With the increased penetration of the patient portal and remote access among our patients, there has been a dramatic increase in the quantity of messages we receive every day, and many different types of requests come to us through this portal. Before we had a portal within our electronic health record, pretty much the only way for patients to reach us was through the telephone, which, as you know, has been a major sticking point at our academic practice for many years (i.e., no one ever answered the phone).
Now, with a large majority of our patients enrolled in the online portal, we are easier to reach, with a few clicks of a mouse or taps on their phone. What seems to be the difficulty now is figuring out the fine line between what makes up an appropriate question on the portal and what really should be saved for an office visit, or at least turned into some type of encounter for which we can get reimbursed.
Varied in Complexity
During the pre-portal years, we all became accustomed to answering patient phone calls. Patients called in — and still do — with questions about their health: something they forgot to mention at our recent office visit or a question about a lab result, a new symptom that has developed in the interim, or another health issue they want to address.
Sometimes they even ask about entirely new issues — things that we have often handled in a brief call, such as a simple cold, UTI, or ankle sprain. These have always run the gamut from the very simple and easy-to-answer to the incredibly complex, requiring a lot of brain power, provider time, and resource utilization.
So, with this increased access through the patient portal, where do we draw the line? Where do we say that this should become a billable encounter? In the bad old days, I knew many doctors who made patients come in for every refill of chronic medications. Obviously, that was way over the line.
Many people say that the minute someone calls up with a new medical complaint, that’s pretty much fair game for some sort of charges. When someone says they’re sick and they want some medical advice, a new prescription, a new referral, or for us to just use our medical brains to set them on a course towards healthy resolution of some issue, we should be charging for our intellectual property just like a surgeon, radiologist, attorney, or accountant would.
Followups Versus New Issues
It seems pretty clear that simple followup for recent visits, including potentially something they forgot to ask about, should be off-limits for new charges. They want to know what to do next about the labs that were just done at a visit, or to further clarify the instructions about what they’re supposed to do. None of this should be something that leads to another charge to the patient or their insurance company.
But something brand new, something that in the old days would’ve been an office visit, if not a trip to the emergency room, certainly should be something that we can be reimbursed for, since our time is just as valuable as anyone else’s.
In these days of Dr. Google and the sometimes extraordinarily unreliable medical information being spread through the Internet, as well as multiple sites offering pay-per-issue medical care, our patients should not be surprised when they reach out to our practice and are told that getting a new medical issue addressed is going to lead to some sort of charge.
Recently, at the end of a day seeing patients, I looked back at my schedule from the morning and saw that one of the patients had not shown up for their office visit. A little bit later, as I was sorting through the large quantity of portal messages that had accumulated through the day, I saw that there was a message from that patient. They stated that since they had not been able to get to the appointment today, they wanted me to set up an order for some blood tests, refill a couple of their medications, put in a couple of referrals, and order some screening tests and vaccines. Then they listed a number of questions they wanted me to answer. Sounds to me like pretty much what I do during office visit, without that physical exam part.
Another example is the recent deluge of portal messages that say, “I have COVID-19; what should I do now?” These seem so simple, but they never are, and it’s usually not enough to just type out some medical advice in a portal message response. This needs a good history, clarifying their vaccine status, weighing their underlying medical conditions, reviewing their symptom complex and whether they are improving or getting worse. And don’t get me started on the work that goes into prescribing Paxlovid or monoclonal antibodies.
We’re Worth It
None of us really want to get into nickel-and-diming our patients, but in this day and age when providers are stretched thin, when we’re all burned out and overwhelmed by all the things coming at us, when providers are working into the night and on weekends, and sacrificing their quality time at home with family in the name of the electronic health record, it only seems fair that we quantify what we do and tell all the world that it’s worth it, that we are worth it, that it’s worth something to get this formerly free medical care and information delivered to our patients.
Many people, at our institution and others, are working with regulators and insurance companies to make sure we don’t cross a line, to set limits on what is billable, and to make sure we inform patients that submitting these types of questions to us will likely lead to a charge for our time and medical thoughtfulness.
To be honest, this should probably be built into every patient’s insurance. They’re paying so much as it is to get the care they need — maybe we can take that out of the profits that the insurance companies are making and transfer it back to us who are doing the work here on the front lines.
I think in this new world of medical information and connectivity and ease of reaching us, we should make sure that we can provide the care we need to our patients right when they need it, while also making sure that this doesn’t continue to fall on the shoulders of the doctors already overwhelmed with taking care of them the best we can.
Right now, all this time and energy spent answering patient’s questions in the portal is just assumed to be something extra, something we do that just comes with the job, that comes with the territory. But since it requires enormous work and mental energy, things that these days feel like we’re already stretched way too thin on, perhaps assigning a fee isn’t that out of line.
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