BOSTON – While more payers such as Blue Cross Blue Shield of Florida are stepping up to the table to reimburse for online consultations (see related story), insurers say it's still not clear what economic model will prevail for "technology-assisted care."

At a conference sponsored by Partners Telemedicine at the Harvard Medical School in Boston, economists, payers and providers ran headlong into a fundamental problem plaguing the nascent e-health market: Once the technology hurdles are solved, who pays – and for what, exactly?

Economist Meredith Rosenthal outlined various models for financing e-health, but said none presented themselves as an obvious choice. A traditional fee-for-service approach would be difficult to implement and cumbersome to maintain, Rosenthal said.

Payers have their doubts about e-consults via chat sessions or email because they may fear substandard outcomes and anticipate harder-to-verify claims. Providers, for their part, may also be concerned that technology-assisted care will replace existing services – at a lower rate, or worse, that a particular e-health service won't be covered at all.

More promising, but not without difficulties, are prospective pay strategies or population-based payment. Rosenthal said these approaches are proving feasible in disease management programs, and could be applied in e-health settings as well, but cost-savings, ROI and increased patient satisfaction would have to be clearly demonstrated.

Robert Mandel , MD, vice president of Blue Cross Blue Shield of Massachusetts, said his company is already reimbursing for some telemonitoring, disease management and "electronic exchange" programs, but in general is not reimbursing for e-health and telemedicine now. However, he predicted that will change.

"We'll start out paying for processes," he said. "But we will move to paying for outcomes."

Generating hard data will be key, agreed Leslie Sebba, MD, medical director of Tufts Health Plan/Secure Horizons. "One of the challenges the industry faces is deciding which services are worthwhile," he said.

As an example, a payer might be asked to pay for 10 different preventative "congestive heart failure" programs, but there is no guarantee that all 10 programs are equally effective. "Do we reimburse just because you classify a program as such?" he asked.

In fact, Mandel said, no matter how much providers may clamor for reimbursements for e-health initiatives, consumers may have a very different attitude. "Our members have not really taken advantage of existing opportunities," he said. "They like e-mailing their doctors. They like e-prescription. But they haven't been breaking down the doors to do electronic visits."

David Cowles, executive vice president of Benemax, identified three road blocks to reimbursement at this time: the cost of technology relative to the size of an enterprise; the usability of technology ("Most people can't program a VCR – me included. How are you going to get people to use it?"); and the timeframe of technology's pay-offs. While the life of a payoff for consumers is, in fact, their lifetime, employers are unlikely to invest in anything with a pay-off of more than seven years, and insurers have an even shorter timeframe.

"Our system is riddled with a lack of outcomes," Sebba said. If providers want reimbursement for their e-health efforts, "we need to be as methodical about outcomes as possible."