UCSF Health received fewer patient portal messages after letting clinicians choose when to charge

An early adopter of patient-provider electronic communication billing saw a decline in the number of messages received from patients after implementing a workflow change in which its clinicians determined whether a virtual exchange warranted charges, according to recently published data.

The decline in message volume at UCSF Health was accompanied by a nearly fivefold increase in weekly billed “e-visits,” though researchers noted that adoption by the clinicians classifying patient messages as billable was low, according to a research letter published in JAMA.

The findings also don’t include any data on how the reduced frequency of patient messages may have impacted patient outcomes and clinician satisfaction or whether the billed e-visits were profitable for UCSF Health.

Still, the system’s dip in messaging volume is likely of interest to the growing number of health systems considering or adopting similar policies.

“Future research should investigate overall costs under different payment models and the effect of billing for messaging on outcomes, health equity and patient and clinician satisfaction,” researchers wrote in the journal.

Following a widespread increase in electronic patient-provider messaging during the pandemic and new regulatory allowances, UCSF Health began allowing patients sending asynchronous messages through a patient portal to designate their inquiry as an e-visit in late 2020.

In November 2021, the system adjusted its approach to have clinicians determine when a message thread qualified as an e-visit, defined as asynchronous messages that require medical decision-making and at least five minutes of the clinician’s time over a seven-day period. The change was accompanied by an updated patient user interface that encouraged continuous message threads and a warning that their messages may incur a bill.

In comparing message trends before the workflow change (November 2020 to November 2021) and after (November 2021 to October 2022), researchers saw the weekly mean number of billed e-visits increase from 50.6 to 235.7. Weekly mean patient messages and message threads both declined from 59,648 to 57,925 and 19,739 to 16,838, respectively.

Statistical analysis showed “an immediate level change” in the three volume measures following the implementation, the researchers wrote. There were no significant changes in UCSF Health’s scheduled visits or unscheduled telephone calls between the study periods.

“This study found an association between implementation of clinician-initiated billing and an increase in e-visits, but adoption was low,” the researchers wrote. “Multiple factors likely contributed, including lack of awareness of e-visit workflow, perception that additional steps to complete e-visits were not worth the reimbursement, and concerns about negative patient perceptions of charging for messages.

“Nonetheless, an association with a reduction in patient portal messaging (both threads and individual messages) was observed that may be attributable to awareness of the possibility of being billed. The reduction in threads may be partially due to the simultaneous change in the portal interface, but this should not have affected patient message volume,” they wrote.

Billing for patient portal messaging became a hot topic late last year when Cleveland Clinic started charging up to $50 for messages meeting similar criteria to UCSF Health’s e-visits.

Critics of the practice at these and other systems have said that the impact on a clinician’s time is negligible enough to be included as part of a provider’s original bill. Systems defending the policy point to the compounding workload burden of numerous online requests and stressed that billable messages comprise fewer than 1% of total message volume.