Will this advance convenience and consumer preference?

I completely understand the recent movement to charge patients for communicating electronically with their physicians and other providers via patient portals. Multiple health systems have recently announced their new policies and several news stories have popped up. I appreciate that messages from portals have increased dramatically due to the pandemic. I can understand how charging for messages may tamp down on the volume of messages, protect physician time, and allow for reimbursement. From the consumer side, I also see growing desire for more convenient access to care, including technology-based solutions. But my questions revolve around how consumers will respond when they are charged for previously free messages and whether the policies will reinforce a bricks and mortar mindset, at least in the short-term.

Lingering Questions

The COVID 19 pandemic helped spur on a changing health care market. Patients needed to stay home, which gave rise to more technology in care delivery. COVID necessitated virtual, asynchronous communications, like e-visits and virtual check-ins, along with the traditional synchronous telehealth visits. The Centers for Medicare & Medicaid Services (CMS) provided additional regulatory flexibility and reimbursements for these interactions, including allowing waiving Medicare co-pays. Consumer preferences and expectations shifted to embrace these options. On the other hand, the pandemic led to higher levels of provider burn-out and stress. Those implementing these new charges point to portal messages as part of that ongoing burden.

As these new policies begin to roll out, my lingering questions and thoughts are below:

• Will consumers accept charges for these portal messages? I suspect many will if an e-visit can substitute for an in-person visit. This would demonstrate an ongoing consumer movement towards convenient, technology-based care. I do believe there will be some, at least in the short-term, who will balk at being charged. This will all depend on whether the charge and policy are reasonable.
• If a patient declines to be charged, will they then call the clinic or revert back to in-person visits? In-person visits won’t help an already busy clinic schedule and long scheduling wait times. If they decide to call their provider, are those calls charged under a virtual check-in?
• Does the patient know the amount they will be charged (Medicare vs. insurance vs. high-deductible vs self-pay)? I suspect many will not which could lead to patient frustration when being charged or receiving a bill.
• Did the patient consent to be charged? Patients must still consent to be charged for these communications.

Paying for Portal Messages

Medicare started paying for portal messages (e-visits) and other patient-initiated communications (virtual check-ins) in 2019. Many other types of insurance have followed suit. The new policies several health systems have announced appear to be relate to e-visits.

E-Visits (99421, 99422, 99423; G2061, G2062, G2063). These codes describe interactions using online patient portals. The codes reflect patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office. The codes were for established Medicare patients to initiate non-face-to-face communications with physicians using online patient portals. The communications can happen over a seven-day period. Patient consent is needed.

• 99421: E/M service, established patient, cumulative time in seven days, 5-10 minutes
• 99422: E/M service, established patient, cumulative time in seven days, 11-20 minutes
• 99423: E/M service, established patient, cumulative time in seven days, 21 minutes or more
• G2061: Online assessment and management (qualify non-physician profession) with an established patient, cumulative time during seven days of 5-10 minutes
• G2062: Online assessment and management (qualify non-physician profession) with an established patient, cumulative time during seven days of 11-20 minutes
• G2063 — Online assessment and management (qualify non-physician profession) with an established patient, cumulative time during seven days of 21 minutes or more

Virtual Check-ins (G2012, G2010). These are another two codes that Medicare began reimbursing in 2019. They represent interactions by phone or where a digital image is submitted. They are for established patients where the communication is not related to a medical visit within the previous seven days and does not lead to a medical visit within the next 24 hours (or soonest available appointment). Requires patient consent to receive a virtual check-in. G2012 reflects patient-initiated interactions, such as by phone. G2010 reflects when patient sends a video or images to their physician.

Pursuing Patient-Centered Approaches

I am a strong supporter of providing patients additional and convenient avenues to access care. I have used patient portals, virtual check-ins and telehealth. They have all saved me from unnecessarily having to travel to the hospital or clinic. I greatly appreciated that. Other than using telehealth, I was not charged for those interactions, but would consider paying in some select situations.

One of my concerns with these new policies though is that patients will not know which interactions will be charged or not. When reading several of these policies online, they are generic. For the consumer, this isn’t particularly helpful or transparent. Further, my personal expectation is that I won’t be charged for interactions that logically flow from care or tests I received. If patients are charged for every follow-up question or update, it simply reinforces an in-person, fee-for-service mindset.

That said, I think there are both long-term and short-term consideration for health systems and providers when assessing these types of policies.

Over the long-term, these questions will play themselves out. I expect more patients to seek alternative types of visits, including e-visits, virtual visits or even care from any number of substitutes or new entrants. I also see value-based models – whether those are ACOs, direct contracting and or services provided directly from insurers – as potentially making e-visit charges moot since payment will be handled under alternative mechanisms.

In the short term, Medicare has already made these interactions billable, so I expect other organizations may consider following suit. However, keep in mind that consumer expectations are changing, and health care delivery is changing. Even if well intended, providers should remember patients have more options now for care outside of the hospital or clinic. Setting up barriers that dissuade patients from seeking care at your organization or when needed is not a good strategy.

So, what to do before considering charges?

1. Review the data. Are there specific providers receiving higher levels of messages? Are there specific types of providers (i.e.: family practice) receiving the bulk of messages? Are their specific patients who use the patient portal system more? Is there a reason for that (i.e.: chronic health conditions, cognitive issues, mental health issues etc.). Understand these nuances first and address those if possible.
2. Determine whether there are population health or value-based care models that offer more holistic care for your patients without these charges.  
3. Consider adjusting physician productivity measures to include these metrics (responding to non-billable messages) as a part of their compensation package.
4. Provide care management resources (other clinical staff) for physicians seeing high levels of portal messages.
5. Ask for your patient’s perspectives. Have you talked with patient representatives on your boards or used focus groups to gain that insight?  

In the end, if pursuing a new charging policy, ensure it is compliant with billing, coding requirements and is reasonable to consumers.

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