Thinking about messaging your physician about a weird rash? You may want to hold off on it. Some hospital systems have started charging patients for digital messages to their doctors via the electronic medical record, either a flat rate (like a copay) or on sliding scale depending on the time or complexity of the physician’s response. Sometimes it’s billed through an insurer, sometimes as a direct cost to the patient. Costs have ranged between less than $10 and $100 for a message.
Now that at least 22 hospital systems have implemented the practice, a great debate has broken out in the medical profession: Is charging patients to send a note to a doctor just common sense or an unjust expense?
In asking family, friends, and colleagues about this, my grandmother’s response was the most enlightening: “I’m surprised doctors ever stopped charging for phone calls!”
When she was a little girl, the family dog went into heat. Concerned her dog was sick, my precocious grandmother called the family doctor’s house. He patiently explained to her the birds and the bees, then warned to keep Spot away from the neighborhood stray.
The next week my grandmother’s father entered the living room brandishing a bill from the doctor for the price of a week’s allowance. “It wasn’t much, but the message was clear,” my grandmother said. “A doctor is obliged to put his patient’s interests before his own, but not at the exclusion of his own.”
The family doctor’s penny-candy bill of long ago and the EMR messages of today have much in common. But under the current hospital-centered health care system, charging for MyChart messages as a policy instrument cannot accomplish the purported goals of 1) reducing physician inbox burden or 2) compensating them fairly for the work they do “after hours.”
I suspect, rather, that vast hospital systems, health systems, and corporate entities — who employ the vast majority of physicians, both specialists and primary care doctors — are the only ones to seriously benefit. Charging for MyChart messages is neither necessary nor sufficient for reducing the tragedy of convenience that instant and easy communication contributes to physician burnout. Nor will the modest reimbursement indirectly to physicians adequately redress the cultural devaluation doctors have suffered for the past couple of decades. Respect must be earned; it cannot be invoiced.
In recent times, insurers would not pay for text, email, or phone, so these amenities remained uncommon. However, beginning in 2011, the Center for Medicare & Medicaid Services instituted so-called “meaningful use” to give hospital systems an incentive to rapidly adopt digital communication between doctor and patient. Hospital systems soon implemented it to reap the reward and avoid CMS’s reprimand. All access, but no advantage. A 2014 survey of clinicians showed only a quarter believed this direct electronic contact would be useful, and in 2017, that proportion declined to one-fifth.
Now that the messaging infrastructure is up and running, however, what started as “meaningful use” can become “profitable misuse,” as hospital systems seek to recapture valuable clinical activity that they themselves squeezed into the ether when they shortened visit times and spaced follow-ups further apart in the pursuit of more new patients with higher reimbursements.
Without the time for follow-ups, many doctors like run epistolary practices trying to address new or developing concerns of patients who otherwise would be left to suffer silently or take their complaint to crowded emergency rooms. A 2018 study suggested that implementing services to fulfill “meaningful use” meant that clinicians were spending nearly three hours a day on messages, a trend that has, based on my experience, only gotten worse. Frankly, a hospital-centric system of health care has forced good doctors into performing shadow services. This uncompensated overworking exacerbates our burn-out.
Hospital systems can say that charging for MyChart messages might curb frivolous overuse egged-on by the convenience of a text, but they might also hope to capture the valuable revenue in the services physicians are providing on their own time because of the perverse incentives of the current health care economy. A major moral objection by doctors to charging for MyChart messages is that the policy will not so much screen out the frivolous excesses of the worried well who can afford to ping, but rather deter by debt the poor who cannot afford to pay.
Pay-to-play MyCharting will leave the doctor’s inbox just as busy as ever, but it will be more profitable for the big-box hospital system. This follows a more general trend in which hospitals see doctors who serve a patient as so-called “providers” of an industrial service. By figuring out a way to squeeze further reimbursement, the hospital system replaces a doctor’s note with a provider’s message, turning our fiduciary service into a factory good.
Michael P.H. Stanley is a neurologist of the Brigham & Women’s Hospital.