Value Versus User Fees: Perspectives of Patients Before and After Using a Web-Based Portal for Management of Diabetes

The objective of this work was to rate the potential or actual usefulness of 15 features of a Web-based portal for diabetes management and assess whether patients would be willing to pay user fees for portal access. We used a combination of qualitative methods (focus group discussions) and quantitative methods (survey responses) to examine patients' perspectives. We enrolled 21 patients before the diabetes-specific portal was released ("preportal" group) and 18 patients after it was released ("portal-users" group). The two groups were similar except that 67% of preportal patients and 100% of portal users were Internet users. Overall, portal features that were rated most favorably were the online calculator to estimate blood glucose control (characterized as "very useful" by 74% of patients), appointment reminder systems (74%), e-mail access to health team (74%), personal tracking logs (69%), and online scheduling (69%). More patients from the preportal group than the portal-users group favored personal logs (86% versus 50%; p = 0.015) and opportunities to form interest groups (62% versus 28%; p = 0.034). Of the 30 patients who assigned a dollar amount for 1 month of portal access, 20 assigned zero dollars. Discussions about payment focused on equity and access. Because fees are expected to discourage portal usage, many patients believed that the potential benefits associated with self-management would not be realized. Others felt that the health system would benefit financially from a portal and should therefore absorb the costs. Even if portals are valued, patients may be resistant to paying for them. This opposition stems from concerns about fairness and from the recognition that health systems may experience cost savings if patients manage their diabetes successfully.