Mayo Clinic Billed 0.3% of Patients' Medical Advice Messages. 8.8% Fewer Message Threads Arrived.

Analysis by DPC Insider — Research Desk
#patient portal#e-visits#physician burnout#Mayo Clinic#UCSF#research#direct primary care
Sources: Bill patients for emailing? This could backfire. · Implementation of Billing for Patient Portal Messages as E-visits in a Large Integrated Health System · Association Between Billing Patient Portal Messages as e-Visits and Patient Messaging Volume · Changes in Secure Messaging After Implementation of Billing E-Visits by Demographic Group · 'Our inbox is a clinic': Consider billing for portal messages · As More Patients Email Doctors, Health Systems Start Charging Fees · How Patients and Providers Respond to Electronic Messaging Fees · Direct primary care offers personal access to physicians · Direct Primary Care (AAFP)

For every patient message Mayo Clinic billed in its first six months of charging, about 31 fewer message threads arrived than a year before.

That ratio is calculated from figures in a study in Annals of Internal Medicine, and it’s the sharpest number in a fight that reached The Washington Post’s opinion page on October 1. Ishani Ganguli, an associate professor of medicine at Harvard Medical School, opened her column with her own inbox. “The messages ping into my inbox at all hours,” she wrote, and one of her patients wonders, “Should I increase my antidepressant dose?”

Her headline: “Bill patients for emailing? This could backfire.” Her subhead says it outright: “Charging for messages undermines the benefits of primary care.”

The research behind that argument has been piling up for three years. It mostly agrees with her, with one finding that cuts the other way.

What Mayo measured

Mayo Clinic began billing eligible portal messages as e-visits on August 18, 2023.

In the six months that followed, patient-initiated medical advice threads fell 8.8%, from 1,813,818 to 1,653,708, compared with the same dates a year earlier. Mayo billed 5,183 messages. That’s 0.3%. Healio’s coverage of the study confirms the health system was Mayo.

Do the subtraction and you get 160,110 fewer threads. Divide by 5,183 and you land near 31 to one.

So the charge itself almost never reached a patient. Patients did see a billing disclaimer on the portal before sending, and some chose not to send. The study’s abstract gives no count of how many stopped there.

Here is the finding that cuts the other way. The researchers checked whether those patients came to harm and found no difference in 7-day emergency department visits or hospitalizations between patients who sent a message after seeing the disclaimer and patients who didn’t send one. They also named their own blind spot. The study couldn’t see whether patients picked up the phone instead.

Seven days is a short window, though. A question about a medication dose rarely becomes an ER visit in a week.

Who stopped writing at UCSF

UCSF Health started billing in November 2021. Two studies in JAMA journals tracked what happened to patient messaging.

The first paper, in JAMA in January 2023, found clinicians billed a mean of 235.7 e-visits a week after launch, about 1.4% of message threads. The cost to patients ranged from $0 to $75 out of pocket on average depending on insurance, Tradeoffs reported.

The second, in JAMA Network Open in August 2024, split 5,558,460 messages by patient group. Total weekly messages dipped 2.0%, a change the study did not find statistically significant. Underneath that flat total, the groups moved in opposite directions:

  • Patients in the “other” payer group, which includes self-pay: down 14.4%
  • Patients ages 18 to 49: down 10.3%
  • Latinx patients: down 5.3%
  • Asian patients: down 5.1%
  • Patients ages 66 to 80: up 6.2%
  • Patients 80 and older: up 7.6%

Medicare and Medi-Cal patients showed no significant change.

The steepest drop came from the “other” payer group, which the paper illustrates with self-pay patients. Patients ages 18 to 49 came next. When Lia Gracey Maniar of Ascension Texas walked a dermatology audience through the UCSF results this spring, Healio’s report of the talk noted that scheduled visits and unscheduled phone calls didn’t rise to make up the difference. That may mean some patients simply went untreated.

The physicians who want the bill

Billing has real defenders, and their complaint is legitimate.

“It’s been a frustration for many physicians for many years that we weren’t reimbursed for our ‘pajama-time’ work,” Sterling Ransone, then chair of the American Academy of Family Physicians’ board, told KFF Health News in 2023. “But rarely do you see other professions do all this online work for free.”

Gracey Maniar’s talk was titled around the same idea. “Many of us probably feel like our inbox is a clinic in and of itself,” she said. By her count, “upwards of 25 major institutions” now bill for portal messages.

Cleveland Clinic’s rate is low as well. It billed only 1.8% of eligible email visits, using three rates tied to how long the clinician spent, KFF Health News reported.

Ganguli’s own opening makes the defenders’ point for them. The messages come at all hours. The argument is about who pays for that time, and what happens to the question when the patient is the one asked to pay.

Where DPC fits

Direct primary care answers that question another way. The AAFP describes a monthly, quarterly or annual fee that covers all or most primary care services, and DPC practices don’t bill insurance. At KarisMed Family Medicine in Katy, Texas, members get direct access to their physician through personal emails and phone numbers, its CEO told Community Impact. A practice with no insurer to bill has no e-visit claim to file for a reply.

That design has a price, and the price is panel size. The AAFP puts the average DPC panel at about 413 patients, with monthly fees that generally run $50 to $100. A physician with a few hundred members can answer the late-night question without a billing tier. A system fielding 1.6 million threads in six months has a different math problem.

Mayo’s numbers show what per-message billing can buy. It billed 0.3% of messages, and 8.8% fewer threads arrived. UCSF’s total barely moved, but the biggest drops there came from the “other” payer group and from adults under 50.

If you’re weighing DPC, you might read this as the model’s bargain stated in plain numbers. A fixed fee buys the patient permission to ask the small question. The small panel is what lets the physician keep saying yes.