You’ve got mail? Not from the doctor

Every lawyer that I know has a Blackberry (or equivalent). They are always available to their clients and colleagues. Of course, I would bet that they do charge a bit for answering email.

Most physicians still avoid email as a method for patient communication. Are we luddites? Perhaps we do reject change more than other professions. More likely, we do not see the business case for adopting email.

Barely a quarter of physicians use e-mail or other electronic communication to reach patients, up from 20% four years ago, according to the Center for Studying Health System Change, a Washington-based research institution.

By comparison, more than half of doctors use computers to store and access patient notes, up from 37% four years ago.

The limited interaction between doctors and patients on the Internet is a symptom of a healthcare system that in many ways is disconnected from patients’ needs, some experts said.

“Most businesses have e-mail because that’s what their customers want,” said David Cutler, a health economist at Harvard University. “Customers want convenience, but nobody in healthcare gets paid for it.”

Some health plans have begun reimbursing doctors who interact with patients on specially created websites, but the numbers are still negligible and for the most part doctors are not paid unless they see patients face to face.

In their offices, however, doctors are under constant pressure to curtail the time spent with patients because they are paid by volume, said Dr. Marcy Zwelling-Aamot, an internist with a private practice in Los Alamitos and a former president of the Los Angeles County Medical Assn. The last thing most of them want is to give patients another way to get ahold of them.

“They don’t want to be bombarded,” said Zwelling-Aamot, who runs a concierge practice, meaning she doesn’t take insurance. Her patients pay her $1,500 a year for full access to her services, including e-mail consultations. But “I have 500 patients,” she said. Other doctors may “have 3,000 patients.”

Wider use of electronic communication could save time and money and improve quality of care, those who use it say.

I believe that our payment methods (not willing to call it a system) make no sense. We are not paid for the amount of work necessary to properly care for the patient. We are paid a fixed rate for a visit.

Imagine going to a lawyer who charges a fixed price for a will. Now image going to another lawyer who specializes in estate law. If you have a modest income and estate, lawyer number one will save you money now and in the future. If you have a large income and estate, you will want to invest the extra money in obtaining the right lawyer - the estate expert. And you will gladly pay more. You will also understand that the cost will depend on how long the lawyer has to spend on the documents. If you want to talk longer, you just pay a bit more (or with many lawyers more than a bit more).

We understand the relationship of cost and time. Yet in medicine we do not receive compensation based on time, but rather based on unit. Now I know that we have a slight gradation based on the complexity of the visit, but most internists that I know bill level 3 or 4 the great majority of the time. Those who “understand” the billing system also understand that you can bill a level 3 for a 10 minute visit or for a 30 minutes visit.

When you only commodities are knowledge and time, the compensation system will drive the amount of time you can afford to spend with each patient. Thus, many physicians try to shorten the time for each visit - so that they can squeeze more visits into their day. These physicians see email as a non-reimbursed activity, which costs time.

Many physicians thus avoid email communication as another cost of time. The excuses against email communication are actually quite lame. There are secure methods for patient communication. Most insurers do not pay for email. Physician avoidance is mostly about money.

If we do not address the financial inequities among physician activities, then we cannot take advantage of technology to improve care. Our reimbursement methods are the problem. They cause the majority of problems in health care access. They drive the use of testing and procedures. We cannot really fix the current system, we should really start over from scratch.