As More Patients E-mail Doctors, Health Systems Start Charging Fees (and Using AI for Responses)

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Yves here. While it is entirely logical for doctors to charge for responding to patient e-mails (and some countries have long-standing billing schemes that allowed for doctors to charge for services outside an office visit, such as a short phone call or writing an Rx), the fact that this practice falls outside the way American doctors have historically practiced medicine, in combination with the US having a profit-driven, as opposed to patient-driven system, means the risk of perverse outcomes is high.

On the one hand, patients who are worried about Covid would particulalry welcome getting advice outside an office visit. And asking a doctor “Should I bother coming in with these symptoms?” would seem to be in everyone’s interest.

But doctors are set up not to bill on time expended but on procedures. The article describes how in many cases it’s not cost justified to figure out if a patient e-mail interaction rises to the level of charging for it. So the article points out that a reason for dinging patients is to discourage e-mails, which of course works to the disadvantage of the poorest and sickest.

What I find alarming is that, late in the article, one health system is working with the biggest electronic records provider, Epic, has developed a chatbot to draft responses that will then supposedly be reviewed by the provider. If you don’t see this as the bleeding edge of introducing chatbots into medical practice, I have a bridge I’d like to sell you. I will admit to hating chatbots with the passion of a thousand burning suns.

By Harris Meyer. Originally published at KFF Health News

Meg Bakewell, who has cancer and cancer-related heart disease, sometimes e-mails her primary care physician, oncologist, and cardiologist asking them for medical advice when she experiences urgent symptoms such as pain or shortness of breath.

But she was a little surprised when, for the first time, she got a bill — a $13 copay — for an e-mailed consultation she had with her primary care doctor at University of Michigan Health. The health system had begun charging in 2020 for “e-visits” through its MyChart portal. Even though her out-of-pocket cost on the $37 charge was small, now she’s worried about how much she’ll have to pay for future e-visits, which help her decide whether she needs to see one of her doctors in person. Her standard copay for an office visit is $25.

“If I send a message to all three doctors, that could be three copays, or $75,” said Bakewell, a University of Michigan teaching consultant who lives in Ypsilanti, Michigan, and is on long-term disability leave. “It’s the vagueness of the whole thing. You don’t know if you’ll get into a copay or not. It just makes me hesitate.”

Spurred by the sharp rise in e-mail messaging during the covid pandemic, a growing number of health systems around the country have started charging patients when physicians and other clinicians send replies to their messages. Health systems that have adopted billing for some e-visits include a number of the nation’s premier medical institutions: Cleveland Clinic, Mayo Clinic, San Francisco-based UCSF Health, Vanderbilt Health, St. Louis-based BJC HealthCare, Chicago-based Northwestern Medicine, and the U.S. Department of Veterans Affairs.

Billing for e-visits, however, raises knotty questions about the balance between fairly compensating providers for their time and enhancing patients’ access to care. Physicians and patient advocates fret particularly about the potential financial impact on lower-income people and those whose health conditions make it hard for them to see providers in person or talk to them on the phone or through video.

A large part of the motivation for the billing is to reduce the messaging. Soon after the pandemic hit, health systems saw a 50% increase in e-mails from patients, with primary care physicians facing the biggest burden, said A Jay Holmgren, an assistant professor of health informatics at UCSF, the University of California-San Francisco. System executives sought to compensate doctors and other providers for the extensive time they were spending answering e-mails, while prodding patients to think more carefully about whether an in-person visit might be more appropriate than a lengthy message.

After UCSF started charging in November 2021, the rate of patient messaging dipped slightly, by about 2%, Holmgren and his colleagues found.

Like UCSF, many other health systems now charge fees when doctors or other clinicians respond to patient messages that take five minutes or more of the provider’s time over a seven-day period and require medical expertise. They use three billing codes for e-visits, implemented in 2020 by the federal Centers for Medicare & Medicaid Services.

E-visits that are eligible for billing include those relating to changes in medication, new symptoms, changes or checkups related to a long-term condition, and requests to complete medical forms. There’s no charge for messages about appointment scheduling, prescription refills, or other routine matters that don’t require medical expertise.

So far, UCSF patients are being billed for only 2% to 3% of eligible e-visits, at least partly because it takes clinicians extra time and effort to figure out whether an e-mail encounter qualifies for billing, Holmgren said.

At Cleveland Clinic, only 1.8% of eligible e-mail visits are being billed to patients, said Eric Boose, the system’s associate chief medical information officer. There are three billing rates based on the time the clinician takes to prepare the message — five to 10 minutes, 11 to 20 minutes, and 21 minutes or more. He said patients haven’t complained about the new billing policy, which started last November, and that they’ve become “a little smarter and more succinct” in their messages, rather than sending multiple messages a week.

The doctors at Cleveland Clinic, like those at most health systems that bill for e-visits, don’t personally pocket the payments. Instead, they get productivity credits, which theoretically enables them to reduce their hours seeing patients in the office.

“Most of our physicians said it’s about time we’re getting compensated for our time in messaging,” Boose said. “We’re hoping this helps them feel less stressed and burned out, and that they can get home to their families earlier.”

“It’s been a frustration for many physicians for many years that we weren’t reimbursed for our ‘pajama-time’ work,” said Sterling Ransone, the chair of the American Academy of Family Physicians’ Board of Directors. Ransone’s employer, Riverside Health System in Virginia, started billing for e-visits in 2020. “We do it because it’s the right thing for patients. But rarely do you see other professions do all this online work for free,” he said.

“We see physicians working two to four hours every evening on their patient e-mails after their shift is over, and that’s not sustainable,” said CT Lin, the chief medical information officer at University of Colorado Health, which has not yet adopted billing for e-mail visits. “But we worry that patients with complex disease will stop messaging us entirely because of this copay risk.”

Many health care professionals share the fear that billing for messages will adversely affect medically and socially vulnerable patients. Even a relatively small copay could discourage patients from em-ailing their clinicians for medical advice in appropriate situations, said Caitlin Donovan, a senior director at the National Patient Advocate Foundation, citing studies showing the dramatic negative impact of copays on medication adherence.

Holmgren said that while patients with minor acute conditions may not mind paying for an e-mail visit rather than coming into the office, the new billing policies could dissuade patients with serious chronic conditions from messaging their doctors. “We don’t know who is negatively affected,” he said. “Are we discouraging high-value messages that produce a lot of health gains? That is a serious concern.”

Due to this worry, Lin said, University of Colorado Health is experimenting with an alternative way of easing the time burden of e-visits on physicians. Working with Epic, the dominant electronic health record vendor, it will have an artificial intelligence chatbot draft e-mail replies to patient messages. The chatbot’s draft message will then be edited by the provider. Several other health systems are already using the tool.

There also are questions about price transparency — whether patients can know when and how much they’ll have to pay for an e-mail visit, especially since much depends on their health plan’s deductibles and copays.

While Medicare, Medicaid, and most private health plans cover e-mail visits, not all do, experts say. Coverage may depend on the contract between a health system and an insurer. Ransone said Elevance Health, a Blue Cross Blue Shield carrier, recently told his health system it would no longer pay for e-mail or telephonic visits in its commercial or Medicaid plans in Virginia. An Elevance spokesperson declined to comment.

Another price concern is that patients who are uninsured or have high-deductible plans may face the full cost of an e-mail visit, which could run as high as $160.

At University of Michigan Health, where Bakewell receives her care, patients receive a portal alert prior to sending a message that there may be a charge; they must click a box indicating they understand, said spokesperson Mary Masson.

But Donovan said that leaves a lot of room for uncertainty. “How is the patient supposed to know whether something will take five minutes?” Donovan said. “And knowing what you’ll be charged is impossible because of health plan design. Just saying patients could be charged is not providing transparency.”

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  1. The Rev Kev

    So what happens here if a person acts on the message that they received thinking that it was from a doctor and not a chatbot, but that then results in disastrous consequences. So who gets taken to court in the example given near the end. The doctor? University of Colorado Health? Epic? The software writers? The State of Colorado? I would guess that there would be more than a few lawyers rubbing their hands with glee at the possibilities here.

  2. square coats

    I might be inadvertently talking out of my you-know-what here, but this seems like a bad approach to a legitimate issue that could have many better ways of being addressed. The chatbot bit is downright disturbing.

    Following on the Rev’s line of thought, I would think the lack of clarity and transparency about pricing on its own might open up the possibility of legal action.

    One initial thought is to consider this vis-a-vis how the same exchange would be dealt with if it happened over the phone, which I feel like is something that must have been going on for long enough that there’s more well thought out or at least established and normalized procedures for it. I could see there being reasons this differs meaningfully from phone interactions though and am interested in others’ thoughts as to how that might be.

    My other initial thought is that this sounds like a problem of being understaffed with doctors, nurses, etc having too high a case load to have the time in an average working day to meaningful engage with all the patient needs they encounter, and/or being overly taxed by all the insurance-related paperwork and such they’re required to do in addition to the meaningful patient engagement. But I don’t totally understand the way their wages/salary/whatever is dependent on how their activities are or are not billable.

    But yeah a chatbot is just perverse. Considering the going rate for ai accuracy, I’d think they’d need to attach another disclaimer, along with the vaguely threatening “there may be a charge”, saying “this information may be inaccurate”.

  3. antidlc

    At this point, I would GLADLY pay a fee if we could contact the doctor directly and get a response.

    I would GLADLY pay to talk to the billing people directly, instead of leaving voicemail after voicemail to get insurance issues resolved,

    The time tax is horrendous, not to mention the delay in getting answers so treatment can go forward, and the impact on mental health in not getting answers.

    — still stuck in Obamacare hell

  4. Sue inSoCal

    Chatbots on patient portals. What could possibly go wrong? Lawsuits will get you nowhere here, imho. A class action may result in hand slaps. These entities all wanted patient portals – from your App Store! Charging for the “message your doctor” feature leaves me speechless. In my experience most don’t answer anyway, and I’d advise staying away from them. Gods know where all of this electronic information ends up. Though there should be complete transparency, I doubt that will be the case. The issue here imho is both chronic understaffing and a medical “care” paradigm that is constantly looking for a way to wring money from the system. Now throw chatbot in the mix. Oy. The American medical industrial complex at its best! (It steams me that some of these institutions- helllooo Mayo!- are not for profit.)

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