Telehealth Has Met the Reality of Medical Billing
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Telehealth Has Met the Reality of Medical Billing

May 28, 2023

Many calls and messages now count as a “visit” that you could be charged for.

The pandemic initiated a slew of transformations, and though many have not stuck, one indisputably has: Telehealth is booming in America. This golden age of electronic engagement has one massive benefit—doctors are more accessible than ever. Unfortunately, this virtue is also proving to be telehealth’s biggest problem. For patients, being able to reach their doctors by video visit, phone call, or email is incredibly convenient, but physicians have been overwhelmed by the constant communication. This cost is now being shifted back to the patients, and almost every interaction with a doctor, no matter how casual, counts as some form of “visit” now.

At the start of the pandemic, telehealth was lauded as the beginning of a revolution in medicine. Patients quickly became adept at using online portals to reach their doctors, frequently writing to them with quick questions or concerns in between visits. But when in-person visits largely resumed, this higher volume of online messaging did not go away. In fact, it did not even seem to decrease. And though a video appointment and office visit might be interchangeable in a doctor’s daily schedule, busy physicians found themselves with little time to respond to those smaller communications.

To stay above water, some doctors and health systems have started charging for many of their responses. These in-between interactions, once considered a standard part of care, are being reframed as separate services, many of which warrant additional charges. Having an informal relationship with your doctor is now just fiction: You get the care that you pay for.

When Jed Jacobsohn got COVID for the first time in May, he began gathering information. How long should he quarantine for? How could his two young children stay healthy? He decided to give his doctor a quick call, and after five minutes, he hung up satisfied, he told me. Next thing he knew, he had a $180 bill. His satisfaction evaporated.

For a patient, five minutes is fleeting; for a doctor, five minutes on the phone generates a chunk of associated work, including reviewing the patient’s chart, updating notes, and putting in orders for medications, tests, or referrals. Most doctors work for health systems that use “relative value units” to calculate how they get compensated. “You can think of them like productivity points,” A Jay Holmgren, an assistant professor at UC San Francisco who researches asynchronous messaging, told me. In order to get paid, doctors must get a certain amount of work done. Since March 2020, billing for both synchronous telehealth (that is, video visits) and asynchronous telehealth (emails and other online messages) has been allowed for the majority of providers, Holmgren told me. One explanation for billing for messages is that health systems were recognizing the time spent responding as work and ensuring that physicians could answer queries without working outside of their hours, reducing their patient load, or taking a pay cut. For those who work in private practice, billing for messaging can function as self-accountability. When Reed Wilson, a doctor in internal medicine and cardiology, used to run a private practice, he rarely had time left by the end of his long workdays to answer or respond to calls or online messages. He worried that they would get pushed aside. “That’s why I had the administrative fee,” Wilson told me. “I was providing a service.” Of course, both health systems and private practices are also businesses, which benefit from new revenue streams

Being billed painfully large amounts of money for seemingly small increments of health care is nothing new. So why does the idea of a $180 bill for a phone call hit so hard? Part of the resistance can be attributed to the distinction between cost and value, Jeremy Greene, a doctor and researcher at Johns Hopkins who also wrote a book on telemedicine, told me. Jacobsohn, for instance, had really only phoned his physician to be responsible and avoid using Twitter or Google as his only source of information. Telehealth can certainly be a good substitute for an in-person visit, but if a quick phone call with a doctor simply affirms what a patient already knows, paying the bill might feel like a waste of money—especially if the patients themselves are coughing up the cash.

Although Jacobsohn paid a particularly high amount because of his insurance plan, even if an insurance company is footing the bill, being charged might still rankle. Calling your doctor or emailing them has long been part of standard care; paying for it is new. The disconnect between patients’ past expectations and new reality comes down to the hidden costs of care. At the same time, though a five-minute phone call is more work for a doctor than many patients realize, it can also feel less fulfilling than another type of visit. For some, feeling truly seen by their doctor requires actually seeing their doctor (whether that’s in person or on a video call).

Patients do value different types of interactions with doctors differently. Burt Rosen, a patient advocate who is dealing with two different types of cancer, puts it this way: “If I were scaling this emotionally, I would say in-person visits should be the most expensive, video should be below it, and then calls should be below that.” If each of these services takes the same amount of time, by a certain logic, they should have the same charge; but for most people it doesn’t quite measure out that way. “If a televisit is not good enough but then costs as much as an in-person visit, then we’re effectively creating a substandard mode of care,” Greene said. This doesn’t mean that telehealth itself is subpar, but rather that paying for an unsatisfying telehealth visit might register more strongly than paying for a disappointing in-person one. Even the purported convenience of telehealth might not be quite the panacea it once seemed: Zoe Steinberg, a medical illustrator who is disabled and deals with many doctor appointments as a result, told me that she generally appreciates telehealth, but finds it frustrating to have to make what counts as an entire doctor appointment for a quick query that any health-care provider—not just a doctor—could answer. “I’ve definitely had days where I was just pulling my hair out because of little issues with telehealth that I’m having,” she said.

Ultimately, these bills for all encounters with a doctor are a more honest representation of how medicine works now than one in which a friendly doctor can field questions as a complimentary service. The field has long been shifting toward corporatization, and away from the more genteel norms once associated with care. This latest trend is edging out one of the remaining areas that had not been made fully transactional. Yes, being a doctor means cultivating meaningful, intimate relationships with patients. But, like so many other jobs, being a doctor is becoming more and more standardized.