Email has become an easy and essential form of communication between patients and physicians -- so much so that doctors are deluged daily with messages from patients.
Now, some hospitals and health systems have started charging for doctors' responses to those messages, depending on the amount of work needed to respond. Only a handful of health systems have started billing for these, and those that do say only a tiny percentage of doctor messages cost anything.
But advocates say they're concerned these charges will wind up limiting an option meant to expand patient access to health care.
“We already know that even a small dollar amount of cost-sharing results in patients utilizing service less,” said Caitlin Donovan, senior director of the Patient Advocate Foundation. “I worry about anything that's going to stop patients from contacting and communicating with their providers.”
A new study suggests Donovan's concerns are well-founded.
Patient e-messages to University of California, San Francisco (UCSF) doctors slightly declined immediately after UCSF Health started charging for some responses, according to research published recently in the Journal of the American Medical Association.
“We started putting this language on our website, on our patient portal that said, as an FYI, there's a potential that if your message meets the requirements to the clinical question, it may be billed,” said lead researcher A. Jay Holmgren, an assistant professor with the UCSF Center for Clinical Informatics and Improvement Research.
After that, “we found a very small, but statistically significant, decrease in the number of messages received,” Holmgren said.
“This is a really interesting test of how we pay for health care in this country, which is really built around this notion that you go to your doctor, you have your 30-minute office visit, and you pay them for that time,” Holmgren said. “That's how medical care was delivered in the 1950s, when health insurance became popular and we built this system.”
But technology has evolved past that pay-per-visit system, Holmgren said, and doctors are now receiving patient emails at all hours.
“How are we going to shoehorn this into a system that was built for 1950s medicine?” Holmgren asked.
Explosive growth in telemedicine
These high-level debates are occurring even as patients like 29-year-old Kacie Lewis start receiving bills for email communications with their doctors.
Since late 2021, Lewis has been billed $32 each for three email threads seeking treatments for psoriasis, eczema, and a yeast infection, according to the New York Times. At the time, she had a high-deductible health plan through Aetna and received health care in Charlotte, N.C.
“Time is money,” Lewis told the Times. “And to be able to submit something super simple and communicate with your doctor over email is much better than driving 20 minutes one way, 20 minutes back the other way and potentially sitting in the waiting room.”
Prior to the pandemic, health care officials saw the promise of what Holmgren calls “asynchronous telemedicine” -- people reaching out to their docs with an email, doctors responding later.
“Most patients had the ability to message their physician or their clinician for over a decade and, for the most part, the take-up of that was relatively low,” Holmgren said. “If you look at the scientific literature prior to 2020, almost everything is about, how do we get more patients engaged in using the patient portal or asynchronously messaging with their clinical team if they want to check in about how their symptoms are going, that sort of thing.”
The pandemic lockdowns changed all that.
Patient emails to doctors jumped to 157% of their pre-pandemic average by the end of 2020, Holmgren reported in a 2021 study published in the Journal of the American Medical Informatics Association.
“There was a sudden explosion of message volume,” Holmgren said.
Cleveland Clinic says messages sent through its MyChart patient portal have doubled since 2019.
“We actually receive an average of about 110,000 MyChart messages that require medical advice a week,” said Dr. Sandra Hong, director of the Cleveland Clinic Food Allergy Center.
These communications benefit the patient, the doctor and the health care system in general, Holmgren said.
“I think it is a useful channel of care delivery. We are in a physician-supply-constrained environment in the United States, especially in primary care, where it takes weeks to get an appointment in a lot of places, or even longer,” Holmgren said. “If you can solve an issue with five minutes of typing on the computer rather than trying to find an open 25-minute visit slot, that is increasing efficiency for everyone.”
However, responding to these emails has started to take up a larger chunk of a doctor's time, Holmgren noted.
“If you are friends with any primary care physicians, as I am, you'll find them answering patient emails at dinner, at conferences, whenever they're out,” Holmgren said.
“It looks like primary care doctors and pediatricians take about an hour to answer MyChart messages outside of their work day,” Hong said. “And family practice doctors and internal medicine doctors take about two hours outside of the time that they're seeing patients to do MyChart messages.”
As a result, both UCSF and Cleveland Clinic decided to start charging for those email responses that required more of a doctor's time and attention.
These charges allow doctors to set aside a portion of their workday and focus on responding to patients' emailed queries, Holmgren said.
Other hospital systems have since followed suit, either with a pilot program or a fully implemented billing schedule, the Times reported.
These include Houston Methodist in Texas; NorthShore University HealthSystem, Lurie Children's and Northwestern Medicine in Illinois; Ohio State University; Lehigh Valley Health Network in Pennsylvania; Oregon Health & Science University; and the U.S. Department of Veterans Affairs.
Which emails are billable?
The federal government anticipated this move.
Back in 2019, the U.S. Centers for Medicare and Medicaid Services introduced billing codes that would let providers get reimbursed for written messages sent through secure patient portals.
Under CMS rules, a billable message must be in response to a patient's inquiry and it must require at least five minutes of a health care professional's time to research and craft.
The Cleveland Clinic warns patients that these types of messages might get billed:
On the other hand, Cleveland Clinic says providers won't bill for messages about:
The key to an email response being billed is how much medical expertise and judgment is required to meet the patient's needs, Hong and Holmgren said.
“It truly is only when we use medical decision-making and only when it's a licensed provider that actually does the care,” Hong said.
Hong -- who helped craft the guidelines -- provides an example.
“If someone needs a new medication or they're calling in for an upper respiratory tract infection, I'll need to look through the chart to make sure that they don't have an allergy, to make sure that their kidney function and liver function looks all right, to make sure that none of their medications will interact with this, to make sure that their insurance will cover it, and then make sure that it's going to the right pharmacy,” Hong said.
“A lot of times we just need to make sure that all of the stars will align correctly to make sure that the patient gets the best care,” she continued. “And if that takes more than five minutes of time and medical decision-making, that's when we'll actually go ahead and charge for it.”
Despite these guidelines, patient advocate Donovan said she's concerned that “it feels kind of arbitrary whether or not you're going to get billed.”
“How do you know ahead of time your question is going to require medical decision-making, if you just want clarity on a treatment they recommended or something like that?” Donovan said.
“It just seems like most of the patients I work with are at a point where they think they're going to get billed for everything,” Donovan said.
Dollars per minute
Still, the number of message responses that are being billed by UCSF and Cleveland Clinic remains surprisingly low, both institutions say.
In any given week, patients are billed for about 2% of doctor responses from UCSF Health and less than 1% for those from Cleveland Clinic, Holmgren and Hong said.
“The vast majority of messages are still essentially free for all patients,” Holmgren said.
“The ability to send and receive messages has made care more convenient for patients and increased access and choice for many, but ultimately these E-visits make up a very small percentage of the messages sent to clinicians from patients, and most patients will never see a bill for messaging their doctors,” the American Hospital Association said in a statement.
How much a patient might shell out depends on their insurance coverage.
Cleveland Clinic bills on a sliding scale based on the amount of time required to respond, Hong said -- five to 10 minutes is $33, 11 to 20 minutes is $41, and more than 21 minutes is $50. Insurance then might pass along a copay for the bill to the patient.
UCSF patients on Medicare or Medicaid aren't charged any copay in relation to their messages, Holmgren noted.
“For private insurance, it depends on the nature of the plan,” Holmgren said. “For the most part, they're the same copay or less than an office visit, so the majority pay between $5 and $20.”
“That said, if you are on a high-deductible health plan and you have not yet met your deductible for the year, you might pay the extra charge, which is closer to $50 depending on the negotiated rate with your specific insurance company,” Holmgren continued.
Given that, experts are worried that financially strapped people might eschew email communications with their doctors, even when it would be best for everyone involved.
Once UCSF warned that some email responses would be billed, the number of messages sent by patients declined by about 4,600 from the prior weekly average of around 56,600, Holmgren's latest research showed.
“It does seem like a small portion of patients simply didn't ask a question or send a message without a substitution to other care,” Holmgren said.
Holmgren and Hong said their health care systems continue to track trends in email messaging and weigh potential disparities that could crop up.
“The worry with stuff like this is that it's kind of hard to put the genie back in the bottle,” Donovan said. “And I doubt that there is a major [health care] system in the country right now that hasn't had a meeting discussing the viability of charging for e-messages.”
The American Medical Association has more about patient portals and e-messages.
SOURCES: Caitlin Donovan, senior director, Patient Advocate Foundation; A. Jay Holmgren, PhD, assistant professor, UCSF Center for Clinical Informatics and Improvement Research; Sandra Hong, MD, director, Cleveland Clinic Food Allergy Center; Journal of the American Medical Association, Jan. 6, 2023; statement, American Hospital Association; New York Times