Billing patients for patient portal messaging services may have negative consequences for both patients and physicians, according to a qualitative analysis.

Looking at survey responses from 13 patients and 16 primary care physicians, certain attitudes and behaviors emerged when considering the implications of billing patients for using these messaging services, such as patients expecting faster, more detailed replies to their messages and physicians expressing concern that patients may decide not to share important medical information to avoid charges, reported Jordan Alpert, PhD, of the Cleveland Clinic, and colleagues.

"Based on our findings, health systems may want to review the advantages and disadvantages of similar policies before deciding on an appropriate implementation strategy," they wrote in the Annals of Internal Medicine.

Alpert told MedPage Today that "the findings highlight just how much primary care physicians care about their patients because they realized how important the patient-physician relationship can be. Physicians wanted to maintain an open, healthy relationship and feared that patients would view interactions with them as 'transactional' if billed for asking a question."

"Although patients were generally accepting of the billing policy, there is potential for patient behavior to change in response," he added. "These expectations can have implications for the health system and for physicians."

The analysis showed that while patients appeared to initially view billing negatively, they also said they understood that the service could be abused by some patients. During an interview, one patient said, "I am feeling torn about the fee. Everyone's time is worth something. I feel it should be based more on the purpose of the message."

Patients also said that they would call the office more frequently rather than use messaging in order to avoid being billed.

Meanwhile, physicians expressed hope that billing for those messages would lead to a reduction in the number of messages received in a day, noting that they believed that patients and the health system took the work of answering messages for granted. One physician said, "If the [health system] sees how much time we put into messages ... [maybe] they'll give us time in our day to respond."

However, they also said they were concerned billing could hinder more open communication between patients and providers. One physician told the authors, "Part of the reason I'm in primary care is that I know my patients and I want them to feel [like they can reach me]."

Physicians also noted that they have received messages from patients asking not to be charged. They said they were "cognizant of patients with difficult socioeconomic circumstances and would choose not to bill them." Physicians also said they based billing decisions mainly on the medical decision making involved instead of the time it took.

Alpert pointed out that both physicians and patients reported confusion over how the billing policy would work in practice. For example, patients were not sure how much time their messages would require from a physician, while physicians expressed some confusion about how to bill patients for these messages, especially when multiple actions might be required for a set of messages.

Matthew Notowidigdo, PhD, of the University of Chicago Booth School of Business, told MedPage Today that billing patients for these messages would likely suppress patient use based on the law of demand.

"People use more of something when it's free, and they use less of it when they have to pay for it," he said, adding that small copays for prescription drugs could be a useful example to consider. "There's a lot of evidence that small amounts of copays have enormous impacts on utilization."

Notowidigdo explained that implementing fees on patient messaging could reduce the workload for physicians, but it might also result in people not receiving needed care immediately, which could increase healthcare costs down the line. He said that the question that health systems should ask is whether reducing patient messaging would be good for quality of care and total costs for the system.

"My knee-jerk view -- until there's a lot of evidence to convince me otherwise -- is that small fees to discourage patients from using valuable services like telehealth or messaging is probably also going to do more harm than good," Notowidigdo noted.

To conduct the analysis, the authors invited 52 patients and 49 primary care physicians from Cleveland Clinic to participate in the survey. In total, 13 patients and 16 physicians agreed to do so. The patients had a mean age of 58 years, and most of them were white (69%) and women (62%). The physicians averaged 13 years of experience, and 63% were white.

To be eligible, patients had to have a primary care visit between June 2021 and April 2023 and to have sent a secure message to their provider. Video interviews were conducted virtually.

Alpert and team pointed to several limitations to their analysis. First, selection bias may have occurred since the participants volunteered to provide their opinions about the billing policy. Second, the survey and interviews were conducted using video software, which may indicate that the participants were already more comfortable and experienced than the average person in using technology to communicate.