Meg Bakewell, who has cancer and cancer-related heart disease, has the option to email her doctor, medical oncologist, or cardiologist for urgent medical advice if she experiences symptoms such as pain or shortness of breath. However, she was surprised when she received her first bill ($13 co-pay) for an email consultation with her doctor at the University of Michigan Health. The health system began charging for “e-visits” through her MyChart portal in 2020. This has left Bakewell worried about the potential cost of future electronic visits and the ambiguity surrounding the co-pays. This issue is not unique to Michigan, as a growing number of health systems across the country are now charging patients when their clinicians respond to messages. While the motive behind billing is to reduce the volume of messages, there are concerns about the economic impact on low-income individuals and those with health conditions that make it difficult for them to meet in person or speak on the phone. Physicians and patient advocacy groups are worried about the balance between compensating healthcare providers for their time and improving patient access to care.
A study conducted at the University of California, San Francisco (UCSF) found that after implementing charges for e-visits, the rate of patient messaging dropped slightly. Many health systems have set criteria for billing, such as responding to messages that take more than five minutes and require medical expertise within seven days. They use billing codes introduced by the federal Centers for Medicare and Medicaid Services, which include visits related to medication changes, new symptoms, changes or tests for long-term conditions, and requests to complete medical forms. Routine matters that don’t require medical expertise, like scheduling appointments or refilling prescriptions, do not incur a charge. However, determining whether an e-visit is billable requires extra time and effort from clinicians, resulting in only a small percentage of eligible e-visits being billed to patients so far.
Cleveland Clinic, which began billing for email visits in November 2021, charges patients based on the time the clinician spends preparing the message. The new policy has not received complaints from patients, according to Eric Booth, the system’s deputy chief medical information officer. Physicians do not personally receive the payments but earn productivity credits instead, with hopes that this will reduce stress and burnout among doctors. However, there are concerns that billing for e-visits may have a negative impact on medically and socially vulnerable patients. Co-pays have been shown to negatively affect medication adherence, and even small co-pays could deter patients from seeking medical advice through email.
Health systems also face questions about price transparency. Patients may not always know when and how much they will have to pay for an email visit, as it depends on insurance deductibles and co-pays. Medicare, Medicaid, and most private health insurance plans cover visits by email, but not all do, and coverage may vary depending on the agreement between the health system and the insurance company. Uninsured patients or those on high-deductible plans may be required to pay the full cost of an email visit, which can be as much as $160. There is a lack of transparency in this regard, as patients may not know the duration or cost of an email consultation, making it difficult to anticipate charges.
The concerns surrounding billing for electronic visits have prompted Colorado Health University to experiment with an artificial intelligence chatbot that can draft email responses to patient messages. This tool aims to reduce the time burden on physicians and support efficiency. However, there are still questions and challenges to address, including the potential negative impact on patients and the need for price transparency in this evolving landscape of healthcare delivery.