House calls are making a comeback, with a virtual twist: Three of the Sacramento region's four major health providers – Kaiser Permanente, UC Davis Health and now Sutter Health – offer video visits with primary care providers.
Dignity Health, the region's fourth major provider, is exploring these services.
Telemedicine began as a way to get specialists to patients in remote areas almost instantaneously. The technology has been adopted rapidly, and now, primary care providers can be consulted by phone for about one-third of the cost of an office visit.
There is a $40 flat rate for a video visit through UC Davis Health and a $49 flat rate for a video visit through Sutter. By comparison, a standard office visit at Sutter costs a flat rate of $129 out of pocket, with most major insurance plans accepted for the service.
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Sutter patients will be charged the same co-pay for a regular office visit, but insurance is not accepted for the service at UCD Health. At Kaiser, the majority of members are not charged for video visits. Based on their coverage, some Kaiser members have a co-pay.
"The benefit of a video visit is its convenience for those common ... illnesses such as a cold, flu, pinkeye, rash or sore throat, especially after hours or on weekends when regular clinics are closed and there’s no apparent need for an emergency room visit," explained UCD Health spokesman Charles Casey.
That means video visits are largely used to consult on minor or common illnesses or injuries such as rashes, bug bites, eye problems and allergies. Patients access these virtual services through their computers or mobile device, similar to a Skype or FaceTime session.
A virtual provider might ask a patient whether they have checked their temperature, Casey said, but otherwise vitals are not checked through traditional means.
"If actual vital signs are required … the virtual clinic provider will escalate the case and refer the patient to either their primary care provider, urgent care, or the emergency department of a nearby hospital," he said. "And if the case is because the symptoms were concerning, the virtual clinic visit fee could be waived since the visit was abbreviated for patient safety reasons."
Sutter, which launched its video house calls in March, already has exceeded the targets it expected to reach over the last few months, said Dr. Veena Jones, the medical director for digital patient experience and a pediatrician at Sutter. The health care companies all strive to provide same-day service for patients seeking video visits, typically staffing the service with the same nurse practitioners and physician assistants who work in walk-in clinics.
Why the move to virtual visits? Health care companies are seeing a growing number of people who are not only willing but demanding to consult medical professionals online. For Kaiser, online visits have begun to surpass in-person visits in recent years, according to its national statistics. In 2017, 59 percent of all provider-patient encounters were virtual. Over the past year, there was an 18 percent increase in visits to KP.org and a 17 percent increase in prescriptions filled online.
Mei Kwong advocates for policies that expand and improve telehealth services as executive director of the Center for Connected Health Policy. She said patients don't have to pay for things like parking if they're doing a home visit or additional fuel costs if they're consulting from a rural hospital. Certainly, she said, providers have to make an initial investment in equipment.
Plus, patients are taking less time from work, Kwong said, and they are likely to see a provider sooner than if they waited for a face-to-face appointment, meaning they are diagnosed earlier and can be served by less-costly treatments.
Telehealth services already have been shown to save lives at one of the region's leading health care providers: Kaiser Permanente restructured its emergency room to ensure a telestroke neurologist was available around the clock at all 21 of its Northern California stroke centers. Because of this redesign, emergency personnel were able to administer the life-saving medication alteplase in nearly half the 60-minute time period recommended by the American Stroke Association, according to a study from the medical journal Stroke.
"Researchers found that Kaiser Permanente Northern California care teams are administering alteplase to stroke sufferers with an average 'door-to-needle' time of just 34 minutes," according to Kaiser Permanente spokesman Edwin Garcia. "These impressive figures are no small feat considering the challenges of pulling together a closely coordinated team of neurologists, physicians, nurses, radiologists and rehabilitation therapists, all in the span of minutes."
At the heart of advancements in virtual care technology is increased access, especially for residents in rural communities. A Yuba City resident who is able to connect with a Sacramento specialist while still in Yuba City through a virtual visit may need a blood transfusion. Instead of having that service done during their visit to Sacramento, the resident can go to a local clinic.
“You’re keeping that money in your community," Kwong said.
In October 2017, when fires were rampant in Ukiah, Adventist Health employees were present to provide on-site help. When it became impossible to enter and leave the area, the health group used virtual care technologies to connect with residents and continue to offer mental health services.
Through the use of these services, Adventist Health has improved access to care for patients, said Cynthia Scheideman-Miller, the director of virtual care at Adventist Health System West.
“We’ve had people who’ve waited two years to see a rheumatologist, and we can get them in two weeks," she said. “Yes, there’s dollars saved by the patients, but it’s more than that."
For the past 10 years, health specialists at Dignity Health have been using mobile, remote presence robots that allow over 23 sites access to subspecialties that might not otherwise be available. At the hospital in Merced, for example, there are no inpatient neurology services, but Dr. Lucian Maidan, a neuro-endovascular surgeon at the Mercy San Juan Medical Center, said that through teleneurology services, the Merced location has gained access to neurological care.
"By evaluating patients right away, even if we don't fly them in, .... we help them to guide the patient to the best specialist," Maidan said.
There are 17 neurologists in Maidan's group and he takes six shifts each month providing teleneurology services, which are offered 24/7. This specialized technology allows Dignity Health facilities "access to specialists in areas such as neurology, cardiology, neonatology, pediatrics and mental health," according to the Dignity Health website.
"These mobile videoconferencing machines move on wheels and typically stand about 5 feet, with a large screen that projects a doctor’s face," the website states. "They feature cameras, microphones and speakers that allow physicians and patients to see and talk to each other."
Providers using virtual care to communicate with patients can control their designated robot's movements and can do so outside of work, as long as they have a secure internet connection.
In addition to the video visit services that UC Davis Health provides for non-emergency situations, similar services are also used for follow-ups with patients post-surgery. Dr. Mark Avdalovic, a professor of clinical medicine who works in pulmonary, clinical care and sleep medicine for UC Davis Health, said telehealth technologies have resulted in improved access to specialists and greater convenience for patients.
Avdalovic specifically mentioned the benefit to patients who come to UC Davis as a destination health facility, who may have traveled from upward of three or four hours away, who can communicate with their provider online instead of traveling back to the Sacramento facility. On top of improved access, because follow-up visits are bundled into the cost of the procedure, there is no additional cost to use the virtual service.
Avdalovic said he has seen the value of the service for local patients as well. At work, for example, instead of taking the time to leave the office for a simple medical question, patients can instead take 15-20 minutes and have an appointment in the privacy of their offices.
As telehealth services become more of the norm, health care providers are adjusting to providing care through a screen. And, likewise, patients are adjusting to receiving care virtually. Even though nurses at Dignity Health prepare patients for the experience of communicating with their doctor through a moving screen, Maidan said, some patients start laughing once they see a specialist's projected face.