WASHINGTON – Next time you ask your doctor about an annoying cough or an itchy rash, the first thing you should do is check your bank account – you could get a bill for the question.
Hospital systems across the country charge for some of the messages patients send to doctors, who they say are spending increasing amounts of time online inquiries, some complex enough to require the level of medical expertise that usually is delivered during a doctor’s visit.
But patient advocates worry that these new fees could discourage people from seeing their doctor and that they are already adding another layer of complexity to the US healthcare system opaque billing process.
“This is a barrier that denies access and creates hesitation or anxiety in communicating, potentially harming patients with lower quality of care and outcomes at much higher costs,” said Cynthia Fisher, founder of Patient Rights Advocate, a Massachusetts-based nonprofit Organization that advocates price transparency in hospitals.
The explosion of Telemedicine in the last three years — fueled by the COVID-19 outbreak and relaxed federal regulations for online care — prompted many physicians to adopt more robust telecommunications with their patients. Consultations that once took place in an office have been transformed into computer or smartphone visits. And health systems were inviting patients to use new online portals to ask their doctors a question anytime, Jack Resneck Jr., president of the American Medical Association, told The Associated Press.
“When people found out that this is cool and could improve care, you saw hospitals and practice groups saying to patients, welcome to your portal… You can ping your doctor with questions if you want,” Resneck said. “We found ourselves as doctors getting dozens of these every day and not having time to do that work.”
Fees vary for each patient and hospital system, with messages costing as little as $3 for Medicare patients and up to $160 for the uninsured. In some cases, the final bill depends on how much time the doctor spends answering.
Healthcare systems that have rolled out these new guidelines, many in recent months, say they automatically alert patients that they may be charged if they notify their doctor through online portals such as MyChart, an online System that many organizations now use to book appointments or discharge test results for patients.
Under the new billing rules developed during the pandemic, physicians are only allowed to charge Medicare for 5 minutes for an online message in any seven-day period, according to the Centers for Medicaid and Medicare.
Doctors need to be paid for the time they spend providing expert medical advice — even over the news, said University of Chicago health economist Katherine Baicker. But it’s also important that hospital systems are transparent about what patients can expect when they introduce these new fees, she added.
“Co-payments are useless if they are not clear to the patient beforehand,” said Baicker.
According to Jess Berthold, a spokeswoman for the system, doctors at the University of California San Francisco Health handle around 900,000 email threads in a year — a total of 3 million messages.
The hospital announced in November 2021 that it would collect fees some of these messages, after noting a surge during the pandemic. Within a year, 1.4% of email threads, or about 13,000, resulted in a bill.
Only certain messages trigger a charge. For example, patients are not billed for refilling prescriptions, scheduling an appointment, asking a follow-up question about a doctor’s visit within the past seven days, or if their doctor advises them to schedule a visit in response.
What types of messages result in an invoice? Send your doctor a picture of a new rash, ask to fill out a form, or ask for a change in medication.
Navigating how much you may owe can be more difficult.
At UCSF, patients on Medicaid who text their doctor have no out-of-pocket expenses, and those on traditional Medicare may have to pay $3 to $6. Patients with private insurance are billed a co-payment — typically around $20 — as are patients with Medicare Advantage, Medicare’s private insurance plans.
Ohio’s Cleveland Clinic, the latest major hospital system to announce online message fees, launched similar guidelines late last month, with messages costing up to $50 for privately insured. And at Northwestern Medicine in Chicago, which charges $35 for some messages, less than 1% of those correspondences resulted in a bill, spokesman Christopher King said.
All of these systems use the MyChart online portal. Epic, the private software company that operates MyChart, doesn’t track which health systems are charging patients for messages, spokeswoman Barb Herandez said in an email. The company did not answer questions about whether it receives a share of the fees from these levies.
Counseling patients online can save a patient time or money in the long run, hospital systems argue. If the doctor can answer a patient’s question via email, the patient can reduce waiting times for an appointment and avoid taking time off work to go to the doctor’s office.
Also, some patients simply prefer the convenience of getting a quick response from the doctor via an app, added UCSF’s Berthold.
“If patients have direct access to a doctor if they have questions or concerns, they can seek treatment and be treated more quickly,” said Berthold.
However, Fisher argues that if patients think twice before notifying a doctor, this could have the opposite effect. Instead, some people turn to free, unreliable advice on the internet.
“It becomes a slippery slope, and that slippery slope is not in the patient’s favour,” she said.
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