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The shift towards charging for patient-provider messaging could pave the way for increased uptake amongst major hospitals

The Cleveland Clinic released a notice last month that, as of Nov. 17, it would start billing up to $50 for particular messages sent by patients to their provider via its MyChart patient portal.

In an announcement, Cleveland Clinic said that it will begin charging for messages that require medical expertise and take a long time for the provider to answer, including medication changes. Quicker notes, appointment scheduling, or clarification after a recent visit, will remain free.

The announcement was met with mixed reactions from patients and the local press. Some residents expressed concern to that the policy will put additional strain on clinicians and lead to higher costs for patients.

Reports suggest other health systems may soon follow in implementing similar policies. University Hospitals and ProMedica say they are considering charges for electronic messaging, while Ohio State University Wexner Medical Center said it already charges between $50 and $160 for certain messages.

“We don’t believe charging for electronic messaging should stop patients from seeking care,” ProMedica argues that these rates would remain lower than regular office visits with a provider – considerably improving it is still an efficient way to receive healthcare without taking too much out of your pocket.

“The latest attempt by hospitals to put profits over patients.”

Cynthia Fisher, founder, and chairman of, described recent hospital policies as “the latest attempt by hospitals to put profits over patients.”

In an article by Fierce Healthcare, she criticized recent policies by hospitals that charge patients separately for electronic messages sent through patient portals. She argues that these messages make up a minority of patients’ questions and those that can generally be handled quickly by physicians without additional charge.

For concerns that are complicated enough to warrant more of their time, providers should “transparently” suggest a separate virtual or in-person visit for which a physician will be compensated.

Fisher highlighted how providing customer service courtesy and electronic messages should be treated the same that is included within the limits of originally agreed upon bills instead of treated as separate costs to patients.

“Many patients will resent having to pay for something that was once free.”

In an op-ed published in The New England Journal of Medicine, Julia Adler-Milstein, Ph.D., and Ateev Mehrotra, M.D., wrote that the abrupt shift to digital touch points during the pandemic is likely to result in a virtual care payment standoff.

They explained that many patients will resent having to pay for something that was once free, and healthcare systems will have to explain which services are free and which will result in a bill.

Adler-Milstein and Mehrotra highlight the necessity of a robust payment system to effectively balance patients’ needs with provider capabilities. Without any changes, both parties would suffer in this multifaceted financial labyrinth; transitioning to capitated payments appears as an optimal solution for all involved.

John Hargraves, director of data strategy for the Health Care Cost Institute, noted to Fierce Healthcare that it is more surprising to witness healthcare organizations being transparent about their billing practices than pushback.

He stated how hospital systems now publicly declare changes in billing behavior instead of quietly making alterations behind the scenes as was traditionally done. Furthermore, he noted that charging patients for text messages has long been an established practice but added a level of transparency appears to have recently increased among providers.

Hargraves believes that this transparency is a result of increased pressure on hospitals have faced over price transparency and federal requirements (with which many hospitals still have yet to comply).


“Billing for electronic messaging comes with equity considerations.”

Billing for electronic messaging comes with equity considerations, according to researchers in the NEJM op-ed. Low-income patients may not be able to afford fees or have the technology required to take advantage of these options.

Hargraves noted that it’s likely electronic message billing policies won’t be going away anytime soon. Billing for electronic messaging could help equal the payment and time commitments of clinicians who “might spend more time responding to patient inquiries through emails,” such as women or primary care physicians.

Many clinicians are facing stress and burnout due to heavy workloads. Valuing their time is critical in order for clinicians to best manage care – billing message responses can help support that effort while creating a new alternative approach toward traditional patient encounters. However, answering emails takes up a lot of time, and if that time isn’t reimbursed, it doesn’t incentivize providers to answer patients.

The decisions by Cleveland Clinic and other early adopters give systems a precedent to roll out their own message billing policies, which could reach an accord with each other and with patients on what types of communications should and shouldn’t be charged.

Hargraves said that it is hard to stop the tide once it starts and that other systems that previously didn’t think it was feasible might reassess their own policies. He believes that having industry-wide guidelines would help in the early stages of this changes.