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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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College football odds: Using FPI to gain an edge on lines

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College football odds: Using FPI to gain an edge on lines

The NBA Finals and Stanley Cup Finals are coming to an end. The men’s College World Series wraps up shortly after, and all that’s left to get us through the scorching summer months are MLB, WNBA and soccer. Of course there’s some golf and the Olympics mixed in, as well.

Without other distractions, it’s the perfect time to get a jumpstart on some college football prep.

ESPN Analytics released its 2024 College Football Power Index (FPI) ratings and ESPN BET has posted lines for Week 0 and Week 1, as well as some other marquee matchups on tap throughout the fall. Where’s the value in what has been posted? What is the public seemingly valuing early on in the process?

You might think 10 weeks is too soon to start looking ahead, but you know how the saying goes: the early Jayhawk catches the Banana Slug.

Odds by ESPN BET. For the most up-to-date lines, click here.


1. Read, then react

Before firing away at August and September bets, take some time to refresh on how last season ended and the sheer volume of change the sport has undergone this offseason. Last year’s semifinalists have vastly different outlooks heading into 2024, with all four getting a new coach, starting quarterbacks or moving into a new conference.

The Pac-12 ceases to exist, three times as many teams can make the playoff, and the transfer portal carousel continues to spin. ESPN Analytics and FPI factor all this into their projections, so it serves as an ideal jumping-off point.

2. The Florida State vengeance tour begins, but will it start with a bang or a whimper?

After an undefeated season and subsequent playoff snub due to Jordan Travis’ injury, FSU will look to silence its doubters in the upcoming campaign. ESPN BET currently has FSU as the favorite to win the ACC at +260, followed closely by Clemson at +275. Yet, the last time we saw the Seminoles, their performance was anything but spectacular, as they needed a fourth quarter comeback against Florida, squeaked by Louisville in the ACC title game and then were walloped by Georgia 63-3 after half the team opted out.

Florida State kicks off the entire collegiate season in Ireland against Georgia Tech, in what’s currently the most bet-on game at ESPN BET. They’re installed as 13.5-point favorites, a fair line since FPI has it as a 13.8-point FSU win. The Noles then travel home to face their second straight ACC foe, laying 21.5 against Boston College, where ESPN Analytics has a much less rosy outlook. The Eagles are given a 16% chance to win and should be only 17-point underdogs, according to the model, a far cry from the 9% chance to win that BC’s +1000 odds are implying.

3. Georgia will be ready to bounce back

The Bulldogs only lost two first-round picks to the most recent NFL draft, which would look like a rebuilding year to nearly anyone except Georgia, which had eight first-round picks in the previous two drafts combined.

Since November 7, 2020, Georgia has gone 46-2, with both losses to Alabama. When the Bulldogs take the field against Clemson, it will have been 1,392 days since Kirby Smart lost to anyone other than the now-retired Nick Saban.

After missing out on the Playoff last season following back-to-back title runs, Smart and Georgia will be ready to hit the ground running this year against a Tigers squad that won only half of its ACC games last season. The Bulldogs are FPI’s top-rated team heading into the season, with Clemson at No. 15. ESPN Analytics has Georgia favored by 15.2, a couple points of value on the current line of 13.5 and also crossing the key number of 14.

4. Is Colorado “primed” to make noise in Year 2 of the Deion Sanders extravaganza?

The literal answer, of course, is yes. There’s going to be a lot of noise coming from Colorado‘s campus as Coach Prime motivates his team, but are the Buffaloes ready to compete? Their season opener against FCS North Dakota State should be a great litmus test. The Summit League powerhouse could easily hold its own in a Group of 5 conference, having reached the FCS title game in 10 of the past 13 seasons, and they’re rightfully respected as just 8.5-point underdogs in Boulder (ESPN Analytics has it projected as an 8.7-point victory).

We tackled the idea of combating the hype with a true analysis of on-field play last season after Colorado started 3-0 (it promptly lost 8 of 9 to end the year), and the same can be done in 2024.

Colorado was plagued by terrible offensive line play last year, ranking at the bottom of FBS in sacks and pressures allowed and couldn’t create in the run game. But Colorado has the No. 3-ranked transfer portal signing class, adding third-team All-AAC OL Tyler Johnson, All-CUSA honorable mention OL Justin Mayers and signing the No. 1 OT in the ESPN 300 (19th overall) in Jordan Seaton.

Colorado’s O-Line last season:

  • 56 sacks allowed (second most in FBS)

  • 232 pressures allowed (third most)

  • 45.3% blown block rate (third most)

  • 0.32 yards-per-rush before contact (last)

All that being said, I can’t bet against North Dakota State in this spot. Since rising to FCS royalty just over a decade ago, the Bison are 6-1 straight up and 6-1 ATS against FBS teams, including 5-1 straight up and 5-1 ATS against power conferences. Their average cover margin is an absurd 17.2 points per game in that span, and sportsbooks have seemingly failed to rate NDSU properly.

5. Public is fading USC following the departure of Caleb Williams

According to ESPN Bet, the single most lopsided betting market is one of the crown jewels of the Week 1 slate, as the Trojans and LSU square off in Las Vegas on Labor Day eve. All eyes will be on this matchup as the final Sunday before the NFL season begins, and so far a whopping 78% of spread bets in this game are in favor of the Bayou Bengals.

The public seems to be fading USC on the basis of Caleb Williams carrying the team for the past few seasons, but ESPN Analytics sees it differently. LSU also lost the No. 2 pick in the draft in Jayden Daniels, and two of his record-setting teammates in Malik Nabers and Brian Thomas Jr. were both first-round selections, as well. FPI suggests the Tigers should be favored by just 1.9 points, so this could be a prime upset spot for the Trojans.

6. The Big 12 has been completely flipped on its head

It’s true that the poorly-numbered conference hasn’t had 12 teams since 2011, but the massive upheaval across college sports has created a 16-team conference where half of the league was elsewhere just two years prior (BYU, Cincinnati, Houston and UCF joined last season, Colorado has returned, along with Arizona, Arizona State and Utah having their conference unveiling this fall).

It’s rather fitting that the two favorites to win the conference, according to ESPN Analytics, have been mainstays since the formation of the league back in the 1990s. Kansas has a 17% chance to win the conference, best in the Big 12, with Kansas State nipping at their heels at 16%. Both Sunflower State schools face FCS opponents — Lindenwood and UT Martin, respectively — to open their season, and there aren’t currently lines available at ESPN BET, but FPI has both teams projected to win by 30+ points.

But don’t get too confident in rock chalk nation just yet. There are seven teams with +1000 odds or shorter to win the Big 12 at ESPN BET.

Shortest odds to win the Big 12:

Utah +325
Kansas State +350
Kansas +600
Arizona +750
Texas Tech +900
Iowa State +1000
Oklahoma State +1000

Quick hitters

  • ESPN Analytics runs simulations to project the leverage a certain game has on teams’ chances to make the CFP depending on whether they win or lose. The game with the highest leverage in Week 1 is Notre Dame vs. Texas A&M, with both teams likely in the mix for a playoff spot and both ranked top 15 in FPI, making it the second-best matchup of the opening week, as well. According to the model, Notre Dame is projected to win by 3.6 points, which is notable because ESPN BET currently has the Aggies favored with -115 money line odds.

  • The largest gap between FPI and ESPN BET on opening weekend comes in an intrastate battle between Georgia State and Georgia Tech. The Yellow Jackets will be coming back from Ireland and will be playing from a travel disadvantage despite hosting the Panthers. Tech is favored by both ESPN Analytics and ESPN BET, but the line is at 19.5 with Georgia State +750 on the money line. FPI has it as a 7-point game with a 34% chance that Georgia State pulls the upset.

  • Looking ahead to Week 2, the national semifinal rematch between Michigan and Texas is actually the second-most lopsided spread bet at ESPN BET, with 77% of tickets coming in on the Longhorns of the SEC. Similar to the Caleb Williams theory, this is a double fade in the public view with JJ McCarthy and Jim Harbaugh both abandoning Ann Arbor and advancing to the NFL ranks. Oh, and leading rusher Blake Corum and leading receiver Roman Wilson are gone, as are four other top-100 picks in the draft back in April. Maybe the masses are onto something here, as Texas is favored by 3.5 while ESPN Analytics sees it as a 6.3-point victory.

Where the lines don’t align

ESPN BET has a few other notable games cued up with lines for later in the season, and there are two games with significant discrepancies between the sportsbook line and the FPI projection.

  • Oregon and Ohio State face off as Big Ten opponents for the first time on October 12. ESPN BET has the Ducks favored by a single point at home, which actually means they view Ohio State as the better team on paper. ESPN Analytics projects the Ducks as the second-best team in FBS this season and would make them almost a touchdown favorite in this spot despite losing Bo Nix to the pros.

  • Alabama and LSU renew their rivalry on November 9, with LSU currently laying 2.5 points. However, FPI values Kalen DeBoer and Jalen Milroe enough to have the Tide rated fifth best entering the season and has Alabama winning by 5.6 points on average.

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College athlete employment bill moves forward

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College athlete employment bill moves forward

A Congressional committee voted Thursday to move forward with a bill that would prevent college athletes from being deemed employees of their schools, conferences or the NCAA.

The vote in the U.S. House Committee on Education and the Workforce represents the first tangible signs of progress the college sports industry has made in its years-long push for a federal law to help reshape college sports. It comes just weeks after the NCAA and its power conferences announced they have agreed to share significantly more revenue with athletes as part of an antitrust lawsuit settlement.

The bill, introduced by Rep. Bob Good (R-Virginia) on the same day the antitrust settlement was announced, is in the early stages of the legislative process. It is likely to face opposition from Democrats in the Senate as well as legal challenges if it’s passed.

The NCAA is currently a defendant in multiple ongoing court cases that argue college athletes should be granted the rights of employees. One case in federal court — Johnson v. NCAA — is seeking minimum wage and other workplace protection for college athletes. Two other active cases in front of the National Labor Relations Board are seeking to give college athletes the right to form unions and collectively bargain.

NCAA president Charlie Baker said earlier this week that he hoped the recent antitrust settlement, if it’s approved by a judge, would provide the framework for a college sports model that allows schools to compensate their athletes without turning them into employees. Baker said he does not believe most college athletes want to be considered employees.

“A lot of the conversations I’ve had with people in Congress is: ‘The reason we’re interested in employment is because of the compensation question,'” Baker said earlier this week. “If the court blesses [the antitrust settlement], then it puts us in a position where we can go to Congress and say one of the three branches of the federal government blessed this as a model to create compensation without triggering employment.”

The NCAA and power conferences have lobbied Congress for laws that would limit their legal liability and prevent athletes from being employees for the past several years. College sports leaders say these laws are necessary to preserve many teams and athletic departments that cannot afford to pay their athletes like workers. Both the NCAA and power conferences have publicly stated their support for Good’s bill.

The bill is intended to be a narrow part of a broader package of federal legislation that guarantees more benefits for athletes in the future while preventing them from being employees. However, no partner bills that would guarantee athlete benefits have been introduced yet.

The Workforce and Education Committee voted 23-16 to move forward with the bill. All 23 votes in favor came from Republicans. All 16 votes against came from Democrats. The debate over whether Congress should weigh in on the college sports business model has been a partisan debate for the past several years.

Democrats in the House and Senate have previously co-sponsored bills that would have the exact opposite effect of Good’s bill — codifying college athletes’ right to unionize. Those lawmakers and other advocates say athletes need the ability to bargain collectively to make sure they can negotiate for items such as improved medical care and a fair share of the money they generate for a multibillion-dollar industry.

Rep. Lori Trahan (D-Mass.) — a former college volleyball player who has been an active participant in the Capitol Hill debate on the future of college sports — said she will vote against Good’s bill if it reaches the House floor.

“Once again, Republicans in Congress have decided to plow forward with legislation to limit the rights of college athletes with little to no input from athletes themselves,” Trahan said in a statement after Thursday’s vote.

If passed, Good’s bill would stop the ongoing efforts of the NLRB and in the Johnson v. NCAA case to make athletes into employees. Paul McDonald, lead attorney for the plaintiffs in the Johnson case, said he believes the bill as written would violate federal equal protection laws. McDonald said it’s against the law to prevent some college students from being employees while others in that category — like cafeteria workers or teaching assistants — are allowed to earn wages and unionize.

“If enacted, [the bill] would never survive judicial challenge. To wit, it is a waste of time,” McDonald said in a statement provided to ESPN after Thursday’s vote. “Dilatory tactics have consequences. The only thing accomplished by the NCAA in needlessly dragging out the recognition of college athletes as hourly employees like their fellow students is to significantly increase the cost of resolution borne by its membership.”

In a news release issued prior to Thursday’s vote, Good said his bill was aimed at making sure the tradition of college sports wasn’t “ruined by reclassifying student athletes as employees.”

“My legislation will help maintain a balance between athletics and academics, ensuring that college sports programs remain viable, beneficial, and enjoyable for all student athletes,” he said.

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Sources: Big 12 mulls windfall for naming rights

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Sources: Big 12 mulls windfall for naming rights

The Big 12 is exploring selling its naming rights to a title sponsor, with potential revenue of hundreds of millions of dollars over the course of the deal, sources told ESPN on Thursday.

The commercial sponsor would potentially take the name “Big” out of Big 12 and replace it with the sponsor’s name. It could end up as one of the largest commercial deals in collegiate athletics history, not including media rights.

The conference, which has explored this option for the past six months, has had in-depth discussions and a decision is expected in the upcoming months, sources told ESPN. A deal could mean millions of dollars annually for the conference’s member schools.

The Big 12 distributed nearly $470 million to its member schools in overall distribution last year, and that number projects to be higher once its new media deal comes to fruition in 2025-26. That projects to be tens of millions of dollars less per school annually than those in the Big Ten and SEC, prompting the league to find new revenue streams.

The Big 12 has also been in discussions with private equity firm CVC Capital Partners for a stake in the league between 15% to 20%, sources confirmed to ESPN. That could give the Big 12 up to a $1 billion cash infusion and would be the first known large-scale private equity investment in college sports.

Sources, however, cautioned that the private equity pieces include some skeptics, especially among presidents. Regardless, there is a clear desire to boost revenue in the Big 12 in the near future.

“Every commercial opportunity the commissioner is bringing is a way to close the financial gap between the Big 12 and SEC,” a Big 12 source told ESPN. “The No. 1 priority of the Big 12 is maintaining competitiveness, and these opportunities potentially help.”

Discussions between CVC Capital Partners and the Big 12 were first reported by CBS.

The Big 12 will have a new look amid the shuffled college landscape in 2024. Gone will be conference stalwarts Texas and Oklahoma (to the SEC), and a new 16-member lineup will include Arizona, Arizona State, Colorado and Utah joining the 12 returning members from last year.

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