“Hello, doctor!” DMing the doctor could cost you (or your insurance plan)

If you wanted to talk to your doctor before the pandemic, you typically had to make an appointment in person. But the sudden and rapid expansion of telehealth means that patients typically can now text or email their healthcare providers.

“When you wanted to get a Zoom visit or an audio visit, you had to sign up for the patient portal, and I think a lot of people realized they could message for the first time” during the pandemic, says A Jay Holmgren, a health information technology researcher at the University of California at San Francisco.

Patients love that one-on-one contact with their doctors so much that their messages are overwhelming in doctors’ inboxes. Now, some patients are being billed by hospitals or health systems for some answers to their message queries.

Holmgren tracked how doctors spent more time managing electronic health records during the pandemic. Even after lockdowns ended, doctors were receiving more than 50 percent more patient messages than before, she notes in a research letter published in the JAMA. That compounded stress for doctors already dealing with a pandemic, so they’re responding to emails after hours, essentially working for free.

“Physicians who get a lot of portal messages tend to report being burnt out, tend to report being more cynical about their work, tend to report that they are considering leaving the clinical practice,” Holmgren says.

Many hospitals and health care systems, from Johns Hopkins to Houston Methodist and Cleveland Clinic to Veterans Affairs, now charge patients for receiving clinical counseling over text. Such expenses are usually covered by Medicare and Medicaid, as well as most private insurance companies, although patients can incur fees, ranging from $5 to $75, depending on the type of plan.

Holmgren says the goal of charging for these messages was both to reimburse doctors, and to discourage patients from over-emailing. In reality, however, he says the new allegations haven’t solved any of those problems. His research shows that doctors bill only a small fraction of messages about 3%. And the move to charge them hasn’t reduced email volume. The fees led to slight decreases of about 2% in the number of messages.

“Adoption hasn’t been very high among our clinical workforce,” Holmgren says, in part because the billing for messages itself is complex and time-consuming. Furthermore, doctors do not want to alienate patients by charging them for communication.

In short, there is still no business model that supports the reality of how patients and healthcare professionals now talk to each other.

But Caitlin Donovan, senior director of the nonprofit National Patient Advocate Foundation, says finding one is essential. She represents patients who are chronically ill or live in rural areas.

“We’ve realized over the past few years that telecommunications are a health issue,” says Donovan, adding that the ability to email doctors has been transformative for many patients: “Sometimes patients just don’t have the energy to make that phone call, let alone walk into the office.” Plus there are people who live hours away from their doctors.

Donovan hopes the ability to email doctors can remain in place, without adding more cost to patients: “We’re balancing both this need to rapidly expand access and really entice providers to make it a part of their practice, while trying to make sure it’s accessible and affordable for patients.”

Eve Rittenberg, a primary care physician and assistant professor at Harvard Medical School, also wants a system that supports the relationship between doctors and patients. “It is an incredible privilege for me that my patients share their fears, concerns and questions with me and I can speak directly to them,” she says.

But it also needs to be sustainable, Rittenberg argues, and what’s needed are better ways to sift through the constant influx of messages, filter administrative tasks, and allow it to focus only on answering clinical questions.

Part of the challenge is the compensation model itself, the most common of which is what’s called a fee-for-service. Healthcare companies bill for each service performed by doctors and nurses. Rittenberg he says he wants to see payment schemes instead compensate doctors for providing general care, whether it’s in an office or through email.

He says it would give doctors and patients the flexibility to decide what works best for them. “Finding ways to make clear communications sustainable is really, really important,” she says.