A few weeks ago, Cleveland Clinic announced that it would begin billing for physician responses to certain patient-initiated messages. Messages that require five minutes or more of the healthcare provider’s time to answer and do not result in a scheduled appointment will be billed. They note that they will be billing the patient’s insurance company. But we all know what happens if there is a deductible or copay or – gulp – the payer doesn’t cover that service: The patient gets the bill or a big chunk thereof. How can patients know if the message they are sending will result in a charge? Cleveland Clinic writes that examples of potentially-billable notes to your provider include changes to your medications, new symptoms, changes to a long-term condition, check ups on your long-term condition care, or requests to complete medical forms. Ouch!Cleveland Clinic outlines the need for this policy by noting that since 2019, the number of messages that physicians and other clinicians deal with has doubled. These are not just data from Cleveland. Nationally, messages from patients seeking medical advice increased by over 150% from January 2020 through January 2021. There can be no question that a global pandemic that abruptly ended most non-urgent in-person clinical care contributed immensely to the huge increase in patient messaging. However, clinician burnout ascribed to responding to portal requests has been a real issue long before COVID-19. In a viewpoint article published in August, leading researchers in the field wrote: “The inbox has become unbearable. A challenge before the pandemic, the electronic health record (EHR) inbox has become Sisyphean — an involuntary, never-ending, after-hours second job for physicians, contributing to burnout and which may lead some physicians to reduce clinical work or leave medicine altogether … .”
Faced with this overwhelming number of patient messages, what are physicians to do? Cleveland Clinic is not alone in deciding to charge for work done by physicians and other clinicians, be it in person, via a telehealth visit, or asynchronously via the patient portal. Health systems from Illinois to California are adopting similar policies. Yet, billing for such services in and of itself does not directly lead to decreased physician burnout. Of course, many of us would assume that clinicians will see fewer patient messages if the messages are associated with charges (I’d take that bet if anyone is interested in making it!).
As experienced physician leaders point out, we can’t change anything without measuring it. We must record the work that clinicians are doing in responding to patient messages and assign work units (e.g., RVUs) against it. Traditionally, it has been difficult to measure work that has not directly resulted in a billable charge. In fact, RVUs are based on dropped charges with the underlying assumption that the physician's work effort is directly incorporated into the billable code. A chief problem with time spent in the EHR inbox is that doctors have nothing to show for it (besides good clinical care, that is!). Even small issues that take less than five minutes to resolve are important to record because a dozen small issues can take an hour of time to complete. That is an hour less to be with one’s family, catch up on reading, or … just sleep. Oh, and after we measure the work, we had better then bake in compensation for it; let us not forget that part.
I believe that the American Medical Association’s decades-long plea for team-based care has a place at the table in dealing with message overload. I recall the ancient days of practice (think the 1990s) in a small group doing primary care pediatrics. We had no EHRs back then; at least most of us did not. If parents were not sure if their children needed to be seen, they would call my office and an experienced nurse would determine whether to: schedule an appointment, give advice with expected outcomes, or, for a small portion of calls, reach out to a physician to decide the outcome. It seems to me that if we practice team-based care and all the team members work at the top of their license, many (perhaps most) patient messages that will obviously require more than a cursory response from a doctor can be transitioned into a scheduled virtual visit or a well-defined asynchronous e-visit. Both types of encounters will be clearly and definitively billable to the patient ahead of time, which I think is a win.
How can we define a priori all of the criteria to determine if a message requires significant clinician time (and hence a billable encounter)? In my experience, it was not that difficult. If a parent called in and thought their child might have an ear infection, the decision was easy: Make an appointment, as I would never prescribe an antibiotic without seeing a child. If a parent called in and told us that they accidentally left the liquid amoxicillin out all night unrefrigerated, the decision again was easy: Call the pharmacy and re-order the remaining course (the risk of liquid amoxicillin abuse is next to zero). Our team of nurses quickly learned when my colleagues and I would want to see the child or talk to the parent and when we would give advice or a referral. I think this sort of loosely regulated teamwork can make triaging these patient messages much less onerous.
Physicians will have to learn to navigate the waters of patient messaging, e-visits, telehealth encounters, and the like. As Michael Ross, MD (CMIO, Northern Light Health - Eastern Maine Medical Center) noted to me:
We’ve grappled with different communication philosophies as our patient portal continues to evolve from the post-pandemic push into the mainstream. On the one hand, we are adding functionality to enhance and increase portal-supported patient communication around specific medical services, with the expectation that a more educated and aware patient population will reduce readmissions and complications. On the other hand, the popularity of portal messaging has increased the work of our already overburdened primary care providers. We’ve started charging e-visits exclusively for patient-submitted photos, but interest is growing in expanding this further. The push-pull of these different patient communication strategies can sometimes feel diametrically opposed to each other.
Dr. Ross has it just right: The paradox of patient messaging is that we want more of it so we can minimize unnecessary morbidity and wasted medical care, yet we want less of it because it is taxing our already overburdened clinicians. We must continue to reach for the sweet spot between these two extremes, knowing full well that it is a moving target.