More health systems are seeking compensation for services doctors provide via patient portals such as MyChart, raising questions among payers about the downstream impact on costs.
Cleveland Clinic of Ohio began charging patients for some MyChart messaging with providers this month, such as replies that require “medical expertise ... typically taking five or more minutes for your provider to answer.” That includes conversations regarding medication changes, new symptoms or checkups on chronic conditions.
Last month, NorthShore University HealthSystem of Evanston, Illinois, also began billing for some messages sent through its patient portal, NorthShoreConnect. And University Hospitals in Cleveland is considering charging for messages that require clinicians to review patient charts, conduct research or undertake additional communication.
Physicians have long resisted engaging with patients via telephone, email and other means of communication that replace or supplement in-person visits, largely because they typically didn't get paid for their time. But emerging technologies, shifting patient preferences and the influence of the COVID-19 pandemic have made electronic messaging more attractive to patients—and a moneymaking opportunity for providers.
As telehealth utilization grows, doctors say they are inundated with electronic messages from patients seeking additional help that goes beyond regular appointments. As a result, some health systems are calling on payers to provide reimbursements that will sustain provider-patient communications. Charging for messages is likely to become more common in the near term, driven in part by convenience and growing consumer preferences for some virtual health services.
“Time has to be paid for by someone,” said Chip Kahn, president and CEO of the Federation of American Hospitals. “We now have a lot of different avenues of communication. Patients and clinicians are going to want to take advantage of all those avenues. For payers to ignore that is to ignore communication, which is really critical to patient care.”
Growing demand
A key precursor to messaging was the implementation of electronic health records with patient portals, such as Epic Systems' MyChart, that evolved into messaging platforms. The Centers for Medicare and Medicaid Services developed billing codes doctors can use to get Medicare payments for “virtual check-ins” and “e-visits." CMS limits how frequently these codes can be used and imposes standards for how much time must be spent responding to patient questions and what kinds of communications are eligible for reimbursement.
Most clinicians didn't use these codes prior to the pandemic because telemedicine was atypical. In addition, the government and health insurers were concerned about fraud and overuse in telehealth, said Jennifer Breuer, co-chair of the digital health practice group at the law firm Faegre Drinker.
“CMS’ fear has always been, frankly, that bored little old ladies are going to call their doctors too often,” she said.
As the pandemic overwhelmed hospitals and shuttered other types of healthcare facilities in 2020, telehealth usage exploded. While this partly addressed access problems, it also exacerbated physician burnout, particularly among women.
Demand for messaging has doubled at Cleveland Clinic since 2019 and providers devote significant time answering hundreds of messages each week, a spokesperson said. UCHealth has seen the number of messages triple to roughly 183,000 a month, said Dr. CT Lin, the Aurora, Colorado-based health system's chief medical information officer.
“You would think that the pandemic settling down means the number would go down. No. Patients have found a new channel, and they like it,” Lin said.
Health systems adopting messaging capabilities complements a broader shift away from inpatient services. Messaging is also an increasingly popular choice among patients enrolled in high-deductible plans who are looking to save money by avoiding office visits.
Unknown implications
A year ago, University of California, San Francisco Health began charging for medical advice via MyChart. Fees range from nothing for Medicaid beneficiaries to $20 copays for Medicare Advantage members to an average of $75 for people with private insurance. The Cleveland Clinic's charges range from $3 for Medicare enrollees to as much as $50 for privately insured patients.
Because these amounts are small, payment disputes between insurers and providers are unlikely to trigger full-blown contract fights, Breuer said. But insurers are expected to conduct regular audits of telehealth utilization, particularly from providers that frequently bill for messaging, she said. If providers fail to maintain documentation that indicates the medical necessity of a service, insurers will deny payment, she said.
“There's still some trepidation among payers that do want to make sure that telemedicine is used judiciously and appropriately,” Breuer said. “That's the balancing act.”
The health insurance trade group AHIP did not respond to an interview request. The Alliance of Community Health Plans, which represents nonprofit insurers, said payment for provider messages has not been an issue for its members and declined further comment.
Private health insurers tend to follow CMS’ lead on reimbursement policy. Still, it could take years for insurers and providers to establish clear, uniform coding rules, said Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research.
These new protocols for coding and billing could create even more administrative burden for providers, particularly for smaller companies with fewer resources. To stay competitive, health systems must invest in better technology for their patient portals.
“I totally appreciate where the providers are coming from, and I think something needs to be done in terms of them getting paid for the effort that they’re putting in,” said Chris George, a senior managing director at FTI Consulting. “You’ll see it flush out over time, but what can’t continue to happen is patients communicate with the provider and a response just takes forever, and it’s because [of] the ... volume of inquiries that are coming in through these different channels.”
Health systems say most inquiries are handled quickly and aren't billed to insurance. Messages to schedule appointments, refill prescriptions or answer post-procedure follow-up questions are still free. In some cases, billable messages may take the place of scheduled virtual or in-person appointments.
Charging for messages could even become a promotional opportunity. For example, an insurer may advertise that they cover the cost of certain types of interactions that their rivals don’t as a way to attract new customers. Health systems could also lose patients over the messages for which they bill. “We could actually see some really interesting competitive developments here in terms of how clinicians compete with each other," Young said. "You can see the TV ads and the billboard ads.”
The implications of this nascent trend for access and cost is difficult to predict, said JoAnn Volk, co-director at the Georgetown University Center for Health Insurance Reforms.
Hitting patients with bills for messages could dissuade some from seeking care, Volk said. Others may be willing to pay to avoid long waits at urgent care facilities. And confusion over messaging charges could have legal ramifications. In Washington state, for example, providers must tell patients if they intend to bill for a phone call and obtain their consent before continuing the audio visit. Otherwise, they could face fines or other disciplinary action from state regulators.
