By Kimball Wilkins, VP of Digital Experience, Blue Shield of California
September 2023 – During the pandemic, the message volume on patient portals rose by an estimated 157%. For overstretched physicians, the increase is contributing to burnout. As the chair of one university medical system put it, “[W]e turned on 24/7/365 access for patients (who of course like it) with no operational or business model to handle it.”
The problem is framed as ‘patients are messaging too much.’ So far, the strategy is to discourage it by letting patients know they may have to pay for a response. Ironically, the same patients get bombarded with too many messages from the same health systems that employ those doctors: reminders to pay their bill, schedule their flu shot or mammogram, and, sometimes, requests to make charitable donations. The reality is that patients are going to keep messaging, and doctors had too much administrative burden before their inboxes exploded.
As the trend continues, a debate has broken out over whether health systems should charge for messaging, and what the effects of this billing practice will be. Cleveland Clinic, Novant Health, UW Medicine (Seattle), UCSF, Mayo and a growing number of other health systems have adopted the practice. In 2019, when the CMS adopted billing codes allowing for reimbursement of time spent on messages, the intent was to charge for the type of expertise and effort that has historically required an in-person visit, for example, making adjustments to a prescribed medication; evaluating new symptoms; or changes in a long-term/chronic condition. In and of itself, it’s not unreasonable. But it sends a dispiriting message to patients who are doing exactly what their doctors purportedly want them to do: get engaged with their health.
Patient engagement has much greater value than a doctor’s billable time responding to messages. It is fundamental to better health outcomes, patient loyalty and revenue derived from delivering the right services at the right time for the right need. And the need for patient engagement is something healthcare providers and payers completely agree on.
The healthcare industry would do well to take a cue here from marketers and call center professionals: a customer is MOST open to taking a specific action that you want them to take, whatever it may be, when they have initiated an interaction. That moment is golden. You have them: you have their attention. That’s why the convenience that messaging provides can lead to higher quality, lower costs and happier, more loyal patients – especially when patients that reach out are rewarded, not charged for it.
The back-and-forth over fees is the result of mislabeling this opportunity as a problem that needs to be fixed. And it is short-sighted. Increased communication is here to stay. Doctors may be burnt out – but so are their patients. It’s a two-way street: health systems, pharmacies and payers are chasing up to date contact information and consumer consent for the privilege of pushing messages to the patients they serve. Most of that interaction already takes place in online channels – text messaging, email, app notifications, portal message centers – and will continue to do so.
Consumers want more access to medical advice and support, and they want it to be convenient, personal, timely and affordable. They also have the ability to get those services from many more sources than ever – including doctors and health care practices that aren’t local – and are more willing to switch than ever. Loyalty matters. Charging a patient for responding to their message is truly a race to the bottom and a bad look. Doctors want their patients to trust them — and generally don’t want to spend yet more of their time on micro-tracking their activity for billing purposes, or having costs take center stage when communicating with a patient. So it’s crucial that health systems and payers find business models that account for what NPR calls “the realities of how patients and providers now talk to each other.” 
The health systems and payers that figure it out first will have the advantage. But it will require real imagination and omni-channel strategies that encompass both real-time interactions and asynchronous care delivery. The “fee for service” payment model isn’t helping here. Health systems have to invest in care models that encourage more – and better – communication between doctors and patients, not less. Instead of Warning! “This message exchange with your health care team may be billed…,” imagine this: One morning you get up and make that cup of coffee. You’re feeling tired and slightly dizzy again. When you scroll through your emails, your doctor’s name catches your eye. You click and read this: “Hi, this is Dr. Bradford. Just checking in. It’s been three months since you started the new medication. How are you feeling? Our next check-up is in March. Let me know if you want to talk sooner.”
About the Author
Kimball Wilkins has 20+ years of healthcare experience and is currently Vice President, Digital Experience at Blue Shield of CA, where she formerly led Brand, Growth Strategy, and Insights. The ideas presented here are strictly her own, and in no way intended to represent those of her employer.
With a strong track record of delivering business results, building talented teams, establishing firsts and designing for the customer, she is effective at inspiring others and collaborating to drive the right kind of change. As a customer experience leader, Kimball delivered significant increases in self-service and NPS scores through improved products and user experiences across digital channels. While heading brand and marketing teams, she repositioned a leading health insurer and drove improved performance on brand differentiation, purchase consideration, employee pride and other measures of reputation. Her team’s market growth strategies led to entry into new segments and contributed to the company’s 30% revenue growth during a 36-month period. Preceding her career in healthcare, Kimball co-founded a widely reviewed, award-winning theater company known for its daring vision and bold aesthetic choices, serving as Executive Producer for seven years. She taught literature & writing courses for 5+ years in U.C. Berkeley’s English Dept. (consistently ranked #1/#2 nationally in U.S. News & World report), where she won multiple teaching and research awards.
 “Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use,” A. Jay Holmgren et al., Journal of the American Medical Informatics Association, Vol. 29, Iss. 3, March 2022, Pages 453-460. NPR interviewed Holmgren, an Assistant Professor of Medicine at UCSF, who also found that “physicians who receive a ton of portal messages tend to report being burned out, tend to report being more cynical about their job, tend to report that they are thinking about leaving clinical practice.”
 “Digital messages from patients to doctors spiked during the pandemic,” Nicole Wetsman, The Verge, 9/17/2021. Interestingly, the burden skews toward women: “Female physicians spend more time working in their EHR in-baskets because both staff and patients make more requests of female PCPs. These differential EHR burdens may contribute to higher burnout rates in female PCPs.” (Primary Care Physician Gender and Electronic Health Record Workload,” Eve Rittenberg, Jeffrey B Liebman, Kathryn M Rexrode, PubMed abstract from Journal of General Internal Medicine, October 2022.
 See What physicians, patients think of charging for MyChart messages, Laura Dyrda, Becker’s Health IT, Nov. 18, 2022, and other articles cited throughout this piece.
 To be reimbursable, the messages must be submitted on a secure patient portal and require more than 5 minutes of a qualified expert’s time over a seven-day period, in addition to meeting specific criteria.
 The continuous evolution of platforms and user interfaces is going to make it easier and easier to triage requests and questions from patients that don’t need to take a doctor’s time – the interface of one popular EHR, for example, already allows some of its customers to funnel refill requests, scheduling and other needs away from the doctor’s inbox, so that they can focus on the messages that require their expertise and knowledge of the patient. Some provider organizations are farther along than others at triaging physician inboxes and coordinating responses from physician assistants, nurses, and other staff.
 “’Hi, Doc!’ DM’ing the doctor could cost you (or your insurance plan),” Yuki Noguchi, Shots: Health News from NPR, July 21, 2023.