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News Roundup: June 24, 2016

How Home Health Can Win in Joint Replacement Bundles

Published by Home Health Care News
By Tim Mullaney
June 24, 2016

The forthcoming bundled payment model for joint replacements presents a significant opportunity for home health agencies, if they formulate and begin executing smart strategies now.

“Be proactive,” advised David VanderGest, senior manager at McBee Associates, a managerial and financial consulting firm focused on health care.

Some hospitals are currently in wait-and-see mode with regard to the Comprehensive Care for Joint Replacement (CJR) initiative, VanderGest said at last week’s Homecare Homebase User’s Conference in Dallas. This is because, even though the mandatory program started in 67 geographic regions as of April 1, there is a “grace period” through the end of 2016, meaning data will be collected but Medicare reimbursements will not yet be tied to results.

Hospitals may eventually regret being passive right now, and home health agencies should not be lulled into complacency as well, VanderGest proposed. Rather, now is the time for HHAs to be getting their ducks in a row and taking the initial steps to position themselves for long-term success in the program.

The basic idea of CJR is that hospitals are responsible for controlling costs from the time of a joint replacement surgery through 90 days of follow-up care; if they fail to control costs, they will owe Medicare money, but if they do a good job of controlling costs while maintaining quality, they will receive incentive payments. They can share these with their post-acute partners, including home health.

These four steps in particular should be considered by forward-thinking agencies, said VanderGest and his colleague, McBee Senior Manager Maria Warren.

1. Identify referral sources: Step one is the basic but essential task of examining referral current referral sources to identify CJR exposure, said Warren.

Agencies need to get a sense of how much potentially is at stake in terms of getting into a CJR collaborator agreement with their referring hospitals, because it is not a given that all agencies will be included. In their effort to better control cost and quality, hospitals are likely to take hard looks at where they are sending their joint replacement patients, and narrowing their networks to only those HHAs that they are confident can help them hit their goals.

So, to be successful in the future, agencies need to identify both potential upside and risks.

“Start running those reports, determining which referrals are coming from CJR hospitals, trying to identify … how to continue to target them and maximize our revenue,” Warren advised. “But what if they don’t choose you? What does that mean from a referral source stream and a revenue stream? How else are we going to be looking to maximize?”

2. Pitch hospitals: Once they’ve developed their hit list of CJR hospitals, home health agencies need to reach out with a pitch for inclusion in a CJR collaborator relationship.

This is essentially a “marketing strategy,” and it will be informed by key financials, operating, and quality measures, Warren said.

“When we go into that meeting … [hospitals] want to know this stuff up front,” she said. “They want to see this information and they want to know how are you going to continue to provide this and work with us?”

3. Assemble a team, develop pathways. CJR not only a new framework for reimbursement but demands adaptation in terms of staffing and operations. Whether it’s reviewing contracts with hospitals or managing the care for patients in the program, home health agencies will need to have the right people doing the right things.

“The important thing internally is to determine who your key stakeholders are, who’s going to be part of your ‘bundles team,’” said Warren.

Some suggestions she shared: a facilitator for bundled care development and operations, case managers, schedule/intake leaders, IT representatives, and financial and revenue cycle workers to track the claims.

That importance of tracking numbers internally to compare against those from the Centers for Medicare & Medicaid Services (CMS) also was emphasized by VanderGest.

“Have someone who understands the data, to make sure CMS is accurate,” he said.

Of course, the clinical care that the joint replacement patients receive will be crucial, as will the ability of the home health team to coordinate and communicate with physicians and other providers in other settings. So, agencies will need to think about and create appropriate clinical protocols and pathways, Warren said.

4. Implement needed technology. Whether it’s tracking quality measures or communicating with the care team, home health agencies can only succeed in a bundled payment world with the right tech tools in place.

“Technology is all-important,” Warren said.

Agencies may want to begin by identifying internal technology capabilities to support the cost- and quality-related data needs for CJR, in order to pinpoint gaps and potential IT solutions, she suggested.

Providers also need to keep tabs of solutions in development, given that technology companies are actively creating new products and capabilities to address some of the pressing needs that are arising out of a bundled payment environment. One of these is the need for standardized, secure communication among different types of providers throughout the 90-day care episode.

“Devices to text doctors is how we’ll manage bundles in the future,” predicted Warren, noting that this already is on the way.

Implementing the newest technology requires an investment, of course, as do many of these other steps. But the returns should come not only in the form of referrals and revenue related to CJR but other bundled payment programs as well, given that joint replacement appears to be only the tip of the iceberg for this type of program. Care for cancer, COPD and other conditions very well might be moving toward bundled payment models in the near future, and there was talk at the conference that congestive heart failure would be the next to arrive.

However CMS handles it, bundled payment is the wave of the future, VanderGest stressed.

“We have to prepare for the expanded rollout,” he said.

Doctors in the House

Published by Managed Care Magazine
By Joseph Burns
June 24, 2016

Bill Hanigan, a wheelchair-bound retired school teacher, is the last patient of the day for geriatrician Deborah Kylander, MD. Hanigan has multiple myeloma and right-side paralysis as a result of a stroke. His wife, Barbara, greets Kylander with a hug at the front door of their Cape Cod–style house on a quiet side street in Duxbury, Mass.

During a 30-minute visit, Barbara explains how getting Bill and his wheelchair out the door, down the back stairs to the garage, and into the car takes half an hour. Given that each trip out of the house risks a fall or injury to both of them, she’s grateful to have a doctor come to their house. After his stroke two years ago, Barbara knew she would need help providing care at home. A nurse at the skilled nursing facility recommended Kylander. “When I called the office, I asked if they were taking any new patients,” Barbara says. “Whoever answered the phone said, ‘No, not really, unless the patient is over 70 and homebound.’ At that point I said, ‘Hallelujah!’”

For Kylander, the mile ride to the Hanigan home is one of a dozen or more she’ll make every week as she fills the gaps in care left by a health care system that is mostly failing the country’s frail elderly. She certainly doesn’t do home visits because it pays well. She gets a salary from a physician group called the Associated Physicians of Harvard Medical Faculty Physicians at the Beth Israel Deaconess Medical Center. She works for Beth Israel Deaconess–Plymouth. They’re all part of the Beth Israel Deaconess Care Organization (BIDCO), but the point is that her two sources of payment do not cover her costs.
BIDCO funds the Village at Duxbury, a community for seniors that has homes, apartments, and an assisted living facility. Kylander works with one other geriatrician, three nurse practitioners (who also do home visits), an office manager, and two medical assistants.

Seeing patients in their homes is about much more than convenience, in Kylander’s opinion. For certain patients, regular home visits are needed to ensure that she provides appropriate and timely care, she says.

Just before driving to the Hanigans, Kylander saw an elderly patient in her office who was an ideal candidate for a home visit. A family member had dropped him off, helping him use his walker to get from the parking lot to the waiting room. To Kylander, he looked weak, tired, and dehydrated. “I didn’t know if he was going to pass out or end up in the emergency department later that day,” she says. She wanted to know which medications he was taking but he didn’t know because a family member manages his prescriptions for him. That family member would not return to Kylander’s office until well after the appointment was finished.

“In some ways, geriatrics can be like pediatrics without the parent,” she says. “You would never see a 4-year-old in the office on their own, but older people with cognitive impairment are seen independently all the time in the office, emergency department and other sites of care.”

So, for this patient, Kylander could not accomplish one of the most important tasks: Medication reconciliation, a potentially life-saving process needed to resolve discrepancies and prevent adverse events for elderly patients, particularly those with many chronic illnesses. “I’m thinking, ‘What can I possibly accomplish here in the office?’” she says.

An old-fashioned practice returns

While it’s rare to find a physician who will make house calls, a growing number of doctors and other clinicians like Kylander are bringing the old-fashioned practice back. CMS recognizes the value of having providers go to patients’ homes and pays for house calls, though not enough to cover the full cost, Kylander says.

According to its physician fee schedule for 2016, CMS pays only about $56 for a 15-minute home visit with an established patient, roughly $86 for a 25-minute visit, and around $129 for a 40-minute visit. Compare those with the higher rates the agency pays for office visits: about $73 for a 15-minute office visit with an established patient, roughly $108 for a 25-minute visit, and around $146 for a 40-minute visit.

Some private payers are willing to pay for home visits and are testing a variety of methods to care for people who have difficulty leaving their homes.
“Geriatrics is not glamorous,” Kylander says. “There’s no money to do geriatrics but I love it.” In addition to doing home visits, she also sees about 15 patients two to three days a week in the office. “But they are all 85 to 90 years old. They’re not coming in for a cold. They’re coming in because they just got out of the hospital with heart failure and GI bleeding, etc.”

CMS is using another one of its demonstration projects to test-drive house calls. Seventeen practices serving about 8,400 Medicare beneficiaries signed up for the Independence at Home project. Eligible beneficiaries must have two or more chronic conditions and have had a non-elective hospital admission within the past year. The project started in 2012 and is scheduled to end next year. According to a CMS announcement last year, the first-year results of the project showed savings of about $3,000 per beneficiary on average, and nine of the participating practices earned incentive payments for meeting quality and expenditure goals.

But neither CMS nor private payers have settled on the most cost-effective way to provide in-home care because such resource-intensive interventions require considerable investments of time and money.

Health plans, with their focus on population health and payment, have a strong tendency to standardize health care. If people need specialized care, insurers want to funnel those members into care coordination, disease management, or illness prevention programs where it’s (mostly) one size fits all. This approach, however, is ineffective for patients who need individualized attention and for whom even a short ride to the doctor’s office is a major obstacle to care, say proponents of bringing back the house call.

A growing number of ad hoc programs are designed to get health care providers into the homes of elderly, chronically ill patients. Major insurers are getting involved. In southeastern Pennsylvania, for example, Aetna has contracted with Health Quality Partners (HQP), a not-for-profit R&D group of physicians that designs new models of care for severe high-risk patients. UnitedHealthcare is working with the Camden Coalition of Health Care Providers to determine if the Camden model should be replicated in other places. (see “High-Utilizing Patients: Where Are the Savings?”Managed Care, January 2014).

Anthem is working with Eric Coleman, MD, a professor of medicine and head of the division of Health Care Policy and Research at the University of Colorado, to develop a program that will provide home visits to members recently discharged from the hospital. In March, Anthem began to enroll patients in northeastern Ohio in the program, according to Richard S. Frank, MD, Anthem’s vice president of health care management. The goal, says Frank, is to enroll enough patients to evaluate whether the program has helped to reduce readmissions.
RN visits
Since 2000, HQP, located in Doylestown, Pa., has provided in-home care for the frail elderly and chronically ill, says Kenneth Coburn, MD, HQP’s president, CEO, and medical director. During office visits, physicians or other providers can easily miss the most important aspects of a patient’s condition, especially factors that can increase the risk of illness or harm for patients with multiple chronic conditions, he explains. For these patients, HQP has registered nurses provide what he calls “advanced preventive care,” a combination of care coordination, disease management and personalized illness prevention delivered in collaboration with the patient’s primary care provider.

HQP, in its seventh year contracting with Aetna, offers the service to over 2,000 of the company’s high-risk Medicare Advantage members in southeastern Pennsylvania. Most (60%) RN contacts with patients are in person, through house calls, accompanying patients to doctor visits, or group programs (weight measurement), with the rest made by telephone.

In Coburn’s opinion, home visits are essential for most chronically ill patients. “I would say home visits are not just for people who are truly homebound and can’t get out to the doctor’s office, but it’s also for people who struggle with self-management or don’t have great support at home, or who may be in early mild cognitive decline and have trouble keeping track of their medications,” he adds.

Once inside a home, HQP’s RNs can see the risks a patient may encounter, from mundane home maintenance issues such as poor lighting or hazardous stairways, to more extreme social hazards such as neglect or abuse. If no one goes into the home to assess risks, these patients often end up in the emergency room or may even need inpatient care that could have been prevented, Coburn says.

Even well-intentioned physicians who specialize in care for the elderly or for patients with multiple chronic illness have no way to assess a patient’s home risk with an office visit. “Mobility and function are really big aspects of home care that you see when you’re in somebody’s home,” Kylander explains. “You see how they get up and move around the house. You see them furniture surfing. You see how they might trip over their oxygen tubing, or their cat or their dog. You see their obstacles and you can also check out their house for potential risks.”

As Kylander points out, even the routine process of evaluating a patient’s medications can be impossible in an office. But a provider in a patient’s home can look at what’s in the medicine cabinet.

Before taking care of Aetna members, Coburn’s HQP participated in a CMS demonstration project that tested a nurse-based care management program that included house calls. According to results reported by Coburn in PLOS Medicine, the program reduced deaths by 25% compared with usual care. In a subgroup of those with heart failure, coronary heart disease, or chronic obstructive pulmonary disease, and at least one inpatient stay in the past year, there were 39% fewer hospitalizations and 37% fewer emergency room visits when compared with the patients who had typical care. This subgroup of patients also had 36% lower Medicare costs and a net savings to Medicare of $397 per participant per month.

The HQP program is one of many that Aetna uses to maintain or increase its Medicare star ratings. So, for frail elderly patients and those with multiple chronic conditions, the HQP initiative has significant value, says Humberto Guerra-Garcia, MD, a senior medical director for Aetna in Philadelphia. To maintain or improve those ratings, Aetna needs to demonstrate that its members are following illness-prevention measures and are getting their needs assessed. Among the over 500 Aetna members currently enrolled in the HQP program, 90% are getting the services they need, he says. “Right now what we see is certainly encouraging, and the fact that we have had this relationship for a few years now means that we certainly believe it,” Guerra-Garcia comments.

Does that mean Aetna will expand the HQP program to other areas? “We haven’t decided that,” Guerra-Garcia says. “We’re looking into what should we do, meaning whether to expand it, or incorporate some of the know-how into our case management programs, or test how other populations would respond to this program.”

Getting into homes

Just an hour’s drive south of Doylestown, Jeffrey Brenner, MD, a primary care physician who founded and serves as executive director of the Camden Coalition of Healthcare Providers, is doing work similar to that of HQP. He developed a care delivery model to serve the most vulnerable residents of Camden, N.J., one of the poorest communities in the nation, by sending providers into patients’ homes. Brenner, who started the coalition in 2009, is an expert in the value of home-visit assessments. In 2013, he won a genius grant from the MacArthur Foundation for his work with the coalition.
Since 2013, the coalition has been working with UnitedHealthcare to serve high-risk members. UHC’s efforts are typical of insurers who are reluctant to fund more robust home-visit programs because of the cost.

As Kylander has found, the payment rates for CMS’s billing codes for home visits are insufficient to make in-home care feasible financially, Brenner says. “Most primary care providers struggle just to keep their offices open in the existing payment model. When you go to someone’s home, the billing code doesn’t pay enough to make up for the amount of time it takes you to get there, do the visit, and get back,” he explains.

Under the coalition model, Brenner’s group uses a combination of grant funds and contracts with Medicare and Medicaid to pay for delivering care in patients’ homes. Like Coburn, Brenner finds it’s less costly to have nurses and other providers do most of the home visits. Doctors working for the coalition do some of that work but mostly they see patients in the office. All of the coalition’s providers help patients navigate the health care system, they coordinate care for them, engage social services if needed, and assess each patient’s prescriptions.

“Just from the standpoint of medication reconciliation, patients can be on 25 different medications and some actually have saved every medication bottle they’ve ever been given. So we’ve gone into homes and found, like, hundreds of medication bottles,” he says.

In one home, Brenner’s staff found a bag containing $50,000 worth of medications that the patient had started and stopped. “I don’t think you can do medication reconciliation well until you’ve stepped into someone’s home and pulled open all the drawers, and cabinets and helped people dispose of all the old medication bottles. So that’s just one small example of how important it is to get into patients’ homes,” he adds.

This spring a nurse visited a patient whose asthma was so bad she needed to be hospitalized repeatedly. Previously, this woman in her 50s had not been diagnosed with asthma. None of the physicians or nurses she saw during any of her hospital stays looked into the cause of the woman’s condition. When Brenner’s staff sent a medical student and physician to the woman’s home, they found a leaky roof. “She had a hole in her ceiling, a hole in the wall, and still active leaking. She had mold all over,” Brenner says. Knowing the patient was unable to afford the necessary repairs, the physician recommended she sleep in a downstairs bedroom.

“By sleeping downstairs and staying away from the mold, she’s doing much better,” Brenner comments. “But how would you figure that out without having visited?”

In fact, he argues, this woman’s condition had been diagnosed incorrectly. “She actually has what’s called extrinsic asthma, allergic asthma due to mold exposure from the leaking roof. That’s a specific diagnosis that’s different than just saying she has asthma,” he says.

That’s the same argument that Coburn and Kylander make: There’s no way to assess a patient properly unless someone visits the patient at home. This is not news. Coburn has been studying the value of home visits since 2000 and has contracted with Medicare to evaluate the effect of a home-visit program on costs and quality.

Health care’s four-letter word is standing in the way of the kind of care that Brenner, Coburn, and Kylander are providing: cost. Brenner is consulting with health plans and communities nationwide on how to develop cost-efficient models of delivering care in homes and is conducting a randomized controlled trial on the effects of his work on costs and quality. To date he has enrolled about 500 patients. He hopes to enroll 300 more and expects to publish results next year.

“My early inkling is that for a certain subset of folks, this model works wonderfully and for a different subset, if they’re homeless, drug addicted, or mentally ill, the services we have in Camden are so poorly structured, it becomes a navigation to nowhere,” he says. These early results have led him to consider the need for safe housing for those who are most chronically ill.

“We’re thinking about what the next wave of work is and have gotten pretty deep into something called ‘housing first,’ which is housing regardless of sobriety,” Brenner explains.

The coalition is testing this housing model with 50 patients, including an 80-year-old man who was living on a park bench in Camden. In this program, the coalition will provide new apartments, addiction treatment, and behavioral health services. “About 25% of our patients are homeless, and if they’re enrolled in the clinical trial, nothing we do works until we get them into safe housing,” he says.

Some health plans may be willing to try programs like Brenner’s that provide housing and health care. Meanwhile, CMS and private insurers continue to explore how to bring back the house call so it’s efficient and effective. “There are some great programs for the elderly,” Kylander says. But they’re not enough of them to care for all the patients who need the home care.

Payers want to see the ROI

It’s no surprise that the first of two hurdles home-visit programs face is the need to show that a program that requires so many resources, including sending providers out to travel many miles over several hours, could be cost-­effective, says Kenneth D. Coburn, MD, president, CEO, and medical director of Health Quality Partners in Doylestown, Pa.

Health plans are reluctant to pay for any program that cannot demonstrate savings within a year or two, he says. “That’s tough for a lot of organizations,” he adds.

“Not everybody wants to pay up front for this because there are a lot of different models out there, most of which are not as tightly designed and effective as they could be,” he explains.

“I understand that real concern. But, at the same time, if you expect physicians or ACOs to do this on their own, and fund it up front and wait for the money downstream, that’s hard for a lot of health systems and ACOs to pull off,” he says.

Another problem is that not all home-visit programs are the same. “There are ways that these programs have to be designed, developed, implemented, and managed tightly to ensure the services that should be provided are provided and in the right time frames,” he adds. “Our program has lots of protocols and we collect lots of data from the field that we do performance measurement on to make it as reliable as we can.”

Tips for Home Health to Prepare for Pre-Claim Submissions

Published by Home Health Care News
By Amy Baxter
June 24, 2016

Though the home health industry has pushed back against the Center for Medicare & Medicaid Services’ (CMS) prior authorization program—dubbed the Pre-Claim Review Demonstration for Home Health Services—the pilot is likely to start soon, and home health agencies are gearing up to deal with the potential of any additional administrative burden.

Agencies in the first five states of the demonstration—Illinois, Florida, Texas, Michigan and Massachusetts—should be aware of the new requirements immediately, but the program is likely to eventually spread throughout the country. The states were selected based on rates of fraud, but the industry overall had a high rate of improper Medicare billing—59%—in 2015, according to CMS.

“The five states were selected because there was a higher incidence of fraud and abuse in these states,” Gina Mazza, RN, BSN and partner at Fazzi Associates, said during a webinar about the demonstration. “You can expect that what is getting tested here is likely to get rolled out to everyone.”

The first demonstration will be rolled out in Illinois and could begin after August 1, 2016. With the program launch date coming up quickly, there are a few things home health agencies can do to be prepare for the changes and reduce the likelihood of delayed or denied reimbursement payments.

Beyond Documents

The demonstration aims to crack down on fraud and improper billing by having agencies prove that home health care services are medically necessary earlier in the process. Agencies will be required to submit a pre-claim to CMS with a tracking number of the care episode along with the demonstration that home health services are medically necessary. A pre-claim for a 60-day episode of care can be submitted anytime before an agency submits a final claim.

While the documentation requirements are clear and unchanging from current requirements of demonstrating medical necessity, there are some additional processes that home health agencies can undergo to improve the chance of their documents being accepted more quickly.

“Aside from the documents, think about how you are presenting this,” Mazza told home health agencies during the webinar. “Make it easy for the [CMS] reviewer. You’re sending a document that you want affirmed and approved demonstrating that you are following coding rules.”

To do so, Mazza suggested including a cover with the documents so CMS knows who is sending the documents and what cases are included within the submission.

It’s also essential that home health agencies follow the documentation descriptions to the letter. This is crucial for demonstrating the homebound clause that deems home heath care services medically necessary for patients. For example, documenting that an activity requires a “taxing effort” for a patient may not prove that they are homebound. Furthermore, demonstrating the “skilled need” is not always clear in documentation, Mazza said.

“At times, it’s not descriptive enough,” Mazza warned. “It’s not always obvious why the skilled need is there and why it’s specific to that patient.”

Above all, home health agencies should think about how to demonstrate why and how home health care is medically necessary for each patient’s claim. Doing so will likely reduce the chances that pre-claims will not be approved right away, Mazza advised.

Track and Re-Submit

An important clause in the pre-claim demonstration has to do with the submission order and process. Agencies must submit a pre-claim review within the requested time frame before they can submit a final claim and be paid by CMS. If the pre-claim is not approved, an agency can refile as many times as it takes to get the right documentation to CMS. CMS has maintained they will respond to the initial pre-claim submissions within 10 days and resubmissions within 20 days.

However, if an agency submits a final claim before the pre-claim is approved, they may still be approved. CMS could also deny the final claim for improper documentation. If the final claim is approved without prior authorization, the home health agency will see a 25% reduction in their reimbursement. This reduction is waived during the first three months of each demonstration for a grace period, so that agencies can get used to the new process.

To avoid reduced payments, agencies must ensure they have a system in place to track each case within the claims process, according to Mazza.

“There is absolutely work to do here,” Mazza said. “It’s up to the agency to respond and resubmit. Please be sure you have a very good tracking system. You’ve got to know which episodes you’ve submitted and where you are in the pre-claim process.”

Staying on top of the claims process and cases will better enable an agency to follow the new compliance process.

While the pre-claim pilots are starting soon for just a sect of the larger home health agency, the program is part of a larger shift of a changing health care environment.

“This kind of thing isn’t going away,” Mazza said. “The entire industry is in a transformational phase.”

Telemedicine gains popularity thanks to lower costs

Published by Healthcare Finance
June 24, 2016

Rushing to a large kiosk in the lobby of the Palm Beach County School District's administrative building where she works, Christianson, 29, consulted a nurse practitioner in Miami via two-way video. The nurse examined her remotely, using a stethoscope and other instruments connected to the computer station. Then, she recommended Christianson seek an ultrasound elsewhere to check for a possible liver problem stemming from an intestinal infection.

The cost: $15. She might have paid $50 at an urgent care center.

The ultrasound Christianson got later that day confirmed the nurse practitioner's diagnosis.

"Without the kiosk I probably would have waited to get care and that could have made things worse," she said.

Endorsements like Christianson's demonstrate how technology and positive consumer experiences are lending momentum to telemedicine's adoption in the workplace.

Less than a decade ago, telemedicine was mainly used by hospitals and clinics for secure doctor-to-doctor consultations. But today, telemedicine has become a more common method for patients to receive routine care at home or wherever they are -- often on their cellphones or personal computers.

In the past several years, a growing number of employers have provided insurance coverage for telemedicine services enabling employees to connect with a doctor by phone using both voice and video. One limitation of such phone-based services is physicians cannot always obtain basic vital signs such as blood pressure and heart rate.

That's where telemedicine kiosks offer an advantage. Hundreds of employers -- often supported by their health insurers -- now have them installed in the workplaces, according to consultants and two telemedicine companies that make kiosks, American Well and Computerized Screening, Inc.

Employers and insurers see the kiosks as a pathway to delivering quality care, reducing lost productivity due to time spent traveling and waiting for care, and saving money by avoiding costlier visits to emergency rooms and urgent care facilities.

Jet Blue Airways is adding a kiosk later this year for its employees at John F. Kennedy International Airport in New York. Other big employers providing kiosks in the workplace include the city of Kansas City, Missouri.

Large health insurers such as Anthem and UnitedHealthcare are promoting telemedicine's next wave by testing the kiosks at worksites where they have contracts.

Anthem has installed 34 kiosks at 20 employers in the past 18 months. John Jesser, an Anthem vice president, said kiosks are a good option for employers too small or disinclined to invest hundreds of thousands of dollars in creating an on-site clinic with doctors and nurses on standby.

"This technology should make it more affordable for employers of many sizes," Jesser said.

Kiosks are typically used for the same maladies that lead people to see a doctor or seek urgent care -- colds, sore throats, upper respiratory problems, earaches and pink eye. Telemedicine doctors or nurse practitioners can email prescriptions to clients' local pharmacies. Employees often pay either nothing or no more than $15 per session, far less than they would pay with insurance at a doctor's office, an urgent care clinic or an emergency room.

Despite kiosks' growing use in telemedicine, it's unclear whether they will be supplanted as smartphones, personal computers and tablets enable people to access health care anywhere with a Wi-Fi connection or cell service. Some employers already offer kiosk and personal device options, including MBS Textbook Exchange in Columbia, Missouri, which has 1,000 workers.

Workplace kiosks' appeal is they are quiet, private spaces to seek care. Consumers can get their ailments diagnosed remotely because the kiosks are equipped with familiar doctors' office instruments such as blood pressure cuffs, thermometers, pulse oximeters and other tools that peer into eyes, ears and mouths. The instrument readings, pictures and sounds are seen and heard immediately by a doctor or nurse practitioner.

"The kiosk gives the doctor more tools to diagnose a wider range of conditions," Anthem's Jesser said.

The downside is that the machines cost $15,000 to $60,000 apiece, which may still be too much for some employers.

"Telemedicine kiosks look promising and may still take off, but I don't see explosive growth," said Victor Camlek, principal analyst with Frost & Sullivan, a research firm.

While kiosks are now found in more workplaces, usage is still relatively low because employees are not sure how they work, said Allan Khoury, a senior consultant with Willis Towers Watson.

Employers' experiences are mixed.

Officials in Kansas City, Missouri, estimate the kiosk placed in city hall almost a year ago has saved the local government at least $28,000. That's what Kansas City hasn't spent because employees and dependents chose the telemedicine option instead of an in-person doctor visit. The city also estimates it has gained hundreds of productive work hours -- that's the time employees saved by not leaving work to see a doctor.

In contrast, fewer than 175 of the 2,000 employees at the Palm Beach County School District headquarters have used the kiosk there in its first year, said Dianne Howard, director of risk management.

Howard remains hopeful: "This is the future of health care."

The district's kiosk was supplied at no cost by UnitedHealthcare, as part of a test also involving two other employers in Florida.

Those kiosks connect employees to nurse practitioners at Nicklaus Children's Hospital in Miami. The hospital employs an attendant at each kiosk location to help workers register and use some of the instruments, such as the stethoscope.

Other telemedicine kiosks, such as those made by America Well, are designed to be totally self-service for employees. They also offer users immediate access to a health care provider. American Well has deployed about 200 kiosks and is in midst of rolling out 500 more, mostly to employers, the company said. It also places kiosks in retail outlets and hospitals.

Telemedicine's increasing sophistication is winning over some traditional-minded physicians.

The WEA Trust in Madison, Wisconsin, a nonprofit that offers health coverage to public employers, installed a kiosk for the benefit of its 250 workers last fall.

Dr. Tim Bartholow, a family doctor by training and chief medical officer for the trust, said he was cautious about physicians treating patients they haven't seen in person. After observing employees using it, Bartholow is convinced it can help them get good care.

"I don't think telemedicine is making a doctor being on site quite agnostic, but it is certainly reducing the premium on being in the same space as the patient," Bartholow said.

Insurers declare they are moving carefully, too, recognizing that telemedicine has its limits and they must depend on practitioners to tell patients when they have to see a doctor -- in person.

"We have to rely on their experience and judgment," Jesser said.