Hidden Costs Lurk Behind Patient Portals

You know those patient portals where you can check your test results, make your next appointment or ask your doctor a non-urgent medical question? Well, what if I told you that many of those interactions come with a price tag? And, according to JAMA, a peer-reviewed medical journal, the trend among health systems to charge patients is increasing.

The U.S. Centers for Medicare and Medicaid Services (CMS) opened the door to charge for messaging doctors in 2019, when it expanded the definition of "e-visits" to include an exchange of messages initiated by patients. It further broadened the definition a year later. Some bigger institutions followed suit, including Cleveland Clinic and Johns Hopkins Medicine. But unlike telehealth visits, patients don't expect to pay for these interactions.

Patients point out that health care institutions encouraged them to register for these portals and make good use of them (to book appointments or check test results, for example), especially before and during the pandemic.

As someone with asthma, several autoimmune diseases and a disability, I quickly became a regular user and appreciate the convenience of telemedicine.

"During the pandemic, patient messaging increased by more than 50%, requiring a substantial amount of uncompensated clinician time," explains the JAMA study. This led health care organizations to start billing for qualifying patient messages — for instance, message exchanges lasting more than five minutes — as e-visits.

There is no doubt that this increase in message traffic has been difficult for providers. I can't begin to imagine what they have been through during these unprecedented times, but looking at the data, it's not good.

A survey of nearly 2,400 physicians from December 2021 through January 2022 found a record 63% of them reported having at least one symptom of burnout. That compared with 38.2% in 2020. Burnout symptoms include exhaustion, loss of appetite, difficult sleep, lingering headaches or joint pain, reduced sense of competence at work and cynicism about the field of medicine.

The survey also found that one in five doctors wanted to leave the profession by 2024. Allowing physicians to bill for patient-initiated email has not alleviated clinicians' burnout.

As a patient advocate, my job is to protect the patient. And, frankly, I am very conflicted about whether to tell patients to use the patient portals to contact their providers.

The last thing I want is for patients to get a co-insurance or co-payment bill they can't afford, so I warn them to do their due diligence and find out what their insurance will cover and what their out-of-pocket charges will be for messaging their provider.

Patients can live far from their doctors or in rural areas with a scarcity of clinicians. Being able to contact your provider via the patient portal allows for easy communication without a long drive or the need to miss work. And if you're too sick or disabled to travel, asking a question via the patient portal allows for accessibility when there wouldn't otherwise be any.

But the system also penalizes deaf people for opting to email their providers since special technology is necessary for the deaf to make a call, points out Caitlin Donovan, Senior Director of Outreach and Communications at the National Patient Advocate Foundation, an organization that advocates for the rights of patients and more equitable health care.

Here's the thing: The United States health care system ranks dead last among 11 developed industrial nations, from New Zealand to Germany to Canada. This is a systemic issue that needs reform and better regulation. According to a Peterson-KFF Health System Tracker, the typical email message claim was $39 in 2021, including the portion paid by insurance and the patients.

Patients need to know if their email will generate a co-payment, co-insurance, or, worse yet, an uncovered bill for a visit because they're under- or uninsured. If this doesn't happen, it may undermine the connections and trust created by the intimacy of telehealth visits and the ease of messaging the provider.

CMS's billing system for patient emails makes it virtually impossible for patients to know whether their message will incur a bill. The established billing thresholds sound like a riddle. They require at least five minutes of a provider's time, but billing is only allowed once a week for the total time spent per enrollee for a new medical consultation. If the bill is related to scheduling appointments or prescription refills and sent within seven days of a visit (in-person or virtual, or after a procedure), then billing for emails is prohibited.

How is a patient expected to decipher these rules, much less apply them?

Epic Systems of Verona, Wisconsin, is a hospital software company that holds over 305 million patient records. It owns MyChart, the secure interface used by patients to access their medical results and email their providers. If you, like me, wonder if Epic receives any revenue from the extra email exchanges, a spokesperson said Epic "does not charge health care organizations based on the number of patient messages sent or received."

As a Latina who has experienced firsthand how racism can affect equal treatment and proper care, I can't help but think of the bigger picture. How will these charges affect health equity? In January 2021, 37.9 million Americans were living in poverty, accounting for 11.6% of the population.

If you live check-to-check, being charged for emailing your clinician is a prohibitive action on the part of the hospital or medical clinic. It can have a silencing effect on poor individuals. A study found that even charging a one-dollar premium for health care benefits can create barriers for low-income people.

Donovan, from the National Patient Advocate Foundation, explains there's something bigger going on. "Doctor's visits are becoming smaller and smaller. We're scratching at an issue that is the result of all the myriad problems in this health care system. We don't have enough clinicians, we don't have enough support staff, we don't have enough administrative staff," she said. "And we're so focused on the financialization of the health care system that you're losing patients."

The system must be revamped to prevent these potentially ruinous outcomes. We could implement a single-payer system or a public option to ensure every person has access to affordable care regardless of income or employment status (wishful thinking, I know).

Accurate cost transparency would help patients make informed decisions about their health care options. We could also prioritize preventive care and wellness initiatives to reduce the burden of chronic diseases, lower health care costs in the long run and promote healthier lifestyles.

To curb rising costs of prescription drugs, we could lobby our congressional representative to unleash CMS to negotiate more — or all — drug prices (10 drugs is a start), promote generic competition and increase transparency in pricing. We can also invest in training and retaining health care professionals, especially in rural and underserved areas, to address workforce shortages and improve access to care.

The point is that we need to search for, harness and nurture humanity in the doctor-patient relationship.

Olga Lucia Torres is a former public defender who teaches narrative medicine at Columbia University. She also works as a patient advocate and has volunteer leadership roles within various foundations that seek to help and empower patients. Olga has been published in the New York Times, Popsugar, the New York Daily News, and various other publications on disability rights, healthcare and Latino issues. Read More