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Amazon threat one big reason for CVS, Aetna to merge

FierceHealthcare reports that  industry analysts say that multiple market forces combine to make drugstore behemoth CVS’s possible takeover of giant insurer Aetna (based in Hartford but moving to New York)  attractive  for both two companies. CVS is based in Woonsocket, R.I.

“One of the biggest ones is Amazon’s possible entrance into the prescription drug distribution business, which Leerink Partners analyst Ana Gupte says is a ‘massive threat’ to CVS, both in the pharmaceutical market and front-store sales,” Fierce reported.

The St. Louis Post Dispatch has reported that the online retail giant has already been approved by 12 states to become a wholesale pharmaceutical distributor there.

If the CVS-Aetna merger happens, CVS could respond to the Amazon-induced market pressure on its retail pharmacies by using more of its retail spaces to offer such healthcare services  as labs and dialysis, say analysts for Jeffries Group, the investment bankers.

Aetna, for its part,  has powerful reasons to want a merger with CVS.

For one, Fierce reports, “CVS’s capabilities, including its Minute Clinics and its Coram home infusion business, could help Aetna improve health outcomes and reduce costs. Aetna’s leaders have also long expressed a desire to move care closer to the consumer, and they’ve hinted at the possibility of working closer with CVS once the insurer’s long-term pharmacy benefits management  (PBM)contract with CVS expires in 2020.”

Gupte  also said that that Aetna has probably felt it should  enter the PBM business given the  announcement by another big insurer, Anthem that it would build its own  PBM partnership with CVS—and UnitedHealth’s success with its in-house PBM, OptumRx.

Aetna “likely sees solidifying a lasting relationship with its preferred partner CVS as a way to leave [Anthem] jilted at the altar,” she said.

Fierce reported that “Gupte pointed out that Anthem was likely not looking for a long-term relationship with CVS anyway, as its ultimate goal was to ‘go it alone’ with its IngenioRx PBM brand. Still, she predicted that Anthem might walk away from its pact with CVS if the company consummates a deal with Aetna.”

In Appalachia, 2 giant hospital chains seek state-backed monopoly

Downtown Johnson City.


For Kaiser Health News


Looking out a fourth-floor window of his hospital system’s headquarters, Alan Levine can see the Appalachian Mountains, which  have  long  defined this hardscrabble region.

What gets the CEO’s attention, though, is neither the steep hills in the distance nor one of his Mountain States Health Alliance hospitals across the parking lot. Rather, it’s a nearby shopping center where his main rival ­— Wellmont Health System, which owns seven area hospitals — runs an urgent-care and outpatient cancer center. Mountain States offers the same services just up the road.

“Money is being wasted,” Levine said, noting that duplication of medical services is common throughout northeastern Tennessee and southwestern Virginia, where Mountain States and Wellmont have been in a healthcare “arms race” for years, each trying to out duel the other for the doctors and services that will bring in business.

The companies now want to merge, which would create a monopoly on hospital care in a 13-county region that studies have placed among the nation’s least healthy places. The merger’s savings would pay for a range of public-health services that they can’t afford now, the companies project. And they are trying to pull it off without Washington regulators’ approval, breaking with hospitals’ usual path to consolidation.

In a typical case, a plan that eliminates so much competition in a market would almost certainly provoke a court battle with the Federal Trade Commission, which enforces antitrust laws and challenges anti-competitive behavior in the health industry.

To avert such a fight, the hospitals are using an obscure legal maneuver available in Tennessee and Virginia and some other states.

Generally known as a Certificate of Public Agreement (COPA), the process works like this: If regulators in Virginia and Tennessee agree that the merger is in the public interest, Wellmont and Mountain States would operate as one company under a state-supervised agreement governing key parts of their operations, including setting prices. The states’ approval would prevent the FTC from challenging the merger under federal antitrust law.

Their decisions could come as soon as this month.

In exchange for approval, Mountain States and Wellmont promise to use money saved from the merger to offer mental-health and addiction-treatment services and attack public-health concerns, such as obesity and smoking — areas previously neglected by the systems that don’t increase hospital admissions and bring in big revenue, hospital officials said

“The question that needs to be asked is whether tight state oversight of a monopoly is better than failed competition,” said Robert Berenson, a health-policy expert at the Urban Institute.

Little-Used And Rarely Challenged Mechanism

The federal antitrust exemption made possible under a COPA dates to a Supreme Court ruling in the 1940s used only about a dozen times to allow hospital mergers. One was an hour away from here, in Asheville, N.C.

There’s little scholarly research on COPAs’ results.

Last summer, the FTC dropped its challenge to a merger of two West Virginia hospitals after the state adopted a COPA law and permitted the deal.

In recent years, hospital mergers and acquisitions have created behemoth health systems that have used their status to demand high payments from insurers and patients. Studies by health economists have repeatedly found that consolidation means higher prices.

But the same calculus may not apply here and in other regions where a preponderance of patients are poor or uninsured, officials from both Mountain States and Wellmont say.

While President  Trump and Republicans in Congress stress the value of free-market principles in healthcare, officials of both hospitals argue that in their part of Appalachia the market has led to unnecessary spending, driven up health costs and forced them to focus on services that produce the highest profits rather than meet the community’s most pressing health needs. In this deeply conservative region, where death rates from cancer and heart disease are among the nation’s highest, the hospitals say only a state-sanctioned monopoly can help them control rising prices and improve their population’s health.

Without their proposed merger, Levine said, both hospital systems would likely have to sell to an out-of-market chain. That would likely eliminate local control of the facilities and could lead to massive layoffs and the closure of hospitals and services, he said. Together, the two hospital systems employ about 17,000 people.

The FTC, which is urging the states to reject the hospitals’ plan, contends the hospitals could form an alliance or take other steps short of a merger to accomplish the benefits they say one will bring. The agency says the hospitals’ market probably would be no worse off if one chain merged with a company outside the area.

Feds Wary Of Promises

The hospitals are making big promises to sell their deal. They say no hospitals would close for at least five years, although some could be converted to specialized health facilities to treat problems such as mental illness or drug addiction. After the merger, all qualified doctors would have staff privileges at all hospitals to treat patients. No insurer would pay lower rates than others. The new hospital system would spend at least $160 million over 10 years to improve public health, expand medical research and support graduate medical education for work in rural areas.

The FTC maintains that the hospitals’ pledges are unreliable and dismissed them as having “significant shortcomings, gaps and ambiguities” in an analysis filed with state regulators in January.

Levine said the plan is the best deal for the community given the factors that handicap the hospitals. Those include declining populations and Medicare reimbursement rates that are lower here than other parts of the country because of lower average wages. Another concern is the cost of caring for uninsured people — neither Virginia nor Tennessee expanded Medicaid under the health law, which would have lowered uninsured rates.

“Competition is and should be the first choice, but in an area where competition becomes irrational and there are limited choices, there has to be a Plan B. If not this, then what?” he said.

Blue Cross and Blue Shield of Tennessee, the state’s largest health insurer, is not opposing the hospitals’ combination, a spokesman said. But its counterpart in Virginia, Anthem, hasn’t been persuaded.

“Anthem does not believe that there are any commitments that will protect Southwest Virginia and Northeast Tennessee healthcare consumers from the negative impact of a state-sanctioned monopoly,” the company said in a statement.

Wanted: Better Job Prospects

The proposed COPA has strong support among large employers in the region, including Eastman, a Kingsport, Tenn., chemical company with $9 billion in annual revenue that employs more than 7,000 people locally. “We get local governance, input and control … and that’s a lot better situation for us,” said David Golden, a senior vice president at Eastman.

Still, walking around Johnson City — the region’s largest city, with almost 67,000 people — it’s easy to feel an unease among small employers and residents about a merger. Many worry about possible job cuts.

“Eliminating duplication of services means eliminating people,” said Dick Nelson, 60, who runs a coffee and art shop downtown and has lived here for 27 years. “I don’t care how much health care costs because my insurance will pay it,” he said.

In Kingsport, where Wellmont and Mountain States each has a hospital, Thorp is leery about a merger, too. “It’s an economic move, not an enhancement of medical care,” said Thorp, who runs a newsstand downtown. “We pride ourselves here for having good education and health care. They say there won’t be any services or jobs cut, but if that’s the case then what’s the point of the merger?”

Levine said no place better supports the case for a hospital merger than Wise County in southwestern Virginia, a scenic area with about 40,000 people whose three hospitals all operate below half their capacity. Mountain States and Wellmont each own a hospital in Norton, the county seat, with 4,000 residents. Despite few patients, the hospitals still bear hard-to-cut costs for buildings, equipment and adequate staffing levels, Levine said.

On a recent weekday morning, Lonesome Pine Hospital, a Wellmont facility in Big Stone Gap, Va., looked nearly deserted. No volunteers or staffers were visible inside its main entrance and fewer than a fifth of its 70 acute-care beds were being used.

A five-minute drive away, Mountain States’ Norton Community Hospital’s 129 beds are about a quarter filled. Its maternity unit delivers fewer than five babies a week. The hospital offers hyperbaric oxygen therapy — a treatment that pays well under Medicare’s reimbursement rates — to help diabetics heal their wounds. But it has no endocrinologists to help diabetics manage their disease to avoid such complications. Despite a high rate of heart disease in the community, there’s no cardiologist on staff.

Whether a state-sanctioned merger will resolve the incongruities — here or in other poor regions — depends on how firmly regulators hold the hospitals to their pre-merger commitments. If the merger plan gets rejected, Mountain States and Wellmont will resume arch-competitive business practices that do not always put community interests first, said Bart Hove, Wellmont’s CEO.

“It’s about competing for the dollar in any way you can and extracting a dollar from your competition,” Hove said. “You do what you can to drive patients to your hospital.”


Insurers may soon lose ACA excuse for their soaring premiums



Ana Mulero, writing in Healthcare Dive, notes that “2016 was a terrible year for insurance costs. Double-digit ACA premium increases were common. Insurance and provider monopolies and near-monopolies look likely to support future increases. But as we go into 2017, it’s reasonable to ask: How long will consumers put up with this?”

After all, “{T}his comes as some payers, including the five largest ones in the U.S., have remained highly profitable. Aetna, Anthem, Cigna, Humana, and Unitedhealth, four of which have multibillion-dollar plans to merge, have collectively profited more than $65.5 billion post-ACA, Public Citizen reported in October.”

Meanwhile salaries for insurance execs continue to surge. Consider, she writes:

”{S}alaries for C-suite executives were raised by 57% last year at Health Care Service Corp. (HCSC), which operates Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma, and Texas, according to a recent analysis by Modern Healthcare. The top ten company executives saw their combined earnings increase from a total of $36.1 million in 2014 to $56.7 million in 2015.”

And,  “Hospitals and health systems may actually be the ones that have felt the squeeze the most, and they have acted in ways that are {also} pushing up costs.

“Health systems are consolidating at a rapid pace, and many of them say they have done so to have more leverage with insurance companies. This activity has in turn led to monopolies and duopolies on the provider side as well, which results in not only increased prices to consumers, but also a decrease in quality care as competition is significantly reduced.”

“Hospital prices in monopoly markets are more than 15% higher” than in non-monopoly markets,  says Deborah Feinstein, the Federal Trade Commission’s director of the Bureau of Competition.

“Requiring more transparency around payers’ operating costs and salaries of their C-suite execs could help address these issues. But with Republicans promising a repeal, the ACA may not be available as cover for high costs much longer.

“Thus, insurance companies looking for whom, or what, to blame for the increases may face an uncomfortable reality soon: For every finger they point, three fingers might point back at them.” And, we might add, at some monopolistic hospital systems, too.

To read her whole article, please hit this link.

5 notable provider-payer collaborations


This FierceHealthcare article looks at five particularly interesting provider-payer collaborations in 2016.

In some cases, “a driving force behind these partnerships is the quest to expand access to data that holds the key to lower costs,” Fierce wrote.

The collaborations are:

  • Geisinger Health Systems and St. Luke’s University Health Network, both in Pennsylvania, announced a new partnershipto cut insurance premiums.  Six hospitals and 270 medical offices within the St. Luke’s system partnered with the Geisinger Health Plan.
  • partnershipbetween Moffitt Cancer Center, in Florida, and UnitedHealthcare established a new bundled payment program to cut the cost of cancer care. For a three-year pilot project, the two organizations developed surgery and radiation therapy bundles focusing on early-stage lung cancer. The goal is to reduce costs by incentivizing providers to reduce variation through evidence-based best practices.
  • Anthem joinedwith Aurora Health Care in Wisconsin to create the Wisconsin Collaborative Insurance Co. The partnership offers a commercial health plan called Well Priority to move patients to high-quality providers within the state. ‘’The new 50-50 venture was born out of a 2012 partnership in which Anthem offered incentives and penalties for Aurora physicians based on specific quality measures,’’ says Fierce.
  • Aetna and Inova Health System, in Northern Virginia, solidified their partnership back in 2012through creating Innovation Health Plans, a jointly owned plan that offered financial incentives for low-cost, high-quality care. Four years later, executives have cited such tangible benefits as a reduction in medical-waste costs.
  • After Humana and UnitedHealth exited Colorado’s Affordable Care Act exchange earlier this year, insurance startup Bright Health saw an opportunity to fill the gaps left behind. The company is set to offer plans on the state’s marketplace starting in 2017. Using its existing partnership with Centura Health System, Bright Health co-founder and President Kyle Rolfing told FierceHealthPayer that the insurer, in Fierce’s words, “plans to leveragethat partnership to maintain cost efficiency and high-quality care and invest in technology that allows the two organizations to share data.’’

To read the whole article, please hit this link



AMA president denounces proposed Anthem-Cigna merger



The president of the American Medical Association has denounced Anthem’s proposed $54 billion purchase of Cigna. The AMA is worried that the bargaining power of such a behemoth would cut into physicians’ pay.

“Competition and choice hang in balance as the court begins to weigh the impact of the proposed deal between Anthem and Cigna,” Andrew Gurman, M.D., said.  “The start of today’s court challenge {the Justice Department suit against the proposed merger} sends a clear message that federal and state regulators are no longer willing to accept the claim that a bigger health insurance company is a better one.”

Indianapolis-based Anthem and Bloomfield, Conn.-based Cigna have argued that their combined scale would, by giving  them more negotiating power over hospitals and physicians, lower prices for policyholders.

Public option being eyed for California


California State Capitol.


For Kaiser Health News

With  some major insurers retreating from the federal health law’s marketplaces, California’s insurance commissioner said he supports a public option at the state level that could bolster competition and potentially serve as a test for the controversial idea nationwide.

“I think we should strongly consider a public option in California,” Insurance Commissioner Dave Jones said in a recent interview with California Healthline. “It will require a lot of careful thought and work, but I think it’s something that ought to be on the table because we continue to see this consolidation in an already consolidated health insurance market.”

Nationally, President Obama and other prominent Democrats have revived the idea of the public option in response to insurers such as Aetna Inc. and UnitedHealth Group Inc. pulling back from the individual insurance market and many consumers facing double-digit rate hikes.

The notion of a publicly run health plan competing against private insurers in government exchanges was hotly debated but ultimately dropped from the Affordable Care Act when it passed in 2010.

Most of the discussion surrounding a public option, however, has focused on a nationwide plan, not one emanating from a state. In July, Democratic presidential nominee Hillary Clinton said she would “pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan.”Health insurers have long opposed the idea, and other critics fear it would lead to a full government-run system.

Jones offered few specifics on what a public option might look like in the Golden State.

“I don’t want to begin to prejudge it,” said Jones, an elected Democrat serving his second term as head of the state Department of Insurance, one of two insurance regulators in California. “I don’t know whether you would start in certain areas of the state and expand from there. I think there would be significant reservations about the state running it. There would be a wide variety of governance models you could come up with.”

Politically, the proposal may gain more traction in Sacramento than Washington with Democrats firmly in control of the state legislature and many lawmakers eager to go beyond the boundaries of the federal health law. Depending on what form it took, a public option would require state legislation, some type of federal approval and some source of funding.

The idea of a California-style public option drew mixed reaction. Some consumer groups say they welcome another run at the public option after a disappointing outcome in 2010.

“We’re certainly very interested,” said Anthony Wright, executive director of Health Access California. “This is something we advocated for in its most ambitious form during the debate over health reform and there are elements of the proposal that could be adapted for California.”

Some health-policy experts questioned whether the proposal would backfire, ultimately reducing competition.

“I don’t know what would compel other insurers to stay in the market, so the public option could quickly become the only option,” said Katherine Hempstead, who directs the Robert Wood Johnson Foundation’s work on health insurance coverage. “I think that is only a clear win when the alternative is nothing.”

State Sen. Ed Hernandez (D.-West Covina), chairman of the Senate Health Committee, said a public option could make sense in some underserved areas. But he said it may not address the problem of large health systems dictating high prices, and it could interfere with the progress made by the Covered California insurance exchange.

Covered California said 7.4 percent of its 1.4 million enrollees will only have two health plans to choose from for 2017. The state’s biggest markets of Los Angeles, San Francisco and Orange County all feature six to seven insurers.

“I don’t know if a public option will create a lower price [for] the consumer,” Hernandez said. “Covered California has done a good job of keeping rates fairly stable and it has enough plans.”

Health insurers agreed. “Covered California has arguably one of the strongest and most stable exchanges in the country. There is robust consumer choice so we don’t think we need to mess with something that isn’t broken,” said Nicole Evans, a spokeswoman for the California Association of Health Plans, a trade group.


For years, Jones has criticized the lack of competition in Covered California, and more recently he has opposed the mergers proposed by industry giants Anthem Inc. and Aetna Inc., saying they’re anticompetitive.

Anthem wants to acquire Cigna, while Aetna is trying to merge with Humana, but the U.S. Justice Department has sued to block both deals.

Covered California has fared better than many states in terms of insurer competition. Eleven health plans are participating in the state-run exchange for 2017, but UnitedHealth is dropping out after just one year in California’s individual market.

Consumer advocates had hoped UnitedHealth would become a strong rival to the state’s four largest insurers. Anthem, Blue Shield of California, Kaiser Permanente and Health Net (now a unit of Centene) account for 90 percent of the state’s exchange enrollment.

After modest 4 percent rate increases in 2015 and 2016, Covered California premiums are set to climb by 13.2 percent on average next year.

Jones said he anticipates that critics will cite the failure of numerous co-ops across America as evidence a public option won’t work. But he said that criticism is unjustified because the Republican-led Congress eliminated crucial funding that many of the co-ops were depending on.

The co-ops are nonprofit insurers backed with federal loans and designed as an alternative to commercial health plans.

Anthem touts a Cigna takeover as good for insurance exchanges


Anthem, seeking to buy Cigna in the face of the opposition of the Justice Department’s Antitrust Division, argues that the deal would boost the health-insurance exchanges created by the Affordable Care Act.

Modern Healthcare opined: “The response signals Anthem will indeed litigate the case to the end even though many analysts and policy experts say the company is unlikely to win.”

Anthem said:
“At a time when large insurers are withdrawing from public exchanges, its acquisition of Cigna will significantly increase consumers’ access to the exchanges,”  Anthem, which has about 923,000 ACA exchange members, expects to lose about $300 million from that business this year but hasn’t said it will quit any markets.

The company asserted that the combined Anthem-Cigna company would enter nine new states with ACA marketplaces.

To read the Modern Healthcare article, please hit this link.

Feds detail case against huge insurance mergers


U.S. Atty. Gen. Loretta Lynch has discussed in detail why the Feds are rejecting the huge insurance company mergers sought by Anthem and Aetna. Anthem wants to buy Cigna; Aetna wants to buy Humana.

“If allowed to proceed, these mergers would fundamentally reshape the health insurance industry They would leave much of the multitrillion-dollar health industry in the hands of three mammoth insurance companies, restricting competition in key markets,”  she said.

The government says the transactions would “substantially lessen competition in numerous markets around the country,” leading to  “higher prices and reduced benefits” for consumers.

Justice Department officials also worry that the deals would kill most competition in the Affordable Care Act’s insurance marketplaces.

For the full article, please hit this link.

DOJ seen likely to kill Cigna-Anthem merger plan this month


The likelihood is increasing that the U.S. Justice Department will kill the proposed merger of giant health insurers Cigna and Anthem this month because  the DOJ’s Antitrust Division thinks that the combined entity would have far too much pricing power.

To read the HealthcareDIVE piece on this, please hit this link.

Phil Galewitz: Your doctor will see you at the kiosk


For Kaiser Health News


On the day abdominal pain and nausea struck Jessica Christianson at the office, she discovered how far telemedicine has come.

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  that 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 such as  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  letting employees connect with a physician 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, Mo.

Large health insurers such as Anthem and UnitedHealthcare are promoting telemedicine’s next wave by testing the kiosks at worksites where they have contracts.
“This technology should make it more affordable for employers of many sizes,” Jesser said.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.

Kiosks are typically used for the same maladies that lead people to see a physician 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 toaccess 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, Mo., 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, Mo., estimate that 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, Wis., a nonprofit that offers health coverage to public employers, installed a kiosk for the benefit of its 250 workers last fall.

Tim Bartholow, M.D., 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.

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