By Stacey Kusterbeck
Many patients are in the habit of communicating with doctors through patient portals, sending messages about everything from medication side effects to concerning symptoms. Unlike other patient/physician interactions, though, there is no clear standard for whether doctors are reimbursed for the time they spend responding to all of those electronic messages.
As the research ethics consultant at Winship Cancer Institute of Emory University, Rebecca D. Pentz, PhD, was fielding concerns from many physicians about this issue.
Physicians were expected to respond to patient portal messages, but it was not considered in their workflow. Therefore, there was no protected time for this activity. Physicians had no choice but to respond after work hours — and the number of messages was only increasing.
“Physicians were concerned that they were not being respectful and responsive to their patients,” says Pentz. On the other hand, physicians were not receiving reimbursement for all the extra work.
Pentz and colleagues saw a need for guidance on this issue and authored a review paper analyzing ethical considerations when patient are billed for electronic communication with their doctors.1 “There are both pros and cons to billing patients,” says Pentz.
In terms of the ethical principle of justice, billing is fair to physicians who are spending a significant amount of time responding to patient messages.
“Billing may help with burnout, since the time needed to respond to electronic messages is being recognized by administration. Hopefully, dedicated time will be created for this, so it’s not a task that has to be done after work hours,” says Pentz.
Billing allows physicians to block out an appropriate amount of time to answer pressing questions thoroughly. It also demonstrates respect for patients, since it allows patients to get answers to their questions electronically, rather than scheduling a telehealth or in-person meeting.
On the other hand, billing raises some ethical concerns about patient autonomy, trust, and healthcare disparities. Billing could disincentivize patients from asking questions that they need answered to help their health. There is also a worry that underserved patients will not ask questions because they cannot afford to pay anything extra.
“If badly implemented, billing could erode trust,” acknowledges Pentz.
The authors proposed these practices for physicians to protect their own well-being while also respecting patients’ needs:
• communicating costs upfront, and being transparent about billing policies;
• basing billing policies on how complex and urgent the question is, and the level of expertise that is required to respond to the question;
• billing small amounts, with a sliding scale based on income;
• waiving fees on the basis of the patient’s socioeconomic status.
“We do worry that adding more cost could undermine trust in the physician. It could make the patients feel that their interactions with physicians are transactional,” says Pentz.
According to the authors, the best way for physicians to address this concern is by being very transparent with patients about the billing, and why it is necessary. Physicians also can be clear that patients can ask for special consideration if they cannot afford to pay.
Another ethical concern is that the physician will feel more connected with patients they interact with frequently electronically, compared to patients who do not send any messages. “We need to remind physicians — and maybe we should include this in implicit bias training — that all patients must be treated equally and respectfully regardless of how communicative they are,” says Pentz.
Ethicists can help to address these issues by proactively developing policies that take into account the ethical considerations of billing. The authors suggested a middle ground approach, with small amounts billed, based on patients’ ability to pay. The authors also recommended that messages be tiered, with complicated questions going to the physician but logistical questions and straightforward messages being answered by the physician assistant or nurse.
Some institutions will not want to bill for electronic messages, since it currently is not the norm. Even so, the underlying problem of physicians’ well-being still needs to be addressed. “Ethicists can assist clinicians in interacting with administrators to make sure there is protected time to answer these messages,” adds Pentz. The ethicist and clinicians should come to the meeting armed with data. Hospital leadership will want to know the answers to questions such as: How much time are physicians spending answering messages? How many messages are received on a daily or weekly basis? Are physicians answering the messages after hours? If so, is it contributing to burnout? “Data is often the best way to convince administrators that a change is needed,” says Pentz.
- Rhee CH, Brown JT, Lang A, et al. Billing for electronic patient-physician communications: An ethical analysis. JCO Oncol Pract 2024;20:1040-1045.
