasks due to increasing regulatory changes.

“So far there hasn’t been a ton of flux away from employment relationships. If you have health system employ hundreds of physicians, of course, there is going to be a handful chose to leave for a variety of reasons,” she said. “But it’s very rare that a group of dozens or more of physicians will leave en masse from a health system. Now that said given where the market is going and all of the change that’s occurring now it’s something that we would expect to see more of down the road.”

Because, Bielamowicz said, some doctors have found being an employee of a large health system isn’t all it’s cracked up to be.

“Most doctors are trained to be independent thinkers and don’t think of themselves as being employees of any organization even if someone is giving them a paycheck and a W2 every year,” she said. “The idea of a parent or employer organization putting limits around how they operate their office or how they would practice, the types of care that they deliver is something very difficult for a lot of physicians to adjust to.”

A few doctors from the original practice decided to stay with Atrium. The health system has said it’s hired nearly 50 providers who have already started or will start by October. As the opening date nears, Owen said his adrenaline is high and he’s excited to practice on his own terms.

“There have been lots of people who said it was going to be too hard to be independent and you can imagine that the hospitals might think that and other independent organizations because they were already independent. Plus, when you are the first do it at this kind of scale and on the backs of primary care. Everybody is going to be watching it.”

Owen and the doctors will start seeing patients the first week in September.

 

 

Atrium Health releases 92 physicians looking to break away

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https://www.beckershospitalreview.com/hospital-physician-relationships/atrium-health-releases-92-physicians-looking-to-break-away.html

Hospital-Physician Relationships

Charlotte, N.C.-based Atrium Health said April 25 it will grant the request of a group of physicians looking to separate and end their employment agreements with the health system Sept. 1, according to The Charlotte Observer.

In an emailed statement to Becker’s Hospital Review April 25, Atrium confirmed it will release a group of roughly 92 Mecklenburg Medical Group physicians from their noncompete agreements, effective Sept. 1. The physicians will continue practicing as part of the health system until Aug. 31.

“While we were hopeful that our many months of discussions would lead to an acceptable solution for everyone involved, we will not seek to prevent these physicians from forming a standalone practice,” the health system told Becker’s.

Atrium said it will also offer the physicians new employment agreements “in the hopes they remain at Atrium Health and their MMG practice … and join the other 1,900 physicians who provide care for our patients,” the health system told Becker’s.

The group of roughly 92 Mecklenburg Medical Group physicians filed a lawsuit against Atrium April 2, arguing the health system engaged in monopolistic and anticompetitive behavior. Atrium said the same day it would allow the physicians to leave the organization. On April 16, the physicians filed a complaint against the health system with the North Carolina Medical Board, alleging the health system violated board regulations by intentionally misleading patients.

Atrium acquired Mecklenburg Medical Group in 1993, according to The Charlotte Observer. In a statement to the publication, the physicians said their attorneys will meet with Atrium’s lawyers to further assess the situation.

Atrium Health CEO Eugene Woods told The Charlotte Observer the health system is in the process of hiring roughly 20 physicians to help fill the vacant positions left by physicians planning to leave Mecklenburg Medical Group. The health system also previously offered to give employees who choose to say a bonus of up to 10 percent of their salary if they remain through the end of the year.

“We feel for our staff, and our first concern was making sure that they feel that we’re with them,” Mr. Woods told the publication. “We offered them retention bonuses because some of them were scared about what the future is going to be.”

 

 

Orthopedic Urgent Care Franchising is THE Opportunity of 2018

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https://medcitynews.com/?sponsored_content=orthopedic-urgent-care-franchising-opportunity-2018-2&utm_campaign=MCN%20Daily%20Top%20Stories&utm_source=hs_email&utm_medium=email&utm_content=61259603&_hsenc=p2ANqtz-9KZbK2I0aYCjcH-L8_oANZXZSsq2K8jondsl8vHF0rHfcb8_zR65kRtQV-cDsnd_VomLuc-G2in5Y4wJcsFWrR8zgKJg

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Healthcare Executives, Physicians, and Healthpreneurs dealing with hospital spending cuts, reduced insurance reimbursements, and reduced market share are looking for solutions to earnings loss which is giving rise to the innovations in specialized focused urgent care.

The economic pressures coupled with the need for lifestyle balance cause many in the healthcare industry to look for alternatives and franchising is leading this nationwide healthcare overhaul.

With approximately 9,000 urgent care centers in the United States offering generalized care, OrthoNOW is the only franchised care center of its kind in the United States — a unique position to gain market share in this highly fragmented industry.

OrthoNOW’s focus is on sports medicine and the treatment and prevention of the full range of orthopedic injuries, all on a walk-in basis. Services include treatment of injuries to the hand, wrist, foot, ankle, knee, spine and shoulder, as well as preventative consultation and regimens by experts in orthopedics.

Strong interest in the brand is being fueled by CDC estimates that injuries have a $671 billion annual impact on the U.S. economy — orthopedic medicine contributes $48 billion to the GDP and urgent care centers produce an additional $30 billion in revenue. Further, 160 million patients seek out urgent care each year; 48 million of those patients will require orthopedic care who, without access to, are referred to the local emergency room only to be redirected to a specialist following a long and expensive visit.

“OrthoNOW offers an innovative turn-key solution with a comprehensive support system built in. Our corporate staff consists of veteran business, medical and franchise professionals who work closely with our franchisees and provide ongoing support. Thus, our operations are efficient and effective,” says Christine Dura, Chief Development Officer. “We have more than 1,000 territories available, and we are aggressively targeting proven multi-unit operators and Regional Developers who understand the power of scalability.”

Have you ever wondered how owning a proven franchise model in healthcare could change your financial future? OrthoNOW’s power-packed 30 minute webinar is the place to start. Get expert answers to your most pressing questions. Some will watch and miss the opportunity. Some may even try a solution on their own. Regardless, their proven model leads the charge in delivering the healthcare solutions many Americans need NOW.

Answer the call of millions of Americans in need of expert and affordable healthcare. Join OrthoNOW’s webinar on February 28, 2018, which covers the four big questions in franchising:

  • Am I the right fit?
  • What is my investment?
  • How much money can I make?
  • Why OrthoNOW?

MedPAC votes 14-2 to junk MIPS, providers angered

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http://www.modernhealthcare.com/article/20180111/NEWS/180119963

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The Medicare Payment Advisory Commission voted 14-2 to repeal and replace a Medicare payment system that aims to improve the quality of patient care. Providers immediately slammed the move.

To avoid penalties under MACRA, physicians must follow one of two payment tracks: the Merit-based Incentive Payment System, or MIPS, or advanced alternative payment models like accountable care organizations.

On Thursday, the Commission voted to asks Congress to eliminate MIPS and establish a new voluntary value program in which clinicians join a group and are compared to each other on the quality of care for patients. Physicians who perform well would receive an incentive payment. The suggestion will be published in the advisory group’s annual March report to Congress.

MedPAC wants to junk MIPS because it believes the system is too burdensomefor physicians and won’t push them to improve care. Members have criticized the program’s design for primarily measuring how doctors perform, including whether they ordered appropriate tests or followed general clinical guidelines, rather than if patient care was ultimately improved by that provider’s actions.

The CMS estimates that up to 418,000 physicians will be submitting 2017 MIPS data.

Prior to the vote, the majority of the debate centered on whether or not MedPac had developed an adequate replacement for MIPS.

David Nerenz, one of the no votes, said he was against the replacement because he worried that only providers with healthy patients would ban together, while those with high risk patients would face difficulty finding anyone to partner with.

He also said evidence was lacking that the group reporting approach would be an effective way to hold providers accountable for quality.

Dr. Alice Coombs, a commissioner and critical-care specialist at Milton Hospital and South Shore Hospital in Weymouth, Mass., was the other no vote. She said she was against getting rid of MIPS as providers are just now getting used to it. Those concerns increased when MedPac staff noted that MIPS repeal likely wouldn’t take place until 2019 or 2020 depending when or if Congress accepted its recommendation.

Warner Thomas, a commissioner and CEO of the Ochsner Health System in New Orleans, LA voted yes, but said he did so with some trepidation as MedPac had not received comments from industry that they were supportive of what the Commission was doing in terms of repealing and replacing MIPS.

“There hasn’t been any support from the physician community around this, and we should be cautioned by that fact,” Thomas said.

Clinicians and providers criticized MedPac following the vote.

“I think they’re wrong,” Dr. Stephen Epstein, an emergency physician at Beth Israel Deaconess Medical Center in Boston said in a tweet. “MIPS could change practice patterns by aligning incentives with performance measures.”

The Medical Group Management Association said it did not support the Commission’s suggestion for a replacement to MIPS.

“It would conscript physician groups into virtual groups and evaluate them on broad claims-based measures which is inconsistent with the congressional intent in MACRA to put physicians in the driver seat of Medicare’s transition from volume to value,” Anders Gilberg, senior vice president of government affairs at MGMA said in a statement.

 

By the Numbers: E-Visits Not Hitting the Mark?

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https://www.medpagetoday.com/PublicHealthPolicy/by-the-numbers/67379?xid=nl_mpt_DHE_2017-08-19&eun=g1061559d0r&pos=0

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Study shows more work, fewer new patients, little health benefit.

Telemedicine and other “e-visits” are supposed to be a win-win for physicians and patients alike. Doctors could spend less time on simple requests, patients would get frictionless access to their provider.

But a new study published in Management Science finds that all that access hasn’t translated into the outcomes so many had hoped for. Instead, e-visits lead to more office visits and more phone consultations without measurable improvement to patients’ health. And maybe most damaging for physicians’ practices, they’re associated with fewer new patients.

The findings may be surprising, but study leader Hessam Bavafa, PhD, of the University of Wisconsin School of Business, said they make sense when you consider the process of the usual e-visit. Patients can reach out with even the smallest concerns, he said, and that puts doctors in a bind.

“There’s an issue of obligation,” Bavafa told MedPage Today. “If you ignore the signal, who knows what’s going to happen next, right?”

The study used five years of data from a large health system with multiple hospitals and more than 2,000 total beds. It included all primary care encounters for 140,000 patients from 2008 to 2013, including office visits, phone calls, and e-visits, all cholesterol tests, and all blood glucose tests for the physicians with the largest panel sizes. It was limited, however, to those patients who had three or more office visits over the period analyzed, as the study was designed to focus on active healthcare users.

The results were stark. After adopting e-visits — in this instance, essentially an email with a subject line and generic box of text — office visits increased by 6% as physicians met with patients who had reached out online. Physicians also ended up spending 45 more minutes each month on those visits.

Oh, and the extra work of responding to patients requests did not bring extra compensation. “God knows what happens if you start paying doctors for these,” Bavafa said.

And with the increased workload came a corresponding 15% drop in the number of new patients physicians saw.

Bavafa said the findings are a natural consequence of physicians’ limited time: if one patient group is getting more of it, another will feel the squeeze.

But Peter Yellowlees, MD, president of the American Telemedicine Association, said the findings go against his own experience and much of the literature.

He questioned the wisdom of excluding patients who had fewer than three office visits. That eliminated a large group of patients, he pointed out, and may have affected the outcome.

“Effectively they only looked at two-thirds of the patients, which is a bit odd to me,” he said. “It’s perfectly reasonable that those people had problems that could be managed with an occasional email and everything’s fine and they don’t need to come in.”

He also pointed to strong adoption of e-visits in the paper as evidence of their value. The study found fewer than 100 monthly e-visits in 2008. By the end of the period analyzed, that had ballooned to nearly 6,500.

“As a physician, we don’t do things that we don’t think are worthwhile. That level of adoption is strong evidence, from my perspective, that this is a really good idea,” Yellowlees said.

He also wondered whether some other change within the system analyzed could have led to the changes observed. He said the e-visits couldn’t be considered causative.

While he didn’t agree with the findings, he said he was happy to see a study try to examine their impact.

Bavafa, too, was hopeful about the future of e-visits and other telemedicine efforts. Already, he said, some providers are toying with pricing to see if they can affect the way patients communicate with their doctors. The experiments include charging a “subscription” fee for electronic access to doctors, or even a charge for each individual contact.

He compared the current process to Amazon in the 1990s, or taxis as opposed to Uber and Lyft.

“This is the future, we just have to think about how to do it,” he said. “The ideas may not be novel, but it’s about figuring out the whole ecosystem.”