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Doctors at the Cleveland Clinic have begun to charge for patient messages sent through the patient portal, the clinic announced, following the practice of a few other health systems.

Patients have been able to send MyChart messages for free, and providers typically respond within three business days,” Becker’s Hospital Review reported. “But now the health system plans to bill for messages about medication changes, new symptoms, changes to long-term medical conditions, checkups on long-term conditions and requests to complete medical forms sent through MyChart, according to a news release from Cleveland Clinic.

“Messages to schedule an appointment, get prescription refills and ask questions that could lead to an appointment will remain free. Patients can also give providers health updates without any extra charges.”

The policy is a departure from previous practice, where messages were free. The clinic said it will bill for any interactions taking five minutes or more to respond, and will bill insurance companies. Medicare patients with secondary insurance will have no co-pays, the clinic said, but some Medicare beneficiaries may see a fee of $3 to $8, it said. Privately insured patients may not have a co-pay, but if they have a deductible or their plan does not cover messaging, they could get a bill of $33 to $50, Beckers reported.

Pandemic effects

The development is one more indication of the ways that Covid changed the health care landscape. Much more care moved online, resulting in a boom for telemedicine and a resulting re-thinking of the idea that a doctor must see a patient in person for effective care. Telemedicine has sagged somewhat from its early peak, but has not evaporated.

Along with the changes in virtual care, continued questions of what will be paid for by insurance companies have resulted in a hodgepodge of what will be covered and what won’t.

Some hospitals and doctors had pre-pandemic policies of not charging for phone calls, and then during the pandemic began charging for video calls but not phone calls. Insurers’ policies also changed.

A discussion about the topic of billing for portal messages erupted on Twitter. One doctor, Shrinivas Bishu, tweeted that both doctors and patients are frustrated — patients can’t get access to their doctors because doctors are booked solid, yet doctors want more patients. He said he is booked straight through until October 2023. “Providers are stuck in the middle,” he tweeted. “We need a better model for chronic care.” He is an inflammatory bowel disease specialist at University of Michigan Health.

Another doctor, Jeffrey M. Duekar, tweeted: “We are proposing a per patient per year model with a single payor. Pay us X for office visit, messaging, care coordination (pop health focus) – Excludes procedure, drug, imaging, emergency, etc. (costly, but tracked) We take care of the patient and don’t bill for these services.”

Attempt to reduce messages

Bishu said in a Zoom interview that he believes the move is an attempt to reduce the number of messages patients send. “It’s very easy to say hospitals want to do this to generate revenue, but actually, the revenue you get from this is tiny,” he said. “I think a bigger thing is really to reduce the volume. So patients really think about — is this a question they really need to ask? Is this a a major health issue?”

Bishu said he has 1,700 patients in his practice, and is booked for office visits through October 2023. He receives around 40 messages a day, in addition to his in-person patient duties and research at the university. Michigan does not charge for messages, he said, but he understands why it might want to.

Some messages may seem urgent to a patient at the time, he added, but it’s not possible for a doctor to treat all messages as urgent. “It’s not like an email relationship,” he added.

“When their doctor doesn’t respond to their messages, they may think we’re sitting around drinking cappuccinos or something all day,” he said. “That’s not reality. We have an ethical code to our patients. And if the health system doesn’t reimburse us, and, charging the patients reduces the number of frivolous messages that come across — that might be good. You know, we’re stuck in the middle, if our patients think that we’re not responsive to them. As far as the health system is concerned, it’s not their problem. And that’s part of why you got a lot of responses for that particular topic on Twitter.”

The volume of messages, he said, can affect not only a doctor’s workflow but also a nurse’s, because nurses are triaging the messages.

Bishu said he responds to emails within 48 hours — but he still encounters frustration from patients. When they try to book an appointment and his earliest availability is a year away, he said, they don’t understand that “making an appointment for them means bumping someone else.” The frustration is on both sides of the doctor-patient relationship, he said.

If patients want an immediate response, he said, they might consider joining a concierge practice, where for a hefty fee, perhaps several thousand dollars annually, they have more access to a doctor — and presumably instant answers to portal messages.

Since he’s an employee of the health system, his income and message practices are different from those of his friends who are private practice doctors, he said. “They bill for everything,” he said. Sometimes insurance pays, and sometimes a patient pays out of pocket, but private doctors always bill for messages, he said.

U.C.S.F. also billing for messages

Cleveland Clinic is not alone. The University of California at San Francisco health system also announced that it would begin charging for messages in 2021.

Most messages are free. But starting Nov. 14, 2021, if a response requires medical expertise and more than a few minutes of your health care provider’s time, it may be billed to your insurance,the U.C.S.F. site says. “Your provider will determine whether a message exchange should be billed to insurance. If so, U.C.S.F. will handle the billing on your behalf.”

The page added that for most Medicare patients, there would be no out-of-pocket cost, but for a small number of patients, the cost could be $3 to $6. “Patients with Medicare Advantage will have a co-payment of $20 (the cost of an in-person or video visit),” it added.

For Medi-Cal patients, California’s Medicaid, there would be no cost. For privately insured people, “Some patients will have co-payments similar to those for in-person or video visits (common copays are $10 and $20). If a deductible applies, the full amount will be charged (average amount is around $75),” the site added.

What might be charged? A new issue or symptom requiring medical assessment or referral, a medication adjustment, chronic disease check-in, flare-up or change in a chronic condition, it added.

What won’t: A request for a prescription refill, request to schedule an appointment, a message that leads your provider to recommend a visit, follow-up care related to a recent surgery (within the past 90 days) – with exceptions for some surgeries, an update for your doctor when no response is needed or a message that takes only a few minutes to answer.

“Messaging health care providers has become a popular way to seek medical advice, especially with the pandemic spurring demand for virtual health care options,” the site added. “Thankfully, insurance companies recognize that virtual care is a valid and important way for patients to get medical advice.” Insurers cover not only in-person visits but also video and phone visits and the MyChart messages, the site added.

Others also charge for messages

Sansum Clinic, a big nonprofit healthcare provider in central California is also charging for messages, according to its web site.

Oregon Health Sciences University has a similar policy, according to its site. “You’ll have a co-pay just like an in-person visit — usually $25 – $40,” the site says. “If you don’t have a co-pay, the most you’ll pay is $77. Your deductible would apply.” For uninsured people, it adds, “The most you’ll pay is $77.”

On the forum “White Coat Investor,” doctors discussed charges. “My policy is if it’s more than a yes/no question then they need to come in or do a telehealth visit. My answers to these messages don’t take more than 5 min so billing that would be fraud…” one doctor wrote.

Another wrote: “MyChart is a good tool, but my wife and I both lament the free visits/treatment patients are able to squeeze out of it. It would be awesome to be able to get some sort of reimbursement for that time and effort. It’s another reason we can never fully detach from work.”

Jeanne Pinder

Jeanne Pinder  is the founder and CEO of ClearHealthCosts. She worked at The New York Times for almost 25 years as a reporter, editor and human resources executive, then volunteered for a buyout and founded...