In the U. S. it is estimated that there is one headache specialist (defined by specific training in headache medicine) per 300,000 people. This means that there is one headache specialist per every 45,000 migraine sufferers (not to mention the other headache types). Of course many of these 45,000 sufferers can be managed effectively by competent, compassionate primary care givers. But that leaves about one headache specialist for every 15,000 patients who needs their level of care. One headache specialist has a maximum capacity of following about 3,000 patients. That leaves 12,000 patients that need specialty care but never get it. Often these patients are referred to the local neurologists, who have had no specialty care in headache and may not have much more to offer a patient than their primary care provider.
We have had a growing demand for our services outside our region. We have had patients from Alaska (where there are no headache specialists) and the entire Pacific Northwest, British Colombia and even northern California.
We realize the hardship for these patients and it isn’t fair that they have to suffer more simply because of where they live. It can also be expensive to travel to Anacortes or Bellingham, not to mention the time away from work to make the trip.
In response to this need, we have been working on a way to make our care more convenient for these patients. There are no simple answers. While virtual medicine is just beginning to take shape in our country (eg. see Simplecare) it is faced with some challenges.
The first challenge is that fact that health insurance companies refuse to pay for such visits. While it would be in their best long-term interest to do so, insurance companies have a habit of finding reasons not to pay for visits and the provider and patient not seeing each other face to face is just one. There is a bill in the Washington legislation that would mandate insurance companies to pay for such visits (Telehealth HB 1448), I’m sure the insurance companies will lobby hard against it.
State laws regarding the practice of medicine is another complicating factor. Unlike having a driver’s license (which translates across state and even international boarders), medical licenses do not. So, following the letter of the law, we can’t write prescriptions in another state. When I worked at Mayo Clinic, I did send prescriptions throughout the U.S., however, it is up to the pharmacist to honor out-of-state prescriptions. Certainly we can not prescribe for our Canadian patients.
The next level of complexity with the issue involves perceived risks (malpractice concerns) and real risks of not having eye-to-eye contact with a patient. In the past two years I’ve diagnosed two brain tumors (thankfully that was all out of two thousand patients with headaches) and both times I had the intuition that they had a tumor based on my face to face contact and my neurological exam. If I had simply talked to those patients on the phone or even Skype, then I could have missed important clues.
At this juncture we are offering Skype follow up visits for our out of the region patients. Actually, we could offer them for any patient that wants them. However, it may only be cost effective for our out of town patients. The reason is, the insurance company will not pay for the visit. We can’t give the 1/2 hour away for free our we would quickly go bankrupt. We do give a 40% discount for cash payment at the time of service, so in this case the visit would be 40% lower than the full charge for a 1/2 hour. So if you would rather have a follow up visit via Skype and can pay at the time of service, we are willing to do that. It would be a devoted visit time with Skype visual interaction.
In the near future I hope to develop a virtual new headache consult for anyone, any place in the world. However, due to the limitations of not being able to do the neurological exam ourselves, we would not be in the position to prescribe medications. However, we would offer a very detailed one hour of our time devoted to the case with a precise diagnoses based in the (state-of-the-art) diagnostic criteria of the International Headache Society and a detailed treatment plan with steps A, B and C based our our three decades of high level experience in headache medicine. The patient could then take the well documented plan to their local PCP (a good PCP who is willing to try and help) and they can prescribe the treatments. I am confident enough in our diagnoses and treatments that I’m considering an unheard of (in evidence-based medicine) of a money-back guarantee for the patient’s satisfaction. We want to do this, not that we need even more business, but because we have a great compassion for the headache sufferers out there who could greatly benefit from our expertise.
So, in summary, the Skype visit is here now. Contact Kaaren for more information. Within the next few months we hope to have the Virtual New Headache Consult.
J. Michael Jones, MPAS-C