A Delicate Balancing Act.

Over the past few days, Sally has been experiencing dizziness, pain along her temples, and pain when visualizing bright light. After realizing something was wrong, she decided to send a text message to her physician asking about her next steps. To Sally’s delight, her physician responded immediately, stating that Sally could be experiencing one of a few different conditions, primarily severe headache or migraine. After 15 minutes, the physician believes Sally may have a migraine; before prescribing any prescription medications, he wants to confirm his diagnosis by having Sally come to the hospital for a short visit. Yet even before Sally visits the hospital, she is charged $50.

A few days ago, I was reading an article titled “Johns Hopkins Medicine joins national move to charge patients for messaging their doctor.” (1)

I learned that the Johns Hopkins Medicine System had decided to begin charging patients for certain MyChart conversations with their care team. These charges will apply specifically for uninsured patients, averaging between $15 to $50. Johns Hopkins will not bill patients for all MyChart messages; messages that may be charged include prescription refill requests, patient requests for referrals to a physician specialist, and messages that require a thorough (taking over 5 minutes) response. (2)

However, Johns Hopkins is joining a national movement; other medical systems including Ohio State’s Wexner Medical Center and the Novant Healthcare System have implemented similar changes.

So what have these other two systems done? Ohio State’s Wexner Center provides patients with an online e-visit form for patients to fill out and receive assistance from their care team. (3) The Wexner Center charges a $25 fee per e-visit form submitted. (4) Because these forms serve a wide variety of patient needs, it seems unlikely that patients would be willing to pay a flat fee if they have a question that can be easily answered online or via another method. Novant Health has adopted a system more similar to Johns Hopkins. Novant also charges patients for MyChart or portal messages; however, patients are billed for every 10 minutes that their conversation lasts. (5) For each 10 minute increment, these costs are $7-28 for Medicaid patients, $14-52 for Medicare patients, and $27-98 for uninsured patients. While this system does mean that patients with more easily answered questions will end up paying less, it also results in large payment discrepancies between patients with different coverage plans. Moving forward, I will use the Johns Hopkins payment plan for analysis and comparison.

Before I continue, I want to revisit the exemplum I provided at the start of this article. The way I pose this scenario is yet another example of framing. Had Sally’s physician been able to identify that Sally had severe headaches, the physician could have recommended bed rest and perhaps aspirin, saving Sally the cost of going to the hospital. Furthermore, Sally would likely have only had to pay a significant amount if she was uninsured. Below I include a comparison of prices for insured and uninsured individuals visiting a hospital and using patient portal messages. These costs are approximate and may change depending on the specific medical issue and hospital system in question.

Essentially, charging for patient messaging may not be as detrimental from a patient’s perspective than we might think. But what are some pros and cons of this policy?

Let’s dive into a short cost-benefit analysis, starting with the benefits:

• Patient messaging takes up a significant portion of healthcare providers’ time. If hospitals were receiving compensation for patient messaging, the best case scenario would be that the increased revenue will be invested back into the hospital, increasing the quality of medical care. (6)

• Another possible benefit would be a decrease in unnecessary messaging between healthcare providers and their patients. If patients realize that their messaging may result in additional costs, they may be less likely to ask easily-answerable questions to their providers, saving providers’ time. (7) The flip side to this benefit however, is eroding trust and the connection between patients and their providers; patients may begin messaging providers in emergency circumstances only, which may increase the prevalence of chronic or non-life threatening (but still debilitating) disease.

• A final benefit might be improving hospital efficiency and reducing healthcare provider burnout. By charging for patient messaging, hospitals ensure that providers are compensated for hours spent conversing with patients. Furthermore, with this policy, providers may focus on patients who require critical attention. Below, we see the size of the clinician workforce over the past two decades. (8) While the size of the workforce has been increasing, we see that until recently, the total number of hours clinicians are working has been increasing as well. Over the past few years, hospital systems have put clinician well being at the forefront, focusing on reducing total hours worked but increasing productive hours. Moving forward, we may see more policies like this one that attempt to put the clinician at the forefront of public healthcare conversations.

So what are some potential costs or downsides of this policy change?

• One downside of this new policy seems to be increasing access disparities. The Johns Hopkins plan seems to target uninsured patients specifically, and raising costs for patient messaging for the uninsured might decrease their quality of care as compared to insured patients. (9)

• Another downside of this policy may be additional insurance costs. If hospitals begin billing insurance agencies for patient messages, insurance claims will increase. (10) To offset additional costs, insurance premiums (or the cost a patient pays to receive insurance) may increase throughout the US. This may have unintended consequences for patients who do not regularly use patient messaging as well, increasing their healthcare insurance costs.

• A final, and perhaps the most important, downside might be reducing patient-clinician interaction. Charging for patient messaging might discourage patients, particularly low-income patients who have greater need for healthcare, from asking questions of their healthcare team. (11) In fact, a JAMA study below reveals the effect of charging for patient messaging on the number of messages received: graph B is most clear in showing that after January 1, 2022 when patients are charged for messages, the number of message threads decreases significantly. (12)

Wrapping up this discussion, let’s determine who might be helped or hurt by this policy. While healthcare providers and hospital systems may be helped in that they receive additional revenue from standard services, we do not know yet how charging for patient messaging will affect healthcare outcomes and how changing outcomes will affect the industry moving forward. (13) On the other hand, patients are generally hurt by this policy. While insured patients will see little change, they may experience slightly increased insurance premiums. Uninsured and low-income patients will experience the greatest negative impact as they see healthcare expenses rise.

Charging for patient messaging seems to be a new strategy for healthcare systems to recover costs and prevent clinician burnout. However, such change may negatively impact the patient experience, possibly affecting healthcare outcomes. As Johns Hopkins, Ohio State, and Novant Health track results over the next few years, we will learn more about how this new policy affects the healthcare industry. As the United States treks into unexplored territory, healthcare policymakers can look to established policies from other nations that accomplish similar goals. For example, in Israel, while patients may be charged for specialist and emergency care visits and prescription medications, the government prevents hospital systems from charging extra for routine services. (14)

As healthcare systems continue exploring new ways to improve the industry, it is important to consider both sides of the coin: the care team and the patient. In a lot of ways, improving clinicians’ experience negatively affects that of patients. Hopefully, moving forward, healthcare systems can navigate this tradeoff and work to design a system that is both fair to physicians and healthcare providers while also providing patients with the best experience and outcomes possible.