As a longstanding proponent of telehealth and telemedicine, the AAFP has for years worked to raise family physicians' awareness of the benefits of telemedicine and remove barriers to use of these services. The Academy recently showcased that support in comments to the Federal Communications Commission(4 page PDF) on a proposed $100 million telehealth initiative, as well as in its response to CMS' proposed 2020 Medicare physician fee schedule,(61 page PDF) both of which cited the AAFP's policy on telehealth and telemedicine. The Academy also offers other resources on the topic, including a free webinar on implementing telemedicine in the clinical practice.
Yet despite these efforts, FPs have been slow to adopt this technology.(www.graham-center.org) Now, results of a study(www.jabfm.org) in the November-December issue of the Journal of the American Board of Family Medicine illustrate some of the obstacles hindering widespread adoption. The study, which examined telemedicine use in more than 7,500 practicing family physicians across the country, found that only a small percentage of FPs offered e-visits to patients. It also highlighted factors associated with whether FPs offered e-visits and other telemedicine services.
Study Methods and Findings
The study authors reviewed data from the 2017 ABFM Family Medicine Certification Examination practice demographic registration questionnaire for 7,580 FPs seeking continued certification. In particular, they focused on a question that categorized the number of hours FPs spent on various activities, including e-visits. Additional data was obtained from ABFM administrative databases.
- A recent study of more than 7,500 family physicians found that nationally, only slightly more than 9% of practicing FPs offered e-visits.
- Several factors were associated with whether FPs offered e-visits, including practice type, scope of practice and practice ownership status.
- The study authors suggested that reimbursement and time were the leading factors behind the low uptake.
The researchers then conducted two analyses: one based on whether FPs offered e-visits and one that predicted the likelihood of offering e-visits based on several factors.
Of family physicians included in the sample, 9.3% reported offering e-visits. Bivariate analysis found statistically significant differences in the likelihood of offering e-visits by gender, with women more likely than men to offer e-visits, and medical school training, with graduates of U.S. medical schools more likely than international medical graduates to offer e-visits.
Other factors associated with the likelihood that FPs offered e-visits included
- partial ownership or shareholder status in the practice,
- working in a practice that included 20 or more clinicians,
- having a broader scope of practice,
- working between nine and 32 hours per week, and
- practicing in a capitated reimbursement model such as an HMO or in a federal health system such as the Department of Veterans Affairs or Department of Defense.
Logistic regression identified several variables that predicted whether an FP offered e-visits, including the following.
- Race. Black and American Indian/Alaska Native FPs were 46% and 28% more likely, respectively, to provide e-visits than white FPs.
- Practice ownership status. Compared with sole owners, FPs with no official ownership stake or some other type of ownership arrangement were between 56% and 71% less likely to offer e-visits.
- Practice size. Compared with solo practices, practices with between two and five providers were 4% less likely to offer e-visits. However, practices with six or more providers were up to 45% more likely to offer e-visits.
- Faculty status. FPs who held volunteer/clinical faculty status were 41% more likely to offer e-visits than FPs who did not.
- Primary practice type. Compared with those in private practice, FPs who worked in a federal health system were more than four times as likely to offer e-visits and those who worked in a managed care setting were nearly 10 times as likely to do so.
Overcoming Barriers to Use
Looking at the primary factors related to whether family physicians offered e-visits, the authors offered their perspective on what factors may be holding them back.
First, the fact that FPs who worked in large, financially strong practice settings such as HMOs or federal health systems were significantly more likely to offer e-visits than those in private practice suggests that reimbursement is a barrier to implementing e-visits, they said. Previous research, including a 2017 study(www.jabfm.org) that also was published in JABFM, appears to support that claim.
The authors noted that although reimbursement remains a barrier to adoption of telemedicine overall, the issue has drawn the attention of legislators and policymakers. "Therefore, it is possible that reimbursement for e-visits will expand over time," they wrote.
In addition, the finding that physicians with fewer than 40 hours a week devoted to patient care were more likely to adopt e-visits suggests that time is a key barrier to implementing e-visits, the authors noted. Specifically, integrating e-visits into the practice workflow may be difficult for FPs who devote most or all of their time to direct patient care. Given that research indicates(www.annfammed.org) FPs are increasingly adopting part-time work schedules to balance work/life demands, some health systems have adopted strategies such as setting aside protected time for e-visits or designating other clinicians to manage e-visits.
The authors called for research to determine which patients and conditions could best be managed through e-visits. Such research, they wrote, could also lead to improvements in reimbursement, quality of care and documentation.
Implications for Family Medicine
Theresa Wilkes, M.S., medical informatics strategist with the Academy's Alliance for eHealth Innovation, told AAFP News that for the typical FP, hesitancy to adopt telemedicine is multifactorial but indeed largely relates to the key factors identified -- payment and time, along with a desire for more education around telemedicine.
"In the fee-for-service world, reimbursement is a major barrier to expanded use of telemedicine, including e-visits," Wilkes explained. "The reimbursement barrier is dissipated in a value-based care and payment environment, and it dissolves entirely in a capitated environment, where viability and financial health are entirely dependent upon using tools and strategies that generate time and cost savings that can be retained within the practice.
"If payment is a nonissue, FPs are freer to be innovative and do what is best for their patients and their unique patient population, using the tools of interest -- such as e-visits -- that make sense for their specific practice."
Along those lines, Wilkes pointed out that the study did not mention considering direct primary care.
"The defining characteristic of a DPC practice is that it offers patients the full range of comprehensive primary care services -- including acute and urgent care, regular checkups, preventive care, chronic disease management, and care coordination -- in exchange for a flat, recurring membership fee that typically is billed to patients every month," Wilkes said. "FPs in DPC practices or partially to fully capitated payment models are very frequently offering e-visits to their patients because it makes sense to do so."
Regardless of practice type, additional reforms are needed to ensure that FPs are paid properly for the services they provide, said Wilkes.
"The big picture takeaway from the low/slow adoption of telemedicine among FPs is the way FPs are being reimbursed today does not ideally support and enable us to implement practice innovations to the extent practices are interested in doing so," she said. "Primary care needs to be paid differently so we can do the things that benefit our patients and practices.
As payment reforms to advanced payment models and more global payments evolve, incorporating these types of tools and technologies will become a more feasible, easier lift."
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