In its report, Crossing the Quality Chasm: A New Health System for the 21st Century, published in 2001 by the U.S. Institute of Medicine, the IOM introduced six dimensions for improving care crucial to foster quality when providing health services. They include:
- Care that is respectful to patients’ values, preferences, and expressed needs;
- Care that is coordinated and integrated; Care that provides information, communication, and education;
- Care that ensures physical comfort, provides emotional support, and involves family and friends.
- Care that includes patient-reported measures that are essential to the accurate assessment of patient-centered care.
- Care that empowers patients to become active participants in their own care by requiring providers to develop good communication skills and address patient’s needs effectively.
- Care that is patient and family-centered and encourages the active collaboration and shared decision-making between patients, families, and providers to design and manage a customized and comprehensive care plan.
Twenty-three years later, at the beginning of 2024, many health system providers have begun to charge their patients a co-pay for messaging via their patient portal, email, or text. In an article in the Wall Street Journal, columnist Sumath Reddy wrote: “Emailing Your Doctor Could Now Cost You,” “Most health care groups,” she said, “are now charging fees to answer patients’ electronic messages.” (Wall Street Journal, March 11, 2024 A11) Although many of these fees are fully or partially covered by health insurance, the co-pays for messaging could mount up, particularly for patients with complex medical conditions who have a care team that could include a primary care doctor and several specialists. These patients often find it necessary to communicate with their doctors between visits, to clarify the side effects of their multiple medications, to ask what to do about a wound or rash, to determine how to adjust their medications, or a thousand other important medical questions that come up, but do not require an in-person visit with the doctor.
The decision to institute the charges was influenced by the pandemic when patients and providers were forced to resort to telehealth visits and other virtual communication because it was unsafe to have a face-to-face visit. A study reported in the Journal of the American Medical Informatics Association, reported that messages via patient portals increased by 157 percent between 2020 and 2021, and they appear to continue to be increasing. Many doctors say that they spend more than two hours every day responding to patient messages and sending emails back and forth, often several times, with the same patient without being reimbursed for their time. Some messages concern routine matters that patients could handle on their own, such as how to renew a prescription or schedule a visit. Unfortunately, universal guidelines on messaging do not work because patients come from different backgrounds, and physician practices all have their own unique culture. So where does the buck stop?
The problem with imposing co-pays is that they represent yet another layer of out-of-pocket charges to patients already overburdened with healthcare costs. It is the polar opposite of what the Institute of Medicine proposed when they put forth the concept of Patient Centered Care. Quality patient care will not survive in an atmosphere where patients pay a fee every time they need to talk with their physician. The choice is clear; practice the six principles of patient-centered care to ensure quality and patient safety, or charge a fee for every message and stifle patient communication.