Here are 22 health systems billing patients for certain EHR and text messages

Online messages have become a linchpin of many patients’ relationships with their doctors.

The digital access points—often baked into patient portals and electronic health record systems like Epic’s MyChart—offer patients the opportunity for quick clarifications about their medication regimen or test results. In more pressing cases, a back-and-forth with their clinician can help patients understand whether their symptoms require an in-person visit or can be managed at home, potentially lightening the load on busy providers.

As the requests pile up, however, many systems have found that the missives can claim a substantial portion of their practitioners’ valuable time. As such, some organizations have announced billing policies that charge patients a fee for certain electronic messaging to providers.

Late last year, Cleveland Clinic, for instance, made waves when it announced that a subset of messages that required medical expertise and more than five minutes to answer could see payers or patients billed up to $50.

Its decision caught the public’s attention, spurring critiques from consumers and advocacy groups who characterized these policies as a new way for hospitals to nickel-and-dime their patients.

“Providers should welcome an open dialogue with their patients and treat them as valued customers who can take their business elsewhere,” Cynthia Fisher, founder and chairman of price transparency nonprofit, told Fierce Healthcare at the time. “Ultimately, electronic messages should be treated the same as customer service in any other part of the economy, as a companion courtesy covered by the original bill.”

Cleveland Clinic and others say the policies can help justify the effort practitioners put toward a time-effective alternative to in-person encounters.

“Both can be true,” John Hargraves, director of data strategy for the Health Care Cost Institute, said in a recent Podnosis interview. “It can be a surprise, especially for the patient who has been utilizing this service for years. … But for the health system and provider side—yeah, it’s one thing to answer a quick email a couple [of times] a day. It’s another to have hundreds of emails.”

Providers that enacted the policies stress that the complicated requests they bill for make up the minority of what their teams receive and that most messages will continue to be answered free of charge.

Still, there’s already evidence that the practice can throw a wrench in patient behaviors.

A UCSF Health study from January found that implementing and informing patients of potential charges (depending on the complexity of their message request) cut down the average weekly number of messages from 59,648 to 57,925 and average weekly message threads from 19,739 to 16,838. 

The “immediate level change” was accompanied by a nearly fivefold increase in weekly “e-visits” billed at clinicians’ discretion—from about 50 to more than 230—and no significant changes to scheduled in-person visits or unscheduled phone calls.

What the study didn’t measure, however, was whether the reduced utilization had an impact on patients’ health. Digital and virtual modalities were embraced by patients during the height of COVID-19, and, now, many are seeking care for health needs they may have deferred or aggravated during the pandemic. The latter is particularly the case with behavioral health, which Hargraves noted increasingly relies on telehealth and asynchronous written communications due to shortages of in-person providers.

Even though the higher end of these charges is limited to the tens of dollars, Hargraves said that patients’ apprehension of additional bills will shift their behavior, and providers adopting these strategies need to address those potential shifts.

Some who are uninformed about the specifics of the policy will likely worry that they could receive the high-ticket charges often featured in media reports on hospital billing practices, he said, meaning that it’s up to organizations to be clear in communicating which messages warrant charges, how much those charges can tally and whether the patient’s insurance will be footing the bill. Failing to do so could cement the policies as an unnecessary barrier to needed care, he said.

“It’s important with the announcing … to [draw] the line between what types of questions are freely answered and which are the more complex ones that could involve a charge,” he said, “because you don’t want people not getting prescription refills—especially if it’s conditions that require rather strict medication adherence—because they’re afraid that their provider is going to charge them for asking for a refill.”

For better or for worse, the creation of billing codes for these types of services and the bulkhead established by leaders like Cleveland Clinic means it’s unlikely that the healthcare industry will “put the cork back in the bottle,” Hargraves said.

Here are 22 health systems that are charging for certain patient-provider electronic messages as of Aug. 16. The links below lead to the organization’s online page detailing the policy and charges or, when that’s unavailable, the original media story reporting that a policy charging for some electronic messages is in place.

BJC Healthcare, based in St. Louis

Cleveland Clinic, based in Cleveland, Ohio

HealthPartners, based in Bloomington, Minnesota

Houston Methodist, based in Houston

Johns Hopkins Medicine, based in Baltimore

Lehigh Valley Health Network, based in Allentown, Pennsylvania

Lurie Children’s Hospital of Chicago, based in Chicago

Mayo Clinic, based in Rochester, Minnesota

Michigan Medicine, based in Ann Arbor, Michigan

NorthShore University HealthSystem, based in Evanston, Illinois

Northwestern Medicine, based in Chicago

Novant Health, based in Winston-Salem, North Carolina

Ohio State University Wexner Medical Center, based in Columbus, Ohio

Oregon Health & Science University, based in Portland, Oregon

Providence, based in Renton, Washington

UC San Diego Health, based in San Diego

UCSF Health, based in San Francisco

UnityPoint Health, based in Des Moines, Iowa

University of Rochester Medical Center, based in Rochester, New York

The U.S. Department of Veterans Affairs, based in Washington, D.C.

UW Medicine, based in Seattle

Vanderbilt University Medical Center, based in Nashville, Tennessee