Accessing a primary care physician through your smartphone for common ailments like a sore throat, pinkeye or the flu is becoming easier in Iowa as more health systems and providers introduce telemedicine services. It’s also becoming more common for Central Iowa employers to offer a telemedicine option through company health plans. 

Although telemedicine service has been ramping up over the past several years in the state, it’s been relatively slow to catch on with patients, even in metro areas such as Greater Des Moines where residents have several options to choose from. 

A new state law that goes into effect on Jan. 1 will require health insurers to cover health services that are provided virtually to the same extent that they cover in-person care. Providers and insurers interviewed for this story say the new law should help spur more demand for telemedicine service, which they say is destined to play a much larger role for health care in Iowa. 

SLOW UPTAKE

In April 2015, the Iowa Board of Medicine approved a rule governing standards of practice for physicians who diagnose and treat patients via online devices, which established the ground rules for providers offering telemedicine. Among the major Iowa-based health systems that have introduced telemedicine over the past three years are University of Iowa Hospitals and Clinics, Mercy Health Network, UnityPoint Health, and the Iowa Clinic. 

National telemedicine providers are also taking an interest in Iowa. In October, 98point6, a 3-year-old Washington state startup, began offering services in Iowa as its 36th state, with a goal of operating nationwide with an in-house group of physicians licensed in every state. 

The slow uptake of telemedicine services is not limited to Iowa. According to the Kaiser Family Foundation’s 2018 Employer Health Benefit Survey, telemedicine visits still represent fewer than 1 percent of total outpatient visits, and do not appear to be significantly replacing traditional in-person physician visits. 

Employer health plans — particularly those offered by large employers — are becoming more likely to provide a telemedicine service as one of their benefits. According to the Kaiser survey, 67 percent of all employers surveyed said telemedicine is offered under their largest-enrollment health plan. 

ENGAGING EMPLOYERS WILL BE KEY

The Iowa Clinic has been working for about five years on developing its telemedicine service, which it recently expanded to offer to people who aren’t regular patients of the clinic, said Kevin Cunningham, chief medical officer. 

“There was expectation that engagement would be high, and it has been in some areas,” he said. “It’s very few and far between for our own patients at this point. Part of that is we haven’t offered it 24/7.”  

Kelly Reed, a family medicine physician with the Iowa Clinic in Urbandale, oversees a team of three Iowa Clinic physicians who currently provide telemedicine care through its eClinic platform. Patients who have used the service range widely in age, she said. 

“We are certainly recognizing that everybody works long hours, and we have millennials who are very tech-savvy,” she said. “But you’d be surprised at how many seniors are becoming tech-savvy also and are utilizing services like this. … It is a service that we’re fine-tuning, and one that I think will become much larger and much more well-utilized as time goes on.”  

Engaging local employers in offering telemedicine will be one of the keys to increasing the rate, Cunningham said. He expects the eClinic service will transition to a 24-hour service within the next two years, and that it will likely partner with a national telemedicine company. 

“Our advantage is that we’re [located] here, with both well-qualified primary care and specialists,” he said. “We’re not just a one-and-done from New York. If you don’t get better, here we are right down the street.” 

PARITY WITH IN-PERSON VISITS

The new telemedicine parity law could help spur more use of telemedicine or virtual care services, particularly those offered by locally based provider groups and health systems, said Nataliya Boychenko, assistant vice president of employee benefits with Holmes Murphy & Associates.

Boychenko said she expects greater usage as local providers’ telemedicine offerings become more established. 

“Those [national telemedicine companies], you would call and speak to a physician assistant or doctor, but not necessarily your doctor,” she said. “So some employees may not have been comfortable doing that. Now what we’re seeing is a response from local physicians and groups. Now that’s a little different concept versus someone somewhere just speaking to you on the phone.”

The new telemedicine parity law should also promote more choice among different providers, she said. Before the legislation, many insurers aligned with a preferred telemedicine provider and wouldn’t cover a virtual visit with a different provider. “Now, [beginning Jan. 1] you’re not just tied to that selected telemedicine provider.” 

Boychenko said that many telemedicine services initially charged employers a per-month, per-employee fee, but now the model of charging on the basis of the actual number of virtual visits has become more prevalent. 

“Right now, most groups are set up to pay only when it’s utilized,” she said. “And the cost of a telemedicine visit is much lower, if you’re able to meet your needs that way.” 

EMPLOYER DEMAND SPURRED WELLMARK’S OFFERING

The state’s largest health insurer, Wellmark Blue Cross and Blue Shield, began offering a national telemedicine provider — Doctor on Demand — as its preferred provider for telemedicine services in late 2016. It was a response to demand from a number of employers who came to Wellmark seeking its approval for a number of different vendors, said Tom Newton, Wellmark’s vice president of network engagement. 

The benefit became popular with a number of self-funded employers, and this year Wellmark began offering Doctor on Demand to fully insured companies as well, Newton said. 

In comparison with in-person visits, however, “it’s not highly utilized,” Newton said. “I think we may have 20,000 to 25,000 people who have registered for our Doctor on Demand site. I think talking with your doctor through your iPad or PC is slow to take off. But the people who have used it tend to use it again.” 

While there probably hasn’t been enough use yet to know whether it’s going to lower costs, a virtual visit is certainly a lower-cost option than a primary care or emergency room visit, Newton said. “If you can avoid an ER visit by using telehealth, you’re saving a pretty significant amount.” 

About two-thirds of the people that are registered with Doctor on Demand through Wellmark are women, Newton said. “I suspect in a lot of cases that that’s not uncommon,” he said. “Often if the kid comes home sick from school, [the mom] may want to get them treatment versus waiting to get in for an appointment.” 

SUPPORTING — NOT REPLACING — PRIMARY CARE

From the perspective of a startup telemedicine company aspiring to cover every state, artificial intelligence is enabling 98point6 to use a relatively small number of full-time physicians, said Dr. Brad Younggren, the company’s chief medical officer. “We have about 15 practicing physicians in 36 states today, driving towards 51,” he said.  

By using an artificial intelligence-based “automated assistant” to conduct each intake interview, 98point6 is able to magnify the number of patients it can handle, Younggren said. By offering unlimited access for a small flat fee per year — $20 for the first year and $120 for the years following — “it completely removes the traditional fee-for-service model.” 

The Seattle-based company has raised $86 million in private capital to fuel its growth in the past three years, according to coverage of the company by the Seattle Times. 

Its goal is to support in-person primary are, not replace it, Younggren said. “We’ve seen a pretty rapid uptake in both [consumer and business clients] that reflects a lack of primary care access,” he said. “It allows patients multiple touch points for their health care.”

Holmes Murphy’s Boychenko said she anticipates continued growth in telemedicine usage. 

“There is no reason to think that utilization will stay low,” she said. “Going forward, I think it will be higher and higher.”