Patient Portal Use is Growing, But Physician Billing in Medicare Hasn’t Caught Up (free sign up required)

Medicare beneficiaries are communicating more with their physicians through patient portal messaging, but just a small portion (about 0.05%) of these results in a bill to Medicare to evaluate or manage health conditions. Of the messages that results in a bill, most involved physicians helping patients with high blood pressure or diabetes, finds a new study published in Health Affairs Scholar.

Early in the COVID-19 pandemic, CMS announced Medicare would pay providers for virtual services, including digital messages through a patient portal, that required at least five minutes of medical decision-making. But after a surge early on, the rate of billed e-visits in traditional Medicare dropped and has stayed relatively constant through the end of 2022, according to researchers from the University of Michigan who conducted this analysis.

Terrence Liu, M.D.

“Patient portal messages are being used as a routine form of telehealth, but there is very little research to date on it. We hope these data will help inform efforts to support providers as they handle these types of visits, lead study author Terrence Liu, M.D., clinical instructor and research fellow at the University of Michigan and Institute of Healthcare Policy and Innovation, said in a news release.

In this study, researchers identified e-visits for Medicare fee-for-service from Jan. 1, 2020, to Dec. 31, 2022. They used the CPT codes 99421 to 99423, the codes assigned by CMS for online digital evaluation and management service based on length of time. Researchers measured monthly digital messaging, called e-visits by CMS, per 100,000 beneficiaries and then compared visits for primary care, specialty, surgical, behavioral health, nurse practitioners and physician assistants.

They found that e-visits reached a peak of 728 monthly encounters per 100,000 at the beginning of the COVID-19 pandemic. For the full year 2020, researchers found that e-visits accounted for 0.09% of all evaluation and management visits. In 2021 and 2022, e-visits accounted for just 0.05% of evaluation and management visits.

Researchers also found that about 30% of the messaging e-visits that led to a bill to Medicare involved the doctor or other provider spending 21 minutes or more on making decisions about the patient’s care. Lui suggested that physicians may have been hesitant to bill for patients using the portals’ messaging. Insurance coverage varies, and Lui said there may be concerns that patients would end up paying the cost.

Previous research done by Chad Ellimoottil, M.D., M.S., a senior author and medical director of virtual care at Michigan Medicine, has found that Medicare coverage for video and phone telehealth visits hasn’t led to an increase in the total number of visits.

In the current study, researchers noted that primary care doctors who did bill for e-visits did so for specialty services. They also noted they weren’t able to measure e-visits that were not billed so they were not able to assess volume or uncompensated workload or whether patients were billed for services.

“We need to understand more about how this type of care can be most effectively used by both patients and providers, and what it means for clinic operations, provider burnout and patient behavior and outcomes,” Liu said.

Access and use of patients is growing. A survey done last year, done by The University of Michigan National Poll on Healthy Aging, asked people age 50 to 80 about their use of and experiences with patient portals. About 78% reported having a patient portal, and 49% of those with a patient portal used more than one. Of those with portal access, 55% had used it in the past month.

The survey last year, however, found that non-Hispanic White older adults and those with higher incomes more likely to have a portal. In addition, those with lower incomes and those with worse self-reported health, expressed less comfort using portals than others in this age group.