The Harms and Benefits of Billing for Patient Portal Messages

“I think that what [billing for portal messaging] does then, it leads to inequities in health care. People who can afford to pay will get their questions answered, and people who won’t, won’t. The people who probably can’t afford to pay are probably the patients that have a harder time accessing health care in general.”

- Pediatric Oncologist 1 from ongoing study

“I am personally of the mindset that we should be documenting and billing all the time that we are spending with families because I think it is grossly underestimated and grossly underappreciated.”

- Pediatric Oncologist 2 from ongoing study

The 21st Century Cures Act prohibits health care systems from “information blocking,” a practice that “interferes with, prevents, or materially discourages access, exchange, or use of electronic health information.”¹  Children’s hospitals comply by providing access to electronic health records (EHR) through online patient portals. Portal use has been associated with multiple benefits for patients and parents, such as better understanding, adherence, and sense of control.²  Yet, health care organizations are navigating competing pressures to leverage portals to improve communication, while also managing clinician workload because of increased portal message volumes. During the coronavirus disease 2019 pandemic, for example, clinicians experienced a 50% increase in patient portal messaging.³  The Centers for Medicare and Medicaid services expanded the ability of clinicians to bill for portal messaging through telehealth “e-visits,” if the message required at least 5 minutes of time and medical decision-making.

With this policy change, several health care organizations have begun billing for portal messages. When patients send a message, they are alerted that they could receive a bill, and clinicians determine whether a portal message qualifies for billing.⁴  My research team studies communication and the role of patient portals in serious pediatric illness. We previously found that communication efforts in pediatrics can be impeded by barriers at multiple levels, ranging from personal characteristics to policy-level factors.⁵  Although patient portals could mitigate some of these barriers, billing policies might create a new policy-level barrier that can hinder communication. As part of an ongoing study, our team asked pediatric oncology clinicians for their perspectives on billing for portal messages. As evidenced by the introductory quotations, responses ranged from enthusiasm to consternation. Some clinicians described feeling undervalued because they spend hours on clinical work that is exhausting, does not generate revenue, and is underappreciated by administrators. Other clinicians emphasized concerns about creating barriers to communication, especially for families that have limited resources or families who distrust the health care system. Even worse, these barriers could lead to delays in reporting important clinical changes or complications.

The institutional decision to bill for portal messaging is not unreasonable. Greater volumes of portal messages require new workflows for triage and follow-up, as well as increased clinician effort. Increased use of portal messaging could also decrease the number of in-person clinic visits and associated revenue. Furthermore, prior studies have shown that EHR documentation contributes to physician burnout.⁶  Payment for portal billing might show that clinicians’ efforts are valued and valuable, thus mitigating some EHR-related burnout.

However, these portal billing policies could also threaten fairness and distributive justice in the health care system.⁷  Even a small, required payment could disincentivize communication, especially for families with lower income. Furthermore, the awareness of a billing policy itself could serve as a disincentive, even without the family receiving a bill. One study at a single academic medical center has evaluated the association between billing for portal messaging and subsequent portal messaging volumes.⁴  The volume of portal messaging decreased after implementation of this billing policy, yet the adoption of billing by clinicians was low. In other words, patients were likely disincentivized to send portal messages after learning about these billing policies, but clinicians were not incentivized to bill for these messages. Pediatric hospitals have similarly found low conversion rates to billable encounters for portal messaging, with some hospitals reporting conversion rates as low as 1%. Even before implementation of these billing policies, other studies have suggested that patients and parents with lower education levels, minority racial or ethnic status, and lower income are less likely to use online portals.^8–10  Billing policies could compound these disparities in portal use by further disincentivizing families with limited resources from engaging in portal messaging, even if they have accessed the portal. Insurance policies with high deductibles or large copays could also contribute to this disincentive.

During a research meeting, our team was provided a personal example of how these billing policies might affect patients. My colleague sent a portal message to her doctor asking if she should change her medication dosage. After pressing send, she received an immediate boilerplate response through the portal explaining that clinicians must spend time to provide important medical advice in response to portal messages. “To best deliver care for your question, we should either schedule you a visit or bill your insurance for the time and work in the portal message.” After this message was a hefty paragraph explaining the legalese of why hospitals are now permitted to bill for these services. She was then asked to consent to being billed for the clinician’s response to her portal message. This message raised several questions. If she did not consent, would her clinician see her message? Would she be billed if she opted to call the office with an urgent question, rather than sending a portal message? How much would this portal message cost? Is there a fee per message? Would there be a copay? How will she know if she is being billed? Is everyone being billed the same as her, or had her clinician decided specifically to bill her for this message?

Changes in pediatric portal billing policies create ethical and practical challenges that could affect communication, clinical relationships, and safety and health of children. Furthermore, institutional requirements for portal message billing could exacerbate (rather than relieve) clinician burnout. With each message, clinicians must consider whether to create a billable encounter and whether their documentation is sufficient to justify the bill. Clinicians might start to receive queries or feedback from administrators on the quality of their documentation in portal messages. As such, clinician burden might actually increase with portal message billing, unless the policy disincentivizes families from sending messages. If these policies disincentivize communication, then families will be placed at risk for poor communication and potentially worse health care outcomes, without generating the intended revenue. Furthermore, patients might resort to phone calls to avoid receiving bills, which requires time-consuming return calls.

Given the risks to communication and the potential to exacerbate clinician burnout, health care organizations should avoid billing for portal messaging. To the extent possible, alternative interventions are needed to address the burden of portal messaging for clinicians. For example, organizations can strive to improve appointment availability, institute patient-generated e-visits, enact word limits on portal messages, or other creative solutions.

However, some organizations are opting to bill for portal messaging. The goals of these policies could range from ensuring that clinicians are paid for their effort, to increasing revenue, to encouraging in-person or telehealth appointments, or even to disincentiving portal messaging as a primary goal. If an organization opts to bill for portal messages, they must strive to avoid negative outcomes for families and exacerbation of existing disparities in communication, health care access, and patient outcomes in pediatrics. For example, organizations might waive copays or out-of-pocket costs to families for sending messages. Similarly, legislative approaches could mandate that insured patients do not receive out-of-pocket costs for portal messaging. Such an approach might allow clinicians to bill appropriately without disincentivizing communication from families. This type of policy will be especially important for patients on Medicaid or Medicare who have limited financial resources. Organizations must also pay close attention to the language and formatting of billing consent documentation. Long, detailed, and legalistic consent messages can be confusing or insulting. Lastly, organizations must monitor the effects of billing policies by tracking message volume, conversion rates to billable encounters, and family perspectives pre- and postimplementation. If families are reporting negative experiences and hardships, then organizations should consider reversing these policies. We urgently need research studying the ethical and practical implications of billing for portal messages, and we must develop user-informed guiding principles for whether and how to implement portal billing policies. Every policy is a blunt tool to achieve desired ends, with some groups experiencing unintended negative consequences. It is imperative to ensure that policies are not threatening the health and wellbeing of children.