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Meg Bakewell, who has cancer and cancer-related heart disease, sometimes emails her primary care physician, oncologist, and cardiologist asking them for medical advice when she experiences urgent symptoms such as pain or shortness of breath.

This story also ran on The Sacramento Bee. It can be republished for free.

But she was a little surprised when, for the first time, she got a bill a $13 copay for an emailed consultation she had with her primary care doctor at University of Michigan Health. The health system had begun charging in 2020 for e-visits through its MyChart portal. Even though her out-of-pocket cost on the $37 charge was small, now shes worried about how much shell have to pay for future e-visits, which help her decide whether she needs to see one of her doctors in person. Her standard copay for an office visit is $25.

If I send a message to all three doctors, that could be three copays, or $75, said Bakewell, a University of Michigan teaching consultant who lives in Ypsilanti, Michigan, and is on long-term disability leave. Its the vagueness of the whole thing. You dont know if youll get into a copay or not. It just makes me hesitate.

Spurred by the sharp rise in email messaging during the covid pandemic, a growing number of health systems around the country have started charging patients when physicians and other clinicians send replies to their messages. Health systems that have adopted billing for some e-visits include a number of the nations premier medical institutions: Cleveland Clinic, Mayo Clinic, San Francisco-based UCSF Health, Vanderbilt Health, St. Louis-based BJC HealthCare, Chicago-based Northwestern Medicine, and the U.S. Department of Veterans Affairs.

Billing for e-visits, however, raises knotty questions about the balance between fairly compensating providers for their time and enhancing patients access to care. Physicians and patient advocates fret particularly about the potential financial impact on lower-income people and those whose health conditions make it hard for them to see providers in person or talk to them on the phone or through video.

A large part of the motivation for the billing is to reduce the messaging. Soon after the pandemic hit, health systems saw a 50% increase in emails from patients, with primary care physicians facing the biggest burden, said A Jay Holmgren, an assistant professor of health informatics at UCSF, the University of California-San Francisco. System executives sought to compensate doctors and other providers for the extensive time they were spending answering emails, while prodding patients to think more carefully about whether an in-person visit might be more appropriate than a lengthy message. Email Sign-Up

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After UCSF started charging in November 2021, the rate of patient messaging dipped slightly, by about 2%, Holmgren and his colleagues found.

Like UCSF, many other health systems now charge fees when doctors or other clinicians respond to patient messages that take five minutes or more of the providers time over a seven-day period and require medical expertise. They use three billing codes for e-visits, implemented in 2020 by the federal Centers for Medicare & Medicaid Services.

E-visits that are eligible for billing include those relating to changes in medication, new symptoms, changes or checkups related to a long-term condition, and requests to complete medical forms. Theres no charge for messages about appointment scheduling, prescription refills, or other routine matters that dont require medical expertise.

So far, UCSF patients are being billed for only 2% to 3% of eligible e-visits, at least partly because it takes clinicians extra time and effort to figure out whether an email encounter qualifies for billing, Holmgren said.

At Cleveland Clinic, only 1.8% of eligible email visits are being billed to patients, said Eric Boose, the systems associate chief medical information officer. There are three billing rates based on the time the clinician takes to prepare the message five to 10 minutes, 11 to 20 minutes, and 21 minutes or more. He said patients havent complained about the new billing policy, which started last November, and that theyve become a little smarter and more succinct in their messages, rather than sending multiple messages a week.

The doctors at Cleveland Clinic, like those at most health systems that bill for e-visits, dont personally pocket the payments. Instead, they get productivity credits, which theoretically enables them to reduce their hours seeing patients in the office.

Most of our physicians said its about time were getting compensated for our time in messaging, Boose said. Were hoping this helps them feel less stressed and burned out, and that they can get home to their families earlier.

Its been a frustration for many physicians for many years that we werent reimbursed for our pajama-time work, said Sterling Ransone, the chair of the American Academy of Family Physicians Board of Directors. Ransones employer, Riverside Health System in Virginia, started billing for e-visits in 2020. We do it because its the right thing for patients. But rarely do you see other professions do all this online work for free, he said.

We see physicians working two to four hours every evening on their patient emails after their shift is over, and thats not sustainable, said CT Lin, the chief medical information officer at University of Colorado Health, which has not yet adopted billing for email visits. But we worry that patients with complex disease will stop messaging us entirely because of this copay risk.

Many health care professionals share the fear that billing for messages will adversely affect medically and socially vulnerable patients. Even a relatively small copay could discourage patients from emailing their clinicians for medical advice in appropriate situations, said Caitlin Donovan, a senior director at the National Patient Advocate Foundation, citing studies showing the dramatic negative impact of copays on medication adherence.

Holmgren said that while patients with minor acute conditions may not mind paying for an email visit rather than coming into the office, the new billing policies could dissuade patients with serious chronic conditions from messaging their doctors. We dont know who is negatively affected, he said. Are we discouraging high-value messages that produce a lot of health gains? That is a serious concern.

Due to this worry, Lin said, University of Colorado Health is experimenting with an alternative way of easing the time burden of e-visits on physicians. Working with Epic, the dominant electronic health record vendor, it will have an artificial intelligence chatbot draft email replies to patient messages. The chatbots draft message will then be edited by the provider. Several other health systems are already using the tool.

There also are questions about price transparency whether patients can know when and how much theyll have to pay for an email visit, especially since much depends on their health plans deductibles and copays.

While Medicare, Medicaid, and most private health plans cover email visits, not all do, experts say. Coverage may depend on the contract between a health system and an insurer. Ransone said Elevance Health, a Blue Cross Blue Shield carrier, recently told his health system it would no longer pay for email or telephonic visits in its commercial or Medicaid plans in Virginia. An Elevance spokesperson declined to comment.

Another price concern is that patients who are uninsured or have high-deductible plans may face the full cost of an email visit, which could run as high as $160.

At University of Michigan Health, where Bakewell receives her care, patients receive a portal alert prior to sending a message that there may be a charge; they must click a box indicating they understand, said spokesperson Mary Masson.

But Donovan said that leaves a lot of roo for uncertainty. How is the patient supposed to know whether something will take five minutes? Donovan said. And knowing what youll be charged is impossible because of health plan design. Just saying patients could be charged is not providing transparency.

Harris Meyer: @Meyer_HM Related Topics Health Care Costs Health Industry Insurance Colorado Copayments Doctors Health IT Michigan Ohio Contact Us Submit a Story Tip

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Sources: Knights land Marner, give star 8 years

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Sources: Knights land Marner, give star 8 years

Mitch Marner was traded to the Vegas Golden Knights — with an eight-year extension in place, sources told ESPN on Monday. Forward Nicolas Roy will go to the Toronto Maple Leafs in return.

Marner’s new deal has a $12 million average annual value, according to sources. Marner, 28, was the biggest name entering Tuesday’s NHL free agency, and multiple teams were hoping to make pitches. Marner was the NHL’s fifth-leading scorer last season with 102 points — 36 more than the next-closest free agent. The winger was drafted by his hometown Maple Leafs with the No. 4 pick in 2015.

The Maple Leafs knew that Marner was looking to test free agency at the end of the season. Over the past few days, Toronto worked with Vegas, which was Marner’s preferred destination, on a trade. The Maple Leafs held Marner’s rights until just before midnight Tuesday.

Had Marner become an unrestricted free agent, he couldn’t have signed a deal for more than seven years.

Marner finished a six-year deal that paid him $10.9 million annually. Marner, who played for Team Canada at Four Nations and likely will make their Olympic team, has 221 goals and 741 points in nine NHL seasons.

Toronto general manager Brad Treliving has stayed busy this week, re-signing John Tavares and Matthew Knies while trading for Utah forward Matias Maccelli earlier Monday.

Roy, 28, is a center who is entering Year 4 of a five-year deal that pays him $3 million annually.

Ahead of the Marner trade, the Golden Knights created cap space by sending defenseman Nicolas Hague to the Nashville Predators on Monday.

The deal makes Marner the highest-paid player on Vegas, however, center Jack Eichel ($10 million AAV) is entering the final year of his contract and is eligible to sign an extension this summer. The Golden Knights might not be done this offseason. According to sources, defenseman Alex Pietrangelo is expected to go on long-term injured reserve, which could create more flexibility.

Sign-and-trades ahead of free agency are becoming a trend for NHL teams that know they will not sign their coveted player; last season, the Carolina Hurricanes dealt Jake Guentzel‘s rights to the Tampa Bay Lightning before he signed a seven-year deal.

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Sources: Panthers keeping Marchand, Ekblad

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Sources: Panthers keeping Marchand, Ekblad

Hours after re-signing Aaron Ekblad, the Florida Panthers kept another integral piece of their Stanley Cup team by re-signing Brad Marchand to a six-year contract extension, sources told ESPN’s Emily Kaplan.

Marchand’s deal has an average annual value of $5.25 million, sources told Kaplan.

Coming to terms with Ekblad on an eight-year extension worth $6.1 million annually left the Panthers with what PuckPedia projected to be $4.9 million in salary cap space.

There was the possibility that Marchand, 37, could have left the Panthers for a more lucrative offer elsewhere considering there were teams that had more than enough cap space to sign him.

Instead? Marchand, who arrived ahead of the NHL trade deadline from the Boston Bruins, appears as if he will remain in South Florida for the rest of his career.

Acquiring defenseman Seth Jones from the Chicago Blackhawks and then adding Marchand were two decisions made by Panthers general manager Bill Zito with the intent of seeing the Panthers win a second consecutive Stanley Cup as part of a run that now has included three straight Cup Final appearances.

Marchand, who was a pending UFA entering the final day before free agency begins Tuesday, used the 2025 postseason to further cement why the Panthers and other teams throughout the NHL would still seek his services. He scored 10 goals and finished with 20 points in 23 playoff games.

For all the contributions he made, his greatest came during the Cup Final series against the Edmonton Oilers.

Marchand, who previously won a Cup with the Bruins back in 2011, opened the series with a goal in the first three games. That includes the two goals he scored in the Panthers’ 5-4 double-overtime win to tie the series with his second being the game-winning salvo.

He scored two more goals in a 5-2 win in Game 5 that allowed the Panthers to take a 3-1 series lead before returning to Sunrise, Florida, where they closed out the series with an emphatic 5-1 win.

Capturing a consecutive title created questions about whether the Panthers can win a third in a row. But there was the understanding that it might be difficult given there was only so much salary cap space to re-sign Conn Smythe winner Sam Bennett, Ekblad and Marchand.

Knowing there was a chance they could lose one, or more, of them, Zito laid the foundation to retain the trio. He began by signing Bennett to an eight-year contract worth $8 million annually on June 27 before using Monday to sign Ekblad and Marchand.

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Sources: Provorov nets 7-year deal from Jackets

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Sources: Provorov nets 7-year deal from Jackets

Ivan Provorov decided to forgo free agency, with the veteran defenseman finalizing a seven-year extension Monday worth $8.5 million annually to remain with the Columbus Blue Jackets, sources told ESPN, confirming earlier reports.

With free agency slated to start Tuesday, the 28-year-old was one of the most notable defenseman who had a chance to hit the open market.

Provorov’s decision to stay with the Blue Jackets comes shortly after it was reported that Aaron Ekblad also avoided free agency by agreeing to an eight-year extension to remain with the Florida Panthers. That now leaves players such as Vladislav Gavrikov, Ryan Lindgren, and Dmitry Orlov among the more prominent pending UFAs who could be available should they fail to strike a deal with their current teams.

Retaining Provorov comes months after a season that witnessed the Blue Jackets shed the title of being a rebuilding franchise to one that could challenge for the playoffs in 2025-26.

Four consecutive seasons without the playoffs created the idea that the 2024-25 campaign could be another challenging one. But a six-game winning streak in January saw Columbus post a 22-17-6 record to create the belief that a turnaround could be in order.

The Jackets closed the season with another six-game winning streak but fell short of the final Eastern Conference wild-card playoff spot, which went to the Montreal Canadiens by two points.

Provorov would finish with seven goals and 33 points in 82 games while his 23 minutes, 21 seconds in average ice time was second behind Norris Trophy finalist Zach Werenski.

Re-signing Provorov comes in an offseason that saw the Blue Jackets also strengthen their bottom-six forward corps by adding Charlie Coyle and Miles Wood in a trade with the Colorado Avalanche.

PuckPedia projects that the Blue Jackets now have $20.957 million in cap space ahead of free agency.

TSN was first to report news of Provorov’s decision.

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