It’s not uncommon for primary care doctor Maria Byron to spend hours every single week sifting through emails from patients seeking her medical advice.
These messages might contain medication questions or completely new concerns patients didn’t mention during face-to-face visits. And while the University of California, San Francisco, where Byron practices, has seen volumes surge from a few hundred thousand such emails in 2016 to about two million in 2021, she and other clinicians typically haven’t been paid for answering them.
“It’s become sort of this extra thing that physicians are spending multiple hours a day doing… that starts to weigh on people,” Byron said.
That’s why she’s leading a novel experiment at UCSF to let clinicians bill insurers for certain medical correspondence. It’s partly to assuage the burnout caused by all the unpaid tasks on a clinician’s plate. But it’s also intended to give clinicians an incentive to spend chunks of their workday on email, a modality patients are increasingly comfortable with.
“Imagine being sent 50 emails a day, all asking for your advice, but having a packed schedule without any time to answer them,” Tim Judson, a UCSF hospital medicine and urgent care physician who studied patients’ response to electronic communication, said in an email. “That’s how most doctors feel every day.”
Since November, doctors, nurse practitioners, physician assistants, and a handful of other UCSF clinicians have been able to bill payers for patient emails that require medical evaluation or more than a few minutes to respond, said Byron, also UCSF’s associate chief medical information officer. UCSF recently expanded the system to all specialties after piloting it for dermatologists.
The move follows pandemic-era policy from the Centers for Medicare and Medicaid Services allowing Medicare reimbursement for these messages, known as e-Visits. Most commercial payers UCSF works with have followed suit, Byron said.
“If it’s not valued and recognized via any payment, it’s very difficult for the health care organization to move [email] into a sort of daytime activity,” Byron said.
It’s still not clear how much of that payment makes it into doctors’ pockets since reimbursement varies depending on the payer and the department they work for, Byron said. But UCSF has seen an average reimbursement of $65 per email consultation, though patients typically pay much less if at all.
If it’s successful, UCSF’s initiative could serve as a roadmap for other health systems eager to compensate clinicians for the time they spend on virtual communication. But it’s also led to a larger debate about the downstream effects of new billing categories, which could create more administrative burden, irk patients who are hit with unexpected co-pays, and move further away from payments rewarding the quality, and not the volume, of health services.
“As nice as it is that these now get paid for, it’s just created another bucket” for billing, said UCSF professor Julia Adler-Milstein, who studies health IT. “It feels a little untenable to keep creating all these buckets, and this feels like kind of a test if this strategy is going to work.”
Still, it could be a good short-term option for ensuring clinicians get paid for virtual communication, given that much of health care operates on a fee-for-service basis, Byron said. “It’s important to recognize that [virtual care] is valuable in the same way that an in-person visit is valuable.”
Other health systems are watching closely as competitors experiment with new strategies for addressing email-related burnout.
“We’re going to put increasing effort into finding a solution, because it just is hard to exaggerate how unhappy this is making physicians,” said Weill Cornell Medicine population health science professor Lawrence Casalino. Casalino sits on a Cornell committee focused on physician workflow that is exploring strategies for reducing burden, including potentially offloading some messaging to artificial intelligence-powered tools.
Casalino said there’s some concern that billing for email correspondence could nudge patients to change providers. “If the organization is going to try to bill for these things, patients are going to be unhappy,” he said.
Adler-Milstein warned that the patients might be reluctant to hit send on a potential message if they’re notified that they might be billed. “The question at that point is, do they stop? Do they pick up the phone?”
Byron said patients at UCSF have largely embraced the system, which notifies them when they send messages through the patient portal that they might incur a co-pay, depending on how much time a response requires from their provider. For the vast majority of patients on Medicare and California’s Medicaid program, the new billing system hasn’t led to a co-pay, Byron said. Patients on some commercial plans have seen co-pays in the $5 to $10 range for a message.
She said UCSF rebranded the portal emails as “medical advice message” instead of “e-Visit” — the term CMS uses for billing — because some patients initially thought they’d be billed for a telehealth visit, which typically costs more.
Casalino said he expects more health systems to experiment with similar models to address the clinician burnout that’s only mounted during the pandemic. “We have to experiment,” he said, but “while the experimentation goes on, I think the clinicians who provide care are really suffering.”