By Christopher Kelly, MD 

The Cleveland Clinic recently announced they will begin charging patients a fee for online correspondence with physicians through their online portal. Such fees are perhaps a necessary response to the ever-growing volume of portal messages, through which patients seek advice outside of the traditional structure of a billable visit.

As a busy clinical cardiologist, my hope is that such a move will initiate long overdue conversation about how physicians are paid for their time. The traditional outpatient fee-for-service structure, centered primarily on office visits, is an anachronism better suited to the days when physicians managed one-off, acute illnesses. In the modern era, physicians deal primarily with chronic illnesses and must make frequent changes to the treatment plan.

As a result, my portal inbox is always full of messages in which patients tell me about their evolving symptoms or self-measured vital signs, looking for answers. Many of you likely have had a similar experience. What is the correct response? To spend a few minutes reading the patient's note, perhaps exchanging another one or two messages, and then proposing a solution? Or to make the patient carve an hour out of their day to come to my office so we can have an in-person discussion?

Clearly, the former is more convenient for the patient, and is also more aligned with what we expect from other professional relationships. After all, you do not need to see your lawyer in person to get a question answered. The key difference, however, is that your lawyer will happily send you a bill for the phone call.

Unfortunately, physician reimbursement for telephone or digital communication still lags far behind office visits. This discrepancy devalues physician time and, even worse, creates perverse incentives for patients. Specifically, patients with minor, short-lived symptoms or minor questions may not feel it is worth their own time or expense to come to the office, but they will happily spend 30 seconds dashing off a portal message -- and then expect a prompt response, for free. As a result, we spend our day performing the billable services that generate our income, and then are forced to spend our after-hours responding to a growing pile of patient messages that have accumulated during that time.

As far as I can tell, there are only a few solutions that will properly realign incentives while still allowing patients and physicians to use modern communication tools.

One is the solution of the Cleveland Clinic -- and perhaps other systems that take a similar approach but haven't announced it so formally -- which is to assign reasonable value to the time spent on portal messages. There are limits, however, on how much participating providers can charge, as Medicare actually has a billable code for portal messages. There are some consequences of this approach in that patients will lose access to a low-cost source of healthcare and are likely to respond negatively. For example, the founder of Patient Rights Advocate statedopens in a new tab or window the Cleveland Clinic's policy "... is just the latest attempt to wring even more blood from the stone."

Another option is to set strict limits on which issues can be addressed with portal messages, and to continue requiring office visits for all else. Although this maximizes the value of the physician's time, it also results in unnecessary office visits and is not as efficient. Such a policy heavily burdens patients who live far from their physicians, or who require transportation or special assistance getting to appointments. A permanent equalization of reimbursements for virtual and in-office visits would partially mitigate this burden, though it does not solve the problems with inefficiency.

A final solution, which I am pursuing in my own practice, is to charge patients a flat, recurring fee that covers all efforts conducted on their behalf between billable visits. The most extreme version of this system is concierge medicine, in which patients pay for the right to contact their physician at any time. Since I wasn't interested in being on-call 24/7, I instead created an online platformopens in a new tab or window that facilitates direct but more limited physician access programs, for a more affordable price than traditional concierge plans. Direct primary care is another version of this model that folds most billable services into the single recurring fee, and sometimes offers concierge-like services as well.

The worst option is to continue ignoring the problem and allow a rising proportion of healthcare to be provided through portal messages that assign little value to a physician's time. Such work is a major source of physician burnout, which in turn negatively impacts medical care and will worsen the physician shortage in the years ahead.

Christopher Kelly, MD, opens in a new tab or window is the chairman of cardiology at UNC Rex Healthcare in Raleigh, North Carolina, and the founder of Exact Healthcare.