Paying Doctors Fees for Email

HEALTH

BENJAMIN RYAN

More hospitals and practices are charging for patient queries.

To Nina McCollum, the Cleveland Clinic’s decision to begin billing for some email correspondence between patients and doctors “was a slap in the face.”

She has relied on electronic communications to help care for her ailing 80-year-old mother, who is in need of specialized psychiatric treatment from the clinic. “Every 15 or 20 dollars matters, because her money is running out,” she said.

Electronic health communications and telemedicine have exploded in recent years, fueled by the pandemic and relaxed federal rules on billing for such care. In turn, a growing number of health care organizations, including some of the nation’s major hospital systems like the Cleveland Clinic, doctors’ practices and other groups, have begun charging fees for some responses to more time-intensive patient queries.

The Cleveland Clinic said that its email volume had doubled since 2019. But it added that since the billing program began in November, fees had been charged for responses to less than 1 percent of the roughly 110,000 emails a week its providers received.

“Billing a patient’s health insurance supports the necessary decision-making and time commitment of our physicians and other advanced professional providers,” said Angela Smith, a spokeswoman for the clinic.

A new study shows that the fees, which some institutions say range from a co-payment of as little as $3 to a charge of $35 to $100, may be discouraging a small percentage of patients from getting medical advice via email. Some doctors say they are caught in the middle of the debate over the fees, and others raised concerns about the effects that the charges might have on health equity and access to care.

Dr. Eve Rittenberg, an internist in women’s health at Brigham and Women’s Hospital in Boston, examined the effects of medical correspondence with patients in a study that found that female practitioners shouldered a greater communications burden.

“The volume of messaging combined with the expectation of quick turnaround is very stressful,” Dr. Rittenberg said. She recalled one day when she took her teenage daughter to the doctor but was distracted by responding to patient messages on her phone. She recently reduced her clinic schedule to free up a few hours outside of office visits to cope with other tasks like patient messages.

The U.S. Centers for Medicare and Medicaid Services introduced Medicare billing codes in 2019 that allowed providers to seek reimbursement for writing messages through secure portals. The pandemic prompted the agency to broaden coverage for telemedicine, and hospitals significantly expanded its overall use.

The federal rules state that a billable message must be in response to a patient inquiry and require at least five minutes of time, effectively making it a virtual visit. Private insurers have widely followed Medicare’s lead, reimbursing health care practices for physicians’ emails, and may charge patients a co-pay. For several major hospital systems across the country, the increase in email fees has opened up a new revenue stream.

Blue Cross Blue Shield said some of its state and regional plans reimburse for doctor emails. But David Merritt, a senior vice president for policy and advocacy for the insurer, expressed concern that the ability “to charge patients for what often should be routine email follow-up could easily be viewed and abused as a new revenue stream.”

According to the Cleveland Clinic, Medicaid patients are not charged. Medicare beneficiaries without a supplemental health plan would owe a co-pay between $3 and $8. The clinic’s maximum charge, hitting those with high deductibles on private insurance plans or without coverage, would be $33 to $50 for each exchange.

Clinic patients are given the option of avoiding fees by choosing to discontinue a query or request an appointment instead.

Not all patient-doctor exchanges carry fees. Emails for simpler concerns largely remain free, including for prescription refills, appointment scheduling and follow- up care. According to several hospital systems and insurers, electronic communications that could prompt a bill would address, for example, medication changes, a new medical issue or symptom, or shifts in long-term health conditions.

Before the pandemic, Dr. Daniel R. Murphy, an internist and chief quality officer at Baylor Medicine in Houston, found in his research that primary care doctors spent about an hour a day managing their inbox. But a recent study of data from Epic, a dominant electronic health records company, showed that the rate of patient emails to providers had increased by more than 50 percent in the last three years.

“We’re at an inflection point with messaging,” said A Jay Holmgren, an assistant professor at the University of California, San Francisco, who led the study. “How are we going to deliver care in the future as we continuously move away from all care being a discrete visit?”

Many doctors and their assistants have little time during work hours for replying to patients. Doctors find themselves attending to such demands before bed, according to Dr. Anthony Cheng, an associate professor of family medicine at Oregon Health & Science.

“We know that this is a contributor to burnout,” Dr. Rittenberg said. “Burnout and resulting attrition in physicians’ work is becoming a crisis in our medical system.”

Critics argue that billing for a small fraction of emails is not likely to reduce physician burnout substantially unless hospitals also set aside workday hours for patient queries and reward clinicians for those efforts.

Jack Resneck Jr., president of the American Medical Association, said he supported insurance coverage for emailing as a way to adjust health care models to fast-changing times.

“How do we reinvent the physician’s day and the care delivery system to actually recognize and support the broad array of ways that we deliver care?” Dr. Resneck asked.

SPECIALIZED TREATMENT Nina McCollum relies on being able to email the Cleveland Clinic to help care for her 80-year-old mother.

DANIEL LOZADA FOR THE NEW YORK TIMES

OFFICE TASKS Dr. Eve Rittenberg reduced her schedule to allow a few hours for patient messages.

SOPHIE PARK FOR THE NEW YORK TIMES