When Johns Hopkins medical offices began charging patients to send some direct messages to their doctors recently, officials said the number who would get a fee would be low.

So how many people got a bill?

“Less than 1% of the nearly 100,000 monthly MyChart medical advice messages were ultimately associated with a charge,” said a statement from Hopkins about the first month under the policy that began July 18.

The small percentage, however, could grow over time as more hospital systems across the country turn to charges to address an avalanche of messages to patient portals, such as MyChart, since the coronavirus pandemic shifted more communications and appointments online.

The Baltimore Banner thanks its sponsors. Become one.

Public and private insurance is largely covering the bills, but patients likely pay a portion. Hopkins estimated costs of $10 to $50 for those with private insurance depending on how much time is billed and the patient’s insurance. Medicare beneficiaries can expect to pay $3 to $10. Hopkins isn’t charging those with Medicaid, or those using other programs for low-income residents.

The move by Hopkins to charge was met with ire from patients’ rights advocates, who said people could put off seeking care.

Anna Palmisano, director of the advocacy group Marylanders for Patient Rights, said some patients were “worried and angry” about the prospect of being charged and others may not realize yet they have been charged or will be charged.

“While 1% sounds slow, 1,000 messages, or patients, a month is a lot of people who need help, but might not be getting it,” she said. “That’s 12,000 a year.”

Instead, she said, the health system could address individuals who overuse the messaging system.

The Baltimore Banner thanks its sponsors. Become one.

At least 14 other major health systems nationally were charging as of January, according to the industry publication Becker’s Hospital Review, but no other major health system in Maryland appears to be following Hopkins’ lead so far.

The health systems and doctor groups say messages are consuming an increasing amount of time by providers, who are struggling to cope in some cases.

The American Medical Association released a survey in February that found 60% of physicians across the nation were experiencing some level of burnout, and their inboxes were one of the causes. The groups said doctors receive 57% more patient portal messages than prior to the pandemic.

“The number of low-value notifications that are clogging up the inbox for physicians has just become unmanageable,” said Dr. Christine Sinsky, vice president of professional satisfaction for the AMA, in a write-up on the group’s site when the survey was released. “Physicians say: I cannot give up several hours of my personal time every night to clearing out my inbox.”

The Baltimore Banner thanks its sponsors. Become one.

The group suggested doctors write personal messages to patients about how much time they spend on the messages and ask them to consider calling support staff instead, or making an appointment.

In a note to patients, Hopkins officials said they were balancing the need for the convenient and necessary messaging service and being paid when the work becomes substantial.

Billed messages, Hopkins said, would be non-urgent, take more than five minutes to respond and require clinical judgment. They would be those that ask about a new issue or symptom requiring medical assessment or referral, and those for adjusting medication or managing chronic diseases.

Not billed would be responses that require no or quick responses, prescription refill requests, appointment scheduling and follow-up care linked to recent surgery or messages about issues addressed in visits in the past week or the next week.

Patients have to agree to payment terms when they select “ask a medical question.”

The Baltimore Banner thanks its sponsors. Become one.

A Jay Holmgren, an assistant professor in the department of medicine at the University of California, San Francisco, looked at portal message volume at the university affiliated medical center and published a research letter in January in the Journal of the American Medical Association.

He found doctors didn’t bill much, about 3% of the messages. That’s likely because the billing required its own work, he said, and they felt patients were certain to dislike it. But messaging at the institution did drop slightly, by about 2%, possibly because people became aware they may be charged, he said.

In an interview, Holmgren said he didn’t believe the level of charging had risen much since January, and follow-up research showed the practice has not disadvantaged vulnerable patients. He said the extensive outreach conducted by officials prior to the change meant the reception from patients wasn’t overly negative.

Still, he said, the charges are “clunky and annoying” to a lot of patients.

The response by other systems has been to remove the option to message doctors directly. He said a message to Harvard University’s health system now goes to a shared nurse inbox.

The Baltimore Banner thanks its sponsors. Become one.

Holmgren said the answer likely needs to be a bigger shift in the fee-for-service style health care system, which was largely built in the 1950s, because it’s ill-suited for technology that allows for such continuous contact. That may mean exploring a way to take messaging into account on a monthly or annual basis.

He said, “My fear is that while patients find messaging valuable, and doctors don’t mind providing care in this way, without some form of payment model this will become a bigger trend — we simply lose the ability to message physicians at all.”


Meredith Cohn is a health and medicine reporter for The Baltimore Banner, covering the latest research, public health developments and other news. She has been covering the beat in Baltimore for more than two decades.

More From The Banner