EPtalk by Dr. Jayne 12/1/22

There has been a lot of discussion in the patient engagement world, as well as around the virtual physician lounge, about the announcements of some health systems that they are going to start to charge for patient portal messages that involve medical advice.

Most physicians I’ve spoken with agree that the surge in patient portal messages during the last three years is contributing to burnout, not only among physicians, but with staff. EHR vendors have been hard at work helping their clients understand the types of messages they are receiving so that clients can work on optimization efforts. At least one vendor has even gone as far as working to filter out messages that contain little more than “thank you” in an effort to reduce the sheer volume of messages in clinician inboxes.

The elimination of the thank you-type messages is fairly controversial. Some clinicians like them and see them as a small bright spot in the drudgery of the inbox, but others see them simply as an annoyance.

Despite the information that is available to organizations about the types of messages they are receiving, quite a few organizations I’ve worked with aren’t even taking the basic steps needed to help tame the inbox beast. Let’s take medication refills, for example. In some systems, this is a good chunk of patient portal requests. I don’t see people looking deeply at why patients are asking for refills via the patient portal. For years, even going back to the world of paper, practice management experts have advocated for providers who treat chronic conditions to issue up to a year of refills during the chronic condition visit. People still don’t do this, and when I shadow in physician offices, I hear statements like “just call us when you need a refill,” which is absurd in this day and age.

As organizations moved to EHRs, there was a migration to have refills requested through the pharmacy, where the transaction could come electronically and be vetted against the patient’s existing medication list for a quick refill. That workflow led to tools that were deployed on top of the EHR (one of the best ones I have ever seen was homegrown at a New York provider group in the late 2000s) that would evaluate certain metrics such as recent lab results and past visits and give the nursing staff a red-yellow-green indicator on whether they could issue refills through a standing order or a delegated refill policy. Other solutions followed, but organizations still didn’t fully embrace them.

Now the pendulum has swung back to where we were in the 1990s, which is the patient asking for a refill in narrative form via a patient portal message. This is the equivalent of calling the office and speaking with someone or leaving a message on a voice mail “refill line.” Patients aren’t even being asked to select a medication from their current medication list, but instead are typing it out. They may not have the name or dose correct, which increases the work for the practice as well as the risk of medical errors. Often there are better tools within the patient portal, but they simply haven’t been deployed yet because leadership feels they are not a priority.

Fast forward to every day in a primary care physician office, where everyone is at their breaking points. Physicians are spending hours each day, often at home, handling refills and messages. Two decades ago, we thought this was infrequent and somewhat subjective, but now our sophisticated EHRs can deliver reports about provider work after hours and it’s clear that a good portion of the workday is occurring in places other than the clinician office.

Often that after-hours work involves what we traditionally define as patient care, which includes explaining or re-explaining things to patients, looking through charts for information to send to a patient, coordinating referrals and follow-ups, and more. This is uncompensated work and it makes sense that clinicians are pushing back against it, leading organizations to consider hiring staff to assist in managing the inbox. Thse resources cost money, hence the move to charge for what has largely been uncompensated care. I say largely uncompensated because in value-based care models, compensation for these non-visit efforts is included in the payment equation in other ways.

In looking at some of the health systems’ documentation on how they plan to charge for patient portal messages, most of the approaches are well reasoned. Organizations are clearly saying that they will charge if a response requires the medical expertise of a licensed provider and requires more than a few minutes of time. Looking at one institution’s website, I found some details. Messages are primarily being billed to health insurance, with varying charges being passed on to the patient. For most Medicare patients, those messages will have no patient cost or a small charge ($5 or so), but for Medicare Advantage plans, it might be up to a $20 co-pay. Medicaid resulted in no charge to the patient, and private insurance ranged from a standard office visit co-pay up to a full $75 charge if the patient has not yet met their deductible.

That particular system is using the CPT codes for online digital evaluation and management, which are time-based. The codes can be billed cumulatively every seven days, so if a message generates a lot of back-and-forth responses, the work can generate a higher level of service. The websites are typically clear on what kinds of conversations will generate the code, including a new issue or symptoms requiring clinical assessment or referrals, medication adjustments, flares of chronic conditions, and requests to complete forms. The latter is a huge time suck for primary care offices and many practices have been charging for completion of forms for years, so I’m not surprised at all by that one. Refill requests or conversations that lead to a scheduled visit aren’t charged, nor are follow-ups related to a surgery with a global billing period.

This type of process is going to be an adjustment for patients because they are used to not having to pay the full value of the services they’re receiving. The presence of insurance in our society has led to a general lack of awareness of the value of provider and staff time, as well as the cost of truly delivering care. Consumers are already used to seeing surcharges on restaurant bills and other invoices for work that was previously free, so at this point, it shouldn’t be as much of a surprise as it feels like. Everyone’s just trying to stay afloat, and it will be interesting to see how the use of these charges plays out over time.

Is your organization charging for certain services delivered via the patient portal, and how is it going? Leave a comment or email me.

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