This week I came across an article by STAT News Health Tech by Mohana Ravindranth titled, “For Doctors Drowning in Emails, One Health System’s New Strategy: Pay for Replies.”
One typical pay model in healthcare is known as fee-for-service (FFS). Ravindranth makes the argument for why email should be included as a billable service. I’m inclined to agree.
Two factors are contributing to the greater demand for patient care delivered through email communication. First, the collection, management, and user comfort level of digital health records through secure portals continue to improve and expand. Second, the COVID-19 pandemic shifted the delivery of care to more virtual and digital options.
The STAT article cites an ongoing experiment at UCSF where MDs, NPs, PAs, and several other types of clinicians can bill payers for patient emails that require “medical evaluation or more than a few minutes to respond.” “It’s partly designed to assuage the burnout caused by all the unpaid tasks on a clinician’s plate. But it’s also intended to give clinicians an incentive to spend chunks of their workday on email, modality patients are increasingly comfortable with,” notes UCSF physician Maria Byron.
“If it’s not valued and recognized via any payment, it’s very difficult for the health care organization to move [email] into a sort of daytime activity,” Byron says.
This seems fair and valid to me.
UCSF has seen an average reimbursement of $65 per email consultation, though patients typically pay much less, if at all. UCSF hopes to provide a roadmap for other health systems who are keen to compensate clinicians for time spent on virtual communication. However, UCSF’s study has led to more questions about the downstream effects of new billing categories, which could add administrative time, frustrate patients who have additional co-pays, and move further from payments rewarding quality, and not volume, of health services.
Personally, I believe we should compensate clinicians for their time delivering care. I don’t expect any professional caregiving to be “free” whether that care is delivered in-person, virtually, or via email. Think about the billable hours attorneys, consultants, and other highly- trained professionals receive for work done through a computer. Why is health care any different?
It’s important to note the quality of care delivered by email communication from provider to patient must be measured and costs must to be regulated, if not standardized, like any health service. Medicaid and Medicare should set prices, under the resource-based, relative-value scale (RBRVS), or include it as a service under capitation arrangements. AI can be used to help manage effectiveness of care delivered through virtual communication. In the future we will likely have virtual-only physicians for some health services, the technology for some types of virtual health care already exists and it is continuing to improve and expand rapidly.
Atul Gawande, a surgeon and public health researcher, authored an article in The New Yorker “The Heroism of Incremental Care.” He would likely agree with the concept of compensating clinicians for care through email. He writes, “We devote vast resources to intensive, one-off procedures, while starving the kind of steady, intimate care that often helps people more.”
I think virtual communication directly between clinician and patient qualifies as “steady, intimate care.” “The heroism of the incremental,” as Gawande writes, means PCPs are the protagonists of long-term, methodical, routine, persistent, continued care. I believe some of this consistent, vigilant care can be delivered through two-way communication between patient and clinician via email.
According to a 2015 Kaiser Permanente study, patient-physician emails improve care quality. “One-third of chronic condition patients who exchanged emails with their care providers said the communication improved their care,” according to the Kaiser study published in The American Journal of Managed Care.
Forrester Research coined the phrase the Age of the Customer and it’s helpful to me to think about successful care delivery in this way. Consumers have begun to expect 24/7 personalized attention from all brands and organizations they interact with, no matter what the product or service. Providing convenient, primary care through multiple platforms, including digital, is the future of health care in the Age of the Customer. If “chronic illness has become commonplace,” according to Gawande, we need to find ways to deliver routine care in an efficient, lower-cost way. Patient--clinician email exchange is one of these ways. Payers should recognize this.
As people continue to access more care online in the “Age of the Customer,” clinicians should be compensated for all quality care provided, whether it’s delivered in an office, via telehealth, or through email. If payers compensate providers for improving patients’ health through personalized email exchange, it could very well lead to better care and health outcomes, not to mention alleviate some of the burnout of unpaid tasks expected of physicians today.