Nominal, transparent billing could provide balance to portal messaging system
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Key takeaways:
- Electronic messaging has resulted in significant overwork for clinicians.
- Billing portal communications could reduce clinician burdens and burnout, but ethical concerns exist.
Clinicians could benefit significantly if medical institutions began billing patients for electronic messages; however, ethical implications of the practice, which include erecting another potential barrier to care, complicate the issue.
A publication in JCO Oncology Practice detailed how patients have extraordinary access to health care workers thanks to the portal, but their ability to freely communicate with medical professionals has created an imbalanced relationship where clinicians consistently work extra hours to accommodate the influx of messages, leading to more burnout.
A pay-per-message system could alleviate some of that burden, but also may discourage individuals from seeking treatment.
“Health care should promote an environment that is efficient and fair, provides patients with timely and valuable access to medical services, and protects the well-being of health care providers,” Bassel Nazha, MD, MPH, assistant professor in hematology and medical oncology at Winship Cancer Institute at Emory University, told Healio. “Improving patient portal messaging can help health systems achieve a balance among these three objectives.”
Clinician burnout
Communication within the patient portal has mostly been a free service for individuals since its implementation, but the COVID-19 pandemic created a surge in the system, according to background information researchers provided.
Patient messaging increased 157% during that timeframe and roughly 117,000 clinicians left health care in 2021.
Healio previously reported oncologists respond to 19 secure patient-physician portal messages per day. Meanwhile, Nazha and colleagues referenced a study that found 22% of oncologists respond to portal messages outside of working hours, and 73% of them did not necessitate an oncologic review.
CMS broadened the definition of an e-visit during the pandemic to include portal messages that required “medical decision making and physician time,” Nazha and colleagues wrote.
The change resulted in a decrease of messages from 59,648 to 57,925 per week, and a reduction in message threads from 19,739 to 16,838, according to an analysis by Holmgren and colleagues at University of California, San Francisco. Conversely, billed e-visits rose from 50.6 to 235.7 per week.
Another study found clinicians who received more than an average number of messages had a 40% higher likelihood of burnout and 38% higher likelihood of reducing clinic work.
“Patients greatly value direct access to their physician team to ask questions, request refills and schedule appointments,” Nazha told Healio.
“The rapid rise of portal messaging has significantly amplified the volume of messages. This is a challenge for both patients in terms of hearing back promptly and for physicians in terms of being able to deliver care in a way that they perceive as sustainable and fulfilling,” he added. “The work structure for physicians has not adapted to this and many physicians are having to address numerous messages beyond clinic hours. Many clinicians believe that there is a definite need to optimize the portal messaging process so that we improve the well-being of patients, physicians, and their teams.”
Benefits of billing, ethical concerns
Nazha and colleagues discussed a study that found clinicians spend 5.9 hours per day dealing with electronic health records, and inbox management accounted for 84 minutes of that.
Another study noted 24% of messages to oncologists should have been addressed during an in-person visit, which could have generated $11,087,292.23 in revenue.
“Moreover, cross-sectional studies have demonstrated a strong correlation between physician burnout and suboptimal patient care, doubled risk [for] medical error, and 17% increased odds of being named in a medical malpractice suit,” Nazha and colleagues wrote.
Clinicians are not the only medical professionals managing the portal.
“In our clinic, management of patient portal messages is a frequent topic of conversation because of the volume of messages managed by all staff members, including schedulers, practice nurses, advanced practice providers and physicians,” Jeffrey Peppercorn, MD, MPH, FASCO, director of the cancer survivorship program at Massachusetts General Hospital and associate professor at Harvard Medical School, wrote in paper published in JCO Oncology Practice paper earlier this year. “We all see the value in timely response to patients, and we can also feel overwhelmed at times by the volume of messages on a wide range of topics. ... I believe it is self-evident that these team members should be paid for their work.”
Billing could alleviate many of these stresses, but patients could suffer because of it.
Nazha and colleagues discussed several ethical challenges in their paper.
Patients may be disincentivized from asking questions about their health, which could lead to a multitude of medical issues.
Researchers cited a collection of 74 studies that found individuals with more financial hardships are twice as likely to not follow cancer medication protocols.
Another study found patients got fewer breast cancer screenings if they also had financial burdens.
In the U.S. in 2021, health care expenditures increased $4.3 trillion, which amounted to $12,914 per person.
Additionally, disadvantaged populations may be impacted more, increasing disparities in care.
Forcing individuals to pay for messaging could also lead to distrust in the system, Nazha and colleagues wrote.
“I have reservations about billing for responses to portal messages, primarily related to concerns over creating a potential barrier to care for my patients,” Peppercorn wrote. “However, I have no reservations about shifting the more complex questions to a telehealth visit.”
Finding ‘balance’
Nazha and colleagues wrote about a “middle ground.”
Procedural terminology codes in the 2020 Medicare Physician Fee Schedule update could be a guide. If clinicians spent 5 to 10 minutes on a patient in a week, the costs of messaging would be up to $15.50, for 11 to 20 minutes it could be a maximum of $31, and more than 20 minutes could cost as much as $50.
However, medical centers may not charge for every message, or most messages.
Nazha and colleagues cited University of California San Francisco Health, which billed 13,000 out of 900,000 message threads in its first year of billing (1.5%).
Researchers also stressed the importance of clear billing policies to maintain trust with patients, and possibly instituting a “sliding scale” of fees so those with financial burdens could still be cared for.
“From an ethical standpoint, we feel that such billing should be nominal, transparent and reflective of the time spent on the message, if adopted,” Nazha said. “This approach reflects a balance for each ethical pillar that pays attention to both the advantages and disadvantages raised by billing for beneficence, respect for persons and justice.”
If institutions do not want to bill, Peppercorn offered alternatives in his paper, including triaging certain questions to calls or visits, having a selection of answers for frequently asked questions, defining what questions could or should be asked on the portal and specifying how long a response could take.
“On the basis of conversations with colleagues across the country in oncology and primary care, this seems to be a universally critical issue that affects quality of care, communication and sustainability of practice,” Peppercorn wrote. “I strongly encourage my colleagues in health services research to expand our knowledge base on this topic.”
References:
- Holmgren AJ, et al. JAMA. 2023;doi:10.1001/jama.2022.24710.
- Peppercorn J, et al. JCO Oncol Pract. 2024;doi:10.1200/OP.24.00176.
- Rhee CH, et al. JCO Oncol Pract. 2024;doi:10.1200/OP.23.00569.
For more information:
Bassel Nazha, MD, MPH, can be reached at bassel.nazha@emory.edu.
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