You have a new message in your patient portal — and a new bill for it, too

Are you thinking about asking your doctor a question through your online patient portal? At the University of Michigan Health and a growing number of hospitals across the U.S., it could cost you.

U-M, Johns Hopkins Medicine, the Mayo Clinic, Vanderbilt Health and the Cleveland Clinic are among the health systems nationally now billing patients for what Vanderbilt calls "asynchronous eVisits." The charge is triggered when electronic patient portal messages require a clinician to spend more than five minutes to respond and if the reply is sent within seven days.

U-M did not detail how much patients are asked to pay out-of-pocket for the service, saying only that the fees vary. For people with insurance, it can be the same as an office-visit copay. Other health systems say the consultations can be free for Medicaid patients or can carry out-of-pocket costs of less than $20 — though patients with high-deductible plans could pay as much as $50 per message.

The Centers for Medicare and Medicaid Services expanded telemedicine billing options in January 2020, just as the coronavirus pandemic took hold. Those billing codes allowed doctors and other qualified health providers to begin charging patients for time they spend interacting via electronic messaging, such as through Epic's MyChart system, which administers the MyUofMHealth patient portal.

8 out of 9 Michigan health systems don't charge for messages

Although health care providers have been allowed to bill patients for online responses to electronic messages for nearly four years, most Michigan health systems continue to offer that service for free to patients.

An informal Free Press survey of nine health systems across the Lower Peninsula found only the University of Michigan Health and Sparrow Health, which became part of the U-M Health network earlier this year, currently charge for online patient portal message responses.

The others surveyed — Henry Ford Health, McLaren Health, Munson Healthcare, Corewell Health, Ascension Michigan, Trinity Health Michigan, the Detroit Medical Center and ProMedica — all said they do not bill patients for the time physicians spend interacting them through their electronic portals.

U-M began billing patients in January 2020

Mary Masson, a spokesperson for Michigan Medicine, the academic medical center of the University of Michigan, said U-M Health began charging patients for some portal message responses in January 2020, as soon as the expanded CMS billing codes were approved.

"Most commercial and government health plans now recognize these services as a covered benefit," she said. "Out-of-pocket expenses for patients vary, depending on their health plan, much like they do for office visit charges."

Patients are notified before they send a message in the online portal that they could be billed for it, Masson said.

"To ensure that patients know there may be a charge associated with the service, they receive a portal message informing them prior to sending a message to their care team," she said. "They must click a box indicating they understand the possibility of a charge before they are able to proceed."

Although some messages are subject to billing at U-M, Masson said "the vast majority" of MyUofMHealth Patient Portal interactions are free.

'We want to make sure it's as easy as possible'

At Trinity Health Michigan, charging patients for responses to their MyChart questions is "not something we are seriously considering at the moment," said spokesperson Von Lozon.

The same is true at ProMedica's three Michigan hospitals in Monroe, Coldwater and Adrian.

"We regularly review our billing practices and have discussed this topic," said Tausha Moore, Promedica's associate vice president of strategic communications. "ProMedica currently does not charge for electronic patient portal message responses and does not have plans to start doing so."

More: As large Michigan health systems merge, independent hospitals are vanishing

Ascension Michigan told the Free Press it doesn't charge patients for using its electronic portal "to fill prescriptions, answer questions and schedule appointments." However, "if a patient's needs are more comprehensive, the provider requests the patient schedule a visit."

Corewell Health — the state's largest health system — provides patients with free correspondence through MyChart because "we want to make sure it's as easy as possible" to communicate with doctors and other medical staff, said Corewell's chief operating officer, Dr. Darryl Elmouchi.

Corewell looks to AI to solve billing issues

Elmouchi acknowledged, however, that it has become increasingly challenging to manage as the volume of electronic messages that Corewell's patients send through the MyChart portal continues to swell; the number of messages has tripled since the pandemic began.

"COVID just caused it to explode," Elmouchi said. "It definitely is a big convenience for individual patients to send a message to their doctors, just asking a question. And it becomes an increasing amount of work for doctors and nurses and other folks on the care team to try to respond to these in a timely manner.

"That's why I think you see a number of institutions across the country going to this. They realize that their most well-trained, most expensive and most important physicians across the organization are doing work that's not getting compensated. That's not fair to the doctors, and that becomes long-term not sustainable."

Still, Elmouchi said, at least for now, the benefit of providing free responses to patients' MyChart messages outweighs the costs at Corewell.

"We are constantly evaluating as the world changes and I can't say for certain that we won't at some point (bill for responses to MyChart questions) in the future, but our goal is to make it as easy as possible for patients and as easy as possible for the doctors," Elmouchi said. "That's something that we're constantly wrestling with."

Henry Ford messages up 5.5 times over pre-pandemic levels

Henry Ford Health provided data to the Free Press that illustrates the enormous rise in MyChart messages from patients seeking electronic medical advice from doctors.

In 2019, before the start of the pandemic, Henry Ford Health said it received 286,302 electronic portal messages from patients seeking medical advice.

That number nearly quadrupled in 2020, to just over 1 million requests. By 2022, Henry Ford physicians received 1.58 million messages from patients — more than 5.5 times the pre-pandemic rate.

In a post on its website, Vanderbilt said the volume of messages from patients seeking medical advice online has risen to 2.3 million per year, and that is what drove its decision to start billing for electronic messages. It was either charge for it, or stop offering it.

"Centers across the country like Vanderbilt Health that manage complex health issues are now charging patients for eVisits in order to continue this valuable service to patients," it said.

Worries that charges will hamper access

There are some concerns, however, that when hospitals charge patients for electronic messages, it could exacerbate inequities in health care, especially for poor people. A research letter published in January in JAMA Network suggests people are less likely to send electronic messages to medical providers when they know they could be billed for it. That means they may put off or avoid seeking medical help when symptoms arise — even if they might be serious — to save money.

A Kaiser Family Foundation survey of American adults found that 41% have unpaid debt from medical or dental bills. Most of those who had medical debts said they had to make sacrifices to pay them off, and 40% said they had to drain their savings accounts or the savings of a relative to pay them.

Additionally, the survey found 1 in 7 Americans with health care debt were turned away by medical providers because they had outstanding bills. Those with health care debt also were more likely to say they have avoided getting needed treatment because of the cost.

Elmouchi said Corewell is working to find other solutions to manage the glut of electronic messages without charging patients or overburdening physicians and causing burnout.

Already, artificial intelligence software is helping to automate prescription refill requests at Corewell, he said. The hope is that AI could also screen notes to physicians and rank them in order of urgency, help with transcriptions and other tasks that take up big chunks of physicians' time.

"I really firmly believe that over the next five to 10 years ... artificial intelligence and voice actuation tools and other things will hopefully make it a whole lot easier for us to practice," Elmouchi said.

Contact Kristen Shamus: kshamus@freepress.com. Subscribe to the Free Press.

This article originally appeared on Detroit Free Press: U-M Health joins national trend of charging for online doctor messages