As major hospitals now bill for some patient-provider messaging, the move could usher wider adoption

A major health system’s public notice of plans to begin charging for previously free patient-provider messaging has sparked public debate over the value of a clinician’s time.

There's also speculation that similar policies will become the norm among providers with digital touch points.

The Cleveland Clinic released a notice last month that, as of Nov. 17, it would begin billing up to $50 for certain messages sent by patients to their provider through its MyChart patient portal.

According to the announcement, Cleveland Clinic now bills for messages that require medical expertise and “typically taking five or more minutes for your provider to answer,” such as a potential change to the patient’s medication. Quicker notes, including appointment scheduling or clarification after a recent visit, remain free.

The announcement caught the attention of patients and local press, with some residents telling they acknowledged the burden on clinicians and others concerned that the policy could be the first step toward additional new charges.

Reports also suggest other health systems may not be too far behind, if they haven’t already rolled out their own version of the billing policy.

University Hospitals and ProMedica each told the publication they are considering charges for electronic messaging, while Columbus-based Ohio State University Wexner Medical Center said it already charges between $50 and $160 for certain messages.

“We don’t believe charging for electronic messaging will deter patients seeking care,” ProMedica reportedly told the publication. “The fees would likely still be lower than a standard office visit with a provider.”

The Chicago area’s NorthShore University HealthSystem also launched an electronic message billing policy this month, per the Chicago Tribune, joining nearby systems Northwestern Medicine and Lurie Children’s Hospital as well as UCSF Health in California.

Cynthia Fisher, founder and chairman of price transparency nonprofit, described the policies as “the latest attempt by hospitals to put profits over patients and pad their historic revenues that often feed Wall Street-style private equity arms.”

Electronic messages related to care make up the minority of patients’ questions, she said, and those that are “can generally be handled quickly by physicians and should be included as part of the original, underlying bill," she told Fierce Healthcare. For concerns that are complicated enough to warrant more of their time, providers should “transparently” suggest a separate virtual or in-person visit for which a physician will be compensated, she said.

“Providers should welcome an open dialogue with their patients and treat them as valued customers who can take their business elsewhere,” she said. “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.”

Representatives of Northwestern and Lurie, which also use MyChart, told the Tribune they have so far billed fewer than 1% of the messages received through the patient portal.

"Once it’s billable, it’s hard to … put the cork back in the bottle"

Pushback against new charges for electronic messages is little surprise to healthcare policy and technology researchers.

In an op-ed published in The New England Journal of Medicine last fall, UCSF’s Julia Adler-Milstein, Ph.D., and Harvard Medical School’s Ateev Mehrotra, M.D., wrote that the abrupt, pandemic-driven shift to digital touch points would likely last and usher a virtual care payment standoff.

“If a previously free portal message is now considered an e-visit, many patients will have higher out-of-pocket costs and will probably resent having to pay for something that was once free,” they wrote in the journal. “Healthcare systems face the daunting task of explaining to their patients which services are free and which will result in a bill, a process that will be further complicated by differences among payers."

Adler-Milstein and Mehrotra’s piece lauded capitated payment systems as the smoothest means to balance providers' and patients’ interests, writing that “without payment-system changes, we can expect to have many unhappy patients and physicians struggling with this complex payment labyrinth.”

John Hargraves, director of data strategy for the Health Care Cost Institute, an independent claims data research organization, similarly said that he is less surprised by the pushback than the decision by Cleveland Clinic and others’ decision to disclose a change at all.  

“It’s not a new practice, necessarily, billing for text-based communications from providers to patients,” he told Fierce Healthcare. “One of the newer things is the transparency in which they’re talking about pricing. If we were looking at years ago, billing for a new service or a change in billing behavior just happened behind the scenes—you didn’t have a press release by a hospital system.”

Hargraves said this “silver lining” is likely a reaction to the increased pressure hospitals have faced over price transparency and federal requirements (with which many hospitals still have yet to comply). Additionally, with more and more people receiving coverage through high-deductible plans, he said “patients should feel like they have skin in the game and be aware of how much healthcare costs” rather than face unexpected out-of-pocket costs.

The decision to bill for electronic messaging also comes with equity considerations, the researchers noted in the NEJM op-ed.

Though greater adoption of digital tools generally increases patient access to care, Adler-Milstein and Mehrotra warned that low-income patients “be less able than higher-income patients to afford fees and less likely to have the technology and digital literacy required to take advantage of these options.”

On the other hand, Hargraves noted that billing for electronic messaging could help equal the payment and time commitments of clinicians who “might spend more time responding to patient inquiries through emails” such as women or primary care physicians.

“But it’s hard to say until we start seeing data,” he said.

For better or for worse, Hargraves said it’s likely electronic message billing policies won’t be going away anytime soon.

Clinicians’ time is already in high demand, and many are facing stress and burnout due to heavy workloads. Billing for message responses helps manage the load and potentially justifies time spent on a time-efficient alternative to traditional encounters.  

“All of us with office jobs who answer lots of emails per day can attest that one email may not take a long time, but hundreds of emails do,” he said. “At some point, how much of a provider’s time goes toward answering emails? If that time isn’t reimbursed, does that incentivize providers to not answer patients?”

Barring any major setbacks in the near future, Hargraves said the decisions by Cleveland Clinic and other early adopters give systems a precedent to roll out their own message billing policies. With time, the industry could reach an accord with each other and with patients on what types of communications should and shouldn’t be charged.

“Once it’s billable, it’s hard to stem the tide, or put the cork back in the bottle,” he said. “As some systems have now indicated publicly that they charge for it, others who previously didn’t think it was feasible might reassess how they’re billing for these. These costs are being incurred by all providers. Having [industrywide] guidelines and clarity around those will help, but in the early stages of this it’s always kind of hard to figure out what those standards are.”