As More Patients Email Doctors, Health Systems Start Charging Fees

Published

2 years ago

September 14, 2023

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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.

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Business

Energy bills: Network charges set to rise as price cap eases

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2 hours ago

July 1, 2025

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Energy bills: Network charges set to rise as price cap eases

A major component within household energy bills is set to rise sharply from next year to help pay for efforts to maintain energy security during the transition to green power.

The industry regulator Ofgem’s draft determination on how much it will allow network operators to charge energy suppliers from 1 April 2026 to 31 March 2031 would push up network costs within household bills by £24 a year.

These charges currently account for 22% of the total bill.

Money latest: ‘I worry I’ll lose my house’

The findings, which will be subject to consultation before a final determination by the end of the year, reflect demands on network operators to make power and gas networks fit for the future amid expansion in renewable and nuclear energy to meet net zero ambitions.

Ofgem says the plans it has given provisional approval for amount to a £24bn investment programme over the five-year term – a four-fold increase on current levels.

A total of 80 major projects includes upgrades to more than 2,700 miles of overhead power lines.

If rubber stamped as planned, the resulting network cost increases threaten further upwards pressure on bills from next April – a month that has now become synonymous with rising essential bills.

The watchdog revealed its plans as the 22 million British households on the energy price cap benefit from the first decline for a year.

It is coming down from an annual average £1,849 between April and June to £1,720 from July to September.

That’s on the back of easing wholesale costs seen during the spring – before the temporary surge in wholesale gas prices caused by the recent instability in the Middle East.

A new forecast released by industry specialist Cornwall Insight suggested households were on track to see a further, but slight, decline when the cap is adjusted again in October.

At the current level it is 28% lower than at the height of the energy-led cost of living crisis – but 10% higher than the same period last year.

The price cap does not limit total bills because householders still pay for the amount of energy they consume.

Ofgem is continuing to recommend consumers shop around for fixed rate deals in the market as they can offer savings compared with the price cap and shield homes from any price shocks seen within their fixed terms.

Jonathan Brearley, the regulator’s chief executive, said: ”Britain’s reliance on imported gas has left us at the mercy of volatile international gas prices which during the energy crisis would have caused bills to rise as high as £4,000 for an average household without government support.

“Even today the price cap can move up or down by hundreds of pounds with little we can do about it.

“This record investment will deliver a homegrown energy system that is better for Britain and better for customers. It will ensure the system has greater resilience against shocks from volatile gas prices we don’t control.

“These 80 projects are a long-term insurance policy against threats to Britain’s energy security and the instability of prices. By bringing online dozens of homegrown, renewable generation sites and modernising our energy system to the one we will need in the future we can boost growth and give ourselves more control over prices too.

“Doing nothing is not an option and will cost consumers more – this is critical national infrastructure. The sooner we build the network we need, and invest to strengthen our resilience, the lower the cost for bill payers will be in the future.”

Politics

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2 hours ago

July 1, 2025

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Politics

Culture secretary Lisa Nandy hits out at BBC over Glastonbury controversy

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2 hours ago

July 1, 2025

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Criminal investigation launched into Glastonbury performances of Kneecap and Bob Vylan

The culture secretary has claimed there is “a problem of leadership” at the BBC, as the controversy over Bob Vylan’s Glastonbury performance deepens.

Lisa Nandy criticised the corporation over its decision not to pull the livestream after the band’s frontman shouted “death, death to the IDF” – referring to the Israel Defence Forces – on Saturday.

A criminal investigation has been launched into the Glastonbury performances of both Bob Vylan and Kneecap after the police reviewed footage.

Ms Nandy condemned the “appalling and unacceptable scenes” at Glastonbury and said the government would not tolerate antisemitism.

She said she had called BBC director-general Tim Davie after the broadcast of Bob Vylan’s set to find out why it had aired, and why the feed had not been cut.

“I expect answers to these questions without delay,” she said.

Later, when asked in the Commons about the BBC’s editorial processes and who would be held accountable, Ms Nandy replied: “When you have one editorial failure, it’s something that must be gripped. When you have several, it becomes a problem of leadership.”

Ms Nandy said she had spoken to members of the Jewish community, including attendees at Glastonbury, who said they were concerned by imagery and slogans and ended up creating their own “safe space”.

Mr Davie has been facing calls for his resignation.

Yesterday, drummer Bobbie Vylan released a video statement on Instagram – saying politicians who have spent time criticising the band should be “utterly ashamed” for giving “room” to this over other issues.

The punk rap duo have had their US visas revoked and been dropped by their US representative, United Talent Agency.

He also addressed what was said on stage, saying: “Regardless of how it was said, calling for an end to the slaughter of innocents is never wrong. To civilians of Israel, understand this anger is not directed at you, and don’t let your government persuade you that a call against an army is a call against the people.”

Shortly after it was posted, the video was no longer available to view.

Israel denies targeting civilians in its war in Gaza.

During Kneecap’s set, one member suggested on stage starting a “riot” outside his bandmate’s forthcoming court appearance, before clarifying he meant “support”.

In a statement, Avon and Somerset Police said that after reviewing footage of the performances of Kneecap and Bob Vylan, further enquiries are required and a criminal investigation is now being undertaken.

“A senior detective has been appointed to lead this investigation,” a spokesperson said. “This has been recorded as a public order incident at this time while our enquiries are at an early stage.”

The force said the investigation will be “evidence-led and will closely consider all appropriate legislation, including relating to hate crimes”.

“We have received a large amount of contact in relation to these events from people across the world and recognise the strength of public feeling,” it added. “There is absolutely no place in society for hate.”

What happened?

During Bob Vylan’s set, the duo performed in front of a screen that showed several messages, including one that said Israel’s actions in Gaza amount to “genocide”.

Bobby Vylan also led chants of “death to the IDF”.

The set was live streamed by the BBC as part of its Glastonbury coverage, but has not been made available on demand.

Politicians including the prime minister have criticised the performance. Glastonbury organiser Emily Eavis said the chants “crossed a line” and that there was no place at the festival for “antisemitism, hate speech or incitement to violence”.

A BBC spokesperson said the broadcaster respected freedom of expression “but stands firmly against incitement to violence”.

They added: “The antisemitic sentiments expressed by Bob Vylan were utterly unacceptable and have no place on our airwaves…

“The team were dealing with a live situation, but with hindsight we should have pulled the stream during the performance. We regret this did not happen.”

Media watchdog Ofcom said it was in talks with the BBC and that the broadcaster “clearly has questions to answer” over the stream.

Irish-language rap trio Kneecap were on stage afterwards. Before their appearance at the festival, there had been calls for Glastonbury to remove them from the bill – as rapper Liam Og O hAnnaidh (who performs as Mo Chara) is facing a terror charge, accused of displaying a flag in support of the proscribed group Hezbollah at a gig in London last November.

Glastonbury organisers kept them on the line-up, but the BBC chose not to stream their set live. An edited version was later made available on demand.

On stage, the band led chants of “f*** Keir Starmer”.

O hAnnaidh’s bandmate Naoise O Caireallain (Moglai Bap) said they would “start a riot outside the courts” for O hAnnaidh’s next appearance, before clarifying: “No riots, just love and support, and support for Palestine.”

Hundreds of people turned out in protest for his first court appearance earlier this month.

Bob Vylan were set to perform in Chicago, Brooklyn and Philadelphia in the autumn. They are due to perform at Radar Festival in Manchester on Saturday and Boardmasters, a surfing and music festival in Newquay, Cornwall, in August.

Sharing a statement on Instagram after the Glastonbury set, Bobby Vylan said: “Teaching our children to speak up for the change they want and need is the only way that we make this world a better place.

“As we grow older and our fire starts to possibly dim under the suffocation of adult life and all its responsibilities, it is incredibly important that we encourage and inspire future generations to pick up the torch that was passed to us.”

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The war in Gaza started after Hamas militants launched attacks in Israel on 7 October 2023, killing 1,200 people and taking roughly 250 hostages.

More than 860 Israeli soldiers have been killed since the war began, more than 400 of them during the fighting in Gaza.

Israel’s offensive in Gaza has devastated the enclave and killed around 56,500 people, according to the Hamas-run health ministry, which does not differentiate between civilians and combatants, but says more than half of the dead are women and children.