Dr. Thomas Harman has been caring for some very sick patients for the past two months. Including some he's never met.

From miles away, the Mayo Clinic family doctor listens to their hearts -- instructing patients at home to hold a stethoscope to their chests while Harman dons headphones to listen via a computer.

On a special touchscreen, they answer his questions about how they feel and input their weights, temperatures and other vital readings. Some have diabetes or chronic lung disease or are obese.

The closest Harman gets is sometimes switching on a camera so he can talk "face-to-face" on the computer screen.

"It doesn't feel that much different and, in many ways, forces us to direct our attention to the patient," said Harman, one of two doctors in Mayo's pilot telemedicine program.

The experiment is just one of several harbingers of yet more change coming at health care consumers as they head into open-enrollment season, dutifully signing up for company wellness programs, picking from increasing numbers of health plans and trying to be smart consumers.

Now Minnesota -- the state that gave birth to managed care, health savings accounts and retail clinics -- has a bunch of new ideas for the health care of the future -- and the future is now. Telemedicine is just one of them.

From space to your home

The technology for telemedicine has been around for years, but there has been a catch: Insurers wouldn't pay for its use. They paid for visits to a doctor's office.

Now that's changing, so more patients are likely to start logging in for their doctor's appointments.

The devices are made by AmericanTeleCare of Eden Prairie. Its devices have been used by astronauts on space missions and by the Centers for Disease Control and Prevention in remote corners of the world. There are about 3,000 of the devices across the country, about one-third used by the U.S. Department of Veterans Affairs.

"You can do pretty much everything except touch and smell the patient," said Dr. Randall Moore, chief executive of AmericanTeleCare.

The payment hitch has prevented widespread use. But starting in January, the Centers for Medicare and Medicaid Services will pay for some telemedicine services, including from nursing homes and community mental-health centers. Private health plans tend to follow Medicare's lead.

At Mayo, monitoring patients remotely costs $1,000 a month, said chief medical officer Dr. David Herman. The average hospitalization costs $15,000. If monitoring can prevent one hospitalization a year, it would save money, he said.

Reviving the company clinic

There was a time when company medical clinics focused on occupational health. A revival of that concept is underway, but now it's aimed at health coaching and disease management -- with potential to reduce health care costs and absences.

More than 80 percent of large employers now ask employees to complete a health-risk assessment and take part in walking classes or other wellness programs to qualify for cash benefits, said Mark Bilderback, a benefits consultant for Watson Wyatt in the Twin Cities. The benefits might include a bigger employer contribution to their health savings accounts.

A recent Watson Wyatt survey of large employers found that onsite clinics have expanded from their traditional focus to include more wellness programs.

At Ameriprise Financial's downtown Minneapolis headquarters, a six-year-old medical clinic is getting a makeover. Previously staffed by registered nurses, the clinic will bring a nurse practitioner on board in November to conduct more screenings and eventually coordinate care with workers' primary-care doctors.

"It's a shift from illness treatment to wellness treatment," said Brent Sabin, vice president of benefits and human resources at Ameriprise.

Last month, Wilson Tool International in White Bear Lake opened a new onsite clinic, run by HealthPartners, for its 450 employees.

"We've got to keep people well, not just keep moving dollars around," said Joe McErlane Sr., chairman of the Minnetonka start-up NeoPath Health, which aims to run onsite clinics for small- and medium-sized companies.

ATM as pharmacy

Prescription drugs by mail have become common. But how about meds from an ATM?

InstyMeds Corp. of Eden Prairie makes a refrigerator-sized machine that dispenses prescriptions. Doctors give patients a prescription and a personal identification number to punch into the machine, usually located in the doctor's office, an urgent care clinic or emergency room.

The drug "ATM" dispenses common pain medication and antibiotics, "things that help people right now," said Robert Bang, InstyMeds director of sales and marketing. The bottles are prepacked, and scanners check the bar code three times before the drugs are dispensed.

The company has installed more than 100 machines across the country. About 30 are in Minnesota, including at Abbott Northwestern Hospital in Minneapolis, North Memorial Medical Center in Robbinsdale and Ridgeview Medical Center in Waconia.

Pay now, please

Finally, get ready to pay upfront for care.

Ten percent of insured Minnesotans already are enrolled in a high-deductible plan. But because of the idiosyncrasies of the insurance system, many don't get asked to pay a cent until long after they've left the doctors' office.

Clinics and hospitals say they are seeing a rise in bad debt from these patients.

Now some doctors are looking at installing kiosks and other devices to swipe a credit card upfront -- just like at hotels and car rental companies. The card is charged only after a service has been performed and the insurer clarifies how much is owed. Minneapolis-based mPay Gateway already has 300 customers for its Web-based software that helps doctors estimate a bill and authorize that amount.

Chen May Yee • 612-673-7434