How Patients and Providers Respond to Electronic Messaging Fees​

Patients may be noticing something new in their online health care portals.

Many leading health systems – like Cleveland Clinic, Northwestern and University of California, San Francisco (UCSF) – are increasingly billing patients for the electronic messages they send clinicians between appointments.

The trend toward patient messaging exploded during COVID – one study showed a 50% increase in messages compared to before the pandemic.

All of this messaging has essentially created a new kind of clinical encounter, sometimes known as an asynchronous visit.
As someone who has cared for patients, I’ve seen both the opportunity and the challenges this type of messaging creates. Sometimes you can quickly give patients high-value information or prescribe medications, such as antibiotics for a urinary tract infection, to avoid an unnecessary visit. But you can also lose hours answering questions around new symptoms, like heart palpitations, that could be answered more efficiently and robustly at an in-person visit.

So when health systems started billing for these messages, I wondered how it could affect that balance of pros and cons.

A recent study in JAMA by A. Jay Holmgren and colleagues provides some early insights.

Some patients are starting to see messages like this one from UCSF in their online health care portals.

How does billing affect patient portal messaging?

The researchers focused on UCSF, which in November 2021 began letting clinicians bill for messages that required some medical decision-making and took more than a few minutes. The cost to patients ranged from $0 to $75 out-of-pocket on average, depending on their insurance.

Patients also began receiving a notification before they sent their message that it could result in a bill (see image).

Within about one year after these billing changes were implemented, the researchers found that:

• Billing for this type of messaging nearly quintupled, but doctors billed patients for less than 2% of all messages involving back-and-forth exchanges.
• The volume of patient messages with back-and-forth exchanges decreased by about 15%.
• The volume of patient messages, in general, decreased by about 3%.

Two limitations of this study are that it only involved one health system, and the researchers could not definitively conclude why providers or their patients changed (or didn’t change) their behaviors.

Three other questions to consider

This study offers a helpful early look at the emergence of this new kind of billing in health care. It also left me with a few more questions:

1. We know from other parts of health care that adding cost-sharing or “skin in the game” can have unintended consequences. Do cost-sensitive patients cut back on wasteful messages or on ones that could have improved their health?
2. Why did doctors still bill less than 2% of back-and-forth exchanges? Did these exchanges not meet the billing criteria or did doctors not feel comfortable billing for them?
3. Is billing per message the right payment approach – or should doctors instead get some kind of monthly “digital health” payment to use in whatever way best suits each patient?

So many of our jobs changed dramatically during COVID – and the same is true for doctors. It’s clear from this study, and intense lobbying around telehealth payments, that our payment policies need time to calibrate to this new normal.