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Fam Pract Manag. 2005;12(6):30-32

E-mail consults get thumbs-up

The ringing of the telephone could soon be replaced by the clicking of computer keys in medical practices across the country, as both doctors and patients grow more comfortable with e-mail exchanges.

“I've got my e-mail open anyway,” said California accountant Brian Settlemoir, quoted in the March 2 New York Times. “It's much easier than calling [my doctor's office] and getting voice-mail prompts and sitting on hold.”

More and more patients echo Settlemoir's sentiment, saying they don't want to leave work and spend time in a waiting room or on hold to ask basic questions. They also say the personal correspondence makes them feel more relaxed and closer to their physician.

For doctors, e-mail offers a convenient way to interact with far more patients than the standard day would allow, reducing the number of office visits and providing more time for face-to-face consults.

Preliminary research at the University of California has found that using e-mail improved physician productivity, decreased overhead costs and improved access while diminishing telephone calls.

Insurers have given their approval as well. Some – such as Cigna, Harvard Pilgrim and numerous Blue Cross and Blue Shield subsidiaries – pay up to $30 for each online visit. Others pay less but offer a $5 to $10 co-pay billed to patients' credit cards. Still other insurers – such as Kaiser Permanente and Fallon Community Health Plan – have gone so far as to implement secure, Web-based, patient-messaging programs.

A bill in the House of Representatives includes a provision to authorize Medicare to make “bonus payments” to doctors for e-mail consultations. If approved, the bill may encourage other insurers to follow suit.

PRACTICE PEARLS from here and there

Aim for perfection

Improving your practice's quality of care often takes bold ideas. For example, instead of comparing your performance to national benchmarks or trying to match your local competition, set your goals higher: Aim for perfection. Benchmarks can contain a number of defects, and pursuing them may merely make you “the cream of the crap.”

Reinertsen JL, Schellekens W., 10 Powerful Ideas for Improving Patient Care: What Every Healthcare Executive Should Know, Health Administration Press; 2005.

Community-based project offers help with depression coding

A coalition of physicians, health plans and employers in the Kansas City, Mo., metropolitan area recently completed a community-based project aimed at overcoming barriers to effective treatment of depression. For primary care physicians, lack of reimbursement for depression-related services was identified as a key obstacle.

To address this, the Mid-America Coalition on Health Care developed a work group of health plans, physicians and medical office managers, which conducted an unprecedented analysis of over 100,000 primary care claims for depression-related services as well as multiple test claims for fully insured benefit plans.

Their study, “The Life of a Depression Claim,” found that when primary care physicians submit an evaluation and management office-visit code (e.g., 99201-99205 or 99211-99215) along with an appropriate ICD-9 depression diagnosis code (see “Recommended ICD-9 codes”) the visit will generally be paid according to the patient's benefit plan. Primary care physicians should not use psychiatric or psychotherapy codes (90801-90899) with a depression claim, according to the study, as these codes are generally reserved for psychiatric providers only.

Of the 100,000 primary care depression claims studied, 3,176 had a primary diagnosis of depression. Of these claims, 270 were not paid; however, less than 1 percent were denied because of the depression diagnosis. Most denials were the result of the patient needing to meet his or her deductible or a co-insurer being responsible for the claim.

The workgroup recommended that primary care physicians contact their health plan representatives to resolve non-paid depression claims.

For additional information on the project, visit


  • 311, depressive disorder, NOS,

  • 296.90, mood disorder, NOS,

  • 300.00, anxiety disorder, NOS,

  • 296.21, major depressive disorder, single episode, mild,

  • 296.22, major depressive disorder, single episode, moderate,

  • 296.30, major depressive disorder, recurrent,

  • 309, adjustment disorder with depressed mood,

  • 300.02, generalized anxiety disorder,

  • 293.83, mood disorder due to medical condition (e.g., postpartum depression),

  • 314 or 314.01, attention deficit/hyperactivity disorder (inattentive and combined types).

Note: The above codes resulted in paid claims during the test period; however, other codes might also be appropriate and reimbursable.

Small practices struggle to adopt quality improvement methods

Increased costs, poor reimbursement and insufficient staff support may stand in the way of physicians' adoption of quality improvement methods and technologies, according to a national survey from the Commonwealth Fund, published in the May/June issue of Health Affairs.

The survey of more than 1,800 physicians found that just one-fourth report using an electronic health record routinely or occasionally, one-third are involved in efforts to redesign systems to improve care, and one-third have access to data about the quality of their own clinical performance.

Physicians in solo or small practices are least likely to be involved in quality improvement efforts. They “simply don't have a quality infrastructure in place, and find themselves facing significant financial barriers to adopting information technologies and systems needed for quality improvement,” said Anne-Marie Audet, MD, lead author of the Health Affairs article and assistant vice president at the Commonwealth Fund. “Since nearly three-quarters of physicians in this country are in solo or small group practice settings, it is critical that those designing quality improvement tools and incentives take this fact into consideration. We have done best to date in designing tools and solutions for large groups of doctors or for those who practice in networks of care or hospitals, but much remains to be done to foster adoption of quality improvement by the individual physician.”

Interestingly, the study found that primary care physicians were more likely than specialists to be involved in practice redesign efforts (40 percent vs. 31 percent).

Potential strategies for increasing involvement are to create payment policies that reward quality or even involvement in QI work, to improve QI training in medical schools, residencies and recertification programs, and to establish quality measures aimed at physicians' offices (vs. hospitals or health plans).

The AAFP is currently involved in an initiative to develop such measures.


The quality improvement cycle (plan, do, study, act) depends on having essential data, which many physician practices lack, according to the survey:

  • 84 percent find it difficult or impossible to identify patients taking high-risk medications that might require follow-up care (e.g., patients taking warfarin);

  • 83 percent find it difficult or impossible to generate a list of patients with abnormal test results (e.g., patients whose hemoglobin levels indicate anemia);

  • 56 percent find it difficult or impossible to generate a list of patients by diagnosis or health risk (e.g., those with diabetes or hypertension);

  • 18 percent have data on their patients' outcomes (e.g., the percentage of patients with diabetes who have good glycemic control).

Source: Audet AJ, Doty MM, Shamasdin J, Schoenbaum SC. Measure, learn and improve: physicians' involvement in quality improvement. Health Affairs. May/June 2005;24(3):843–853.

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