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Getting a doctor to respond through our digital messaging platform is practically impossible. Unless you're extremely persistent and specifically ask for the do

Getting a doctor to respond through our digital messaging platform is practically impossible. Unless you're extremely persistent and specifically ask for the doctor's input (and send 3-4 messages back and forth with the nurse, whose responses are less relevant than a google search), it's impossible. I wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. But if I pay $30 for an appointment, a quick message should be under $15. There would also have to be some sort of SLA, or the ability for a patient to specify that a question/email has expired and no longer requires an answer. I've had situations where I waited for a doctor's callback so long that I ended up calling a friend who was a physician assistant, watching a youtube video about how to fix the problem, and taking care of it myself. The only way that process could be any worse is if I got a reply after I had fixed it — and a bill for the message.

devin 3y ago
I've never had a problem across several doctors on getting a direct reply to my message. For me, there is an SLA. They explicitly state I'll receive a reply within 24 hours. That has been true across multiple health systems I've used. Edit: In no way am I saying "American healthcare is just fine!" only that I actually have had a really good experience using messaging to communicate with my care teams.
- NegativeK 3y ago
  Are you, by chance, using concierge doctors?
  - devin 3y ago
    Negative.
    - NegativeK 3y ago
      Wild. I've never seen anything remotely close to an SLA with the healthcare professionals I've seen.
      - thereticent 3y ago
        I don't know what is happening elsewhere I suppose. I'm a PhD clinician at a US public academic medical center and respond to patients within 24 hours even if it's to say "let me check on that...it may take a week to get the answer/letter/etc." I'm pretty sure that's the expectation for all our MD/DOs and other clinicians. We don't bill for it, and it doesn't contribute to our targets, but it just seems like it falls under a salaried expectation to me. It's for the patient. That said--hospital management, driven by the insurance world, tries to wring as much uncompensated labor out of the medical workforce as possible. Doctors (including my MD colleagues) do not get together to limit the number of doctors available. That's baseless conspiratorial thinking that doesn't withstand a moment's scrutiny when you understand the incentives at work in American healthcare.
        DANmode 3y ago
        > Doctors (including my MD colleagues) do not get together to limit the number of doctors available. There are limited slots each year at the accredited schools you must attend in order to acquire your role. Nobody's accusing you of doing it - but the number of doctors is limited
        thereticent 3y ago
        Not everyone is accusing the doctors involved, but when I wrote the comment, there were numerous armchair expert opinions squarely blaming the doctors, including at least one who said that doctors limit the number of training slots available to keep their prices high. Thankfully, those perspectives have been addressed or at least outpaced by better thought out criticisms since then. Ultimately, the number of training slots in the current system is limited by MHA and MBA administrators who see training and instruction as subservient to profits, not the doctors who make up the departments and training faculty. Or, more broadly, they are limited by the healthcare operations not being legislated in a saner way. I was just clarifying.
smallmancontrov 3y ago
> I wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?
- FireBeyond 3y ago
  Hah, in MyChart, my provider has started having an MA answer your emails, and then "I'll forward this to the provider". Waiting to see if I get billed for the MA's "effort".
  - ejb999 3y ago
    why are you putting effort in quotes? Do you not think there is any 'effort' involved? Why do you think someone else's 'effort' should be free?
    - FireBeyond 3y ago
      This is an absolutist take. No-one's saying it takes zero literal effort. Just "Should I be billed by the practice $25-30 for an MA to get my email and say "I have forwarded your question to the provider"?", and then a subsequent $100+ for the provider's response to my question. Why should that not be part of the intrinsic baseline officework and not a billable service? Especially when it's a 100% artificial roadblock inserted by the practice? After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
      - wighty 3y ago
        > After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider". That is semantics, could be changed to "Message the office" but that isn't going to be the most clear title for the majority of people to understand what it is doing. It's the same as calling the office, 99.9% of offices (basically all outside of concierge/direct care) are going to be triaged by an MA/nurse first. As far as the payment requirements I've heard of, I have never seen anyone bill just for the MA reply.
pants2 3y ago
While waiting 6 weeks for an appointment with a specialist and suffering in pain, my mom diagnosed herself, created a treatment plan, ordered prescription pills from some Chinese site, and started treating her condition herself. She cancelled her appointment because she was feeling much better.
- wannacboatmovie 3y ago
  This is terrible advice.
  - burnished 3y ago
    It isn't advice
NoMoreNicksLeft 3y ago
> I wonder if charging for these messages will make doctors more likely to respond. Why would it do that? If they get money for messages sent (rather than messages sent by doctors) then some flunky can send a message and you can still be billed. Given how this sounds like a profit center, and doctors are cost centers (imagine if they needed to send more messages... now they have to pay more doctors!), I figure physicians will be kept far away from any such system. If we plot out perverse incentives as a space, I believe that our fate will be to trek through every possible point in that landscape such that we eventually see every single one. This means you will eventually get universal healthcare, most likely as the very last of those perverse incentives.
- gnicholas 3y ago
  Interesting point. That could make for some awkward conversations if the patient thinks messages were coming from their doctor but then the director had no memory of the messages. It would also seem fraudulent to have messages signed by the doctor when it wasn’t actually sent by that doctor. I think it’s much more likely that doctors will end up sending AI-autocompleted messages that take very little time to complete but seem like took much longer.
  - NoMoreNicksLeft 3y ago
    I have not used a medical messaging system, but if it's anything like the messages my bank or my insurance company sends on their own systems then these will look much more like text messages and less like emails. No place to "sign". No need to risk it looking like fraud. As for awkward conversations, I'd be shocked if many people don't experience circumstances where their doctors act as if they don't remember previous in-person conversations. They're seeing 25 patients a day for 3 minutes at a time after all. The standard will evolve to something like clinic staff sending the messages which will be overseen/supervised by a medical doctor (who won't be involved in composing the messages or spend any time looking at them before or after they are sent). We'll see trials where the doctor who was supposed to be keeping an eye on the messages wasn't, and some flunky kills a patient by suggesting that drinking used engine oil will cure the sniffles. Keep in mind that the messages can be sent from anywhere too, technically no need to keep that onshore. May eventually get legislation that would guarantee that, but only after a wild west period that lasts a few years.
qudat 3y ago
> I wonder if charging for these messages will make doctors more likely to respond. Physicians won't see a dime of that money unless it's through RVUs and even then it's marginal at best. The real money is in procedures.
- wighty 3y ago
  There are some codes that can be used for asynchronous portal messages, but to be honest the AMA is still pretty broken as far as how much time we need to spend for things... the codes are 99421 (5-10 minutes over 7 days), 99422 (11-20 minutes), 99423 (21+). It is not clear to me how well these codes are actually paid for by private insurance. In a wRVU system a PCP may get paid like $5-13 for the first code, $15-30 for the 2nd, $24-44 for the 3rd. This is a lot less than a visit... and you must spend the minimum 5 minutes on the portal message or you are billing it fraudulently. I can cover an in person level 4 visit (99214) in 5 minutes in some cases, which pays something like $100.
  - AbstractH24 3y ago
    If there are codes like this why don’t all doctors use them already?

devin 3y ago

I've never had a problem across several doctors on getting a direct reply to my message. For me, there is an SLA. They explicitly state I'll receive a reply within 24 hours. That has been true across multiple health systems I've used. Edit: In no way am I saying "American healthcare is just fine!" only that I actually have had a really good experience using messaging to communicate with my care teams.

NegativeK 3y ago
Are you, by chance, using concierge doctors?
- devin 3y ago
  Negative.
  - NegativeK 3y ago
    Wild. I've never seen anything remotely close to an SLA with the healthcare professionals I've seen.
    - thereticent 3y ago
      I don't know what is happening elsewhere I suppose. I'm a PhD clinician at a US public academic medical center and respond to patients within 24 hours even if it's to say "let me check on that...it may take a week to get the answer/letter/etc." I'm pretty sure that's the expectation for all our MD/DOs and other clinicians. We don't bill for it, and it doesn't contribute to our targets, but it just seems like it falls under a salaried expectation to me. It's for the patient. That said--hospital management, driven by the insurance world, tries to wring as much uncompensated labor out of the medical workforce as possible. Doctors (including my MD colleagues) do not get together to limit the number of doctors available. That's baseless conspiratorial thinking that doesn't withstand a moment's scrutiny when you understand the incentives at work in American healthcare.
      - DANmode 3y ago
        > Doctors (including my MD colleagues) do not get together to limit the number of doctors available. There are limited slots each year at the accredited schools you must attend in order to acquire your role. Nobody's accusing you of doing it - but the number of doctors is limited
        thereticent 3y ago
        Not everyone is accusing the doctors involved, but when I wrote the comment, there were numerous armchair expert opinions squarely blaming the doctors, including at least one who said that doctors limit the number of training slots available to keep their prices high. Thankfully, those perspectives have been addressed or at least outpaced by better thought out criticisms since then. Ultimately, the number of training slots in the current system is limited by MHA and MBA administrators who see training and instruction as subservient to profits, not the doctors who make up the departments and training faculty. Or, more broadly, they are limited by the healthcare operations not being legislated in a saner way. I was just clarifying.

smallmancontrov 3y ago

> I wonder if charging for these messages will make doctors more likely to respond. I wouldn't mind a modest copay for these. How long until administration figures out that they can juice revenue by shitting up the emails to increase back-and-forth traffic?

FireBeyond 3y ago
Hah, in MyChart, my provider has started having an MA answer your emails, and then "I'll forward this to the provider". Waiting to see if I get billed for the MA's "effort".
- ejb999 3y ago
  why are you putting effort in quotes? Do you not think there is any 'effort' involved? Why do you think someone else's 'effort' should be free?
  - FireBeyond 3y ago
    This is an absolutist take. No-one's saying it takes zero literal effort. Just "Should I be billed by the practice $25-30 for an MA to get my email and say "I have forwarded your question to the provider"?", and then a subsequent $100+ for the provider's response to my question. Why should that not be part of the intrinsic baseline officework and not a billable service? Especially when it's a 100% artificial roadblock inserted by the practice? After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider".
    - wighty 3y ago
      > After all, the communication portal in MyChart is "Message My Provider", not "Message An MA To Message My Provider". That is semantics, could be changed to "Message the office" but that isn't going to be the most clear title for the majority of people to understand what it is doing. It's the same as calling the office, 99.9% of offices (basically all outside of concierge/direct care) are going to be triaged by an MA/nurse first. As far as the payment requirements I've heard of, I have never seen anyone bill just for the MA reply.

pants2 3y ago

While waiting 6 weeks for an appointment with a specialist and suffering in pain, my mom diagnosed herself, created a treatment plan, ordered prescription pills from some Chinese site, and started treating her condition herself. She cancelled her appointment because she was feeling much better.

wannacboatmovie 3y ago
This is terrible advice.
- burnished 3y ago
  It isn't advice

NoMoreNicksLeft 3y ago

> I wonder if charging for these messages will make doctors more likely to respond. Why would it do that? If they get money for messages sent (rather than messages sent by doctors) then some flunky can send a message and you can still be billed. Given how this sounds like a profit center, and doctors are cost centers (imagine if they needed to send more messages... now they have to pay more doctors!), I figure physicians will be kept far away from any such system. If we plot out perverse incentives as a space, I believe that our fate will be to trek through every possible point in that landscape such that we eventually see every single one. This means you will eventually get universal healthcare, most likely as the very last of those perverse incentives.

gnicholas 3y ago
Interesting point. That could make for some awkward conversations if the patient thinks messages were coming from their doctor but then the director had no memory of the messages. It would also seem fraudulent to have messages signed by the doctor when it wasn’t actually sent by that doctor. I think it’s much more likely that doctors will end up sending AI-autocompleted messages that take very little time to complete but seem like took much longer.
- NoMoreNicksLeft 3y ago
  I have not used a medical messaging system, but if it's anything like the messages my bank or my insurance company sends on their own systems then these will look much more like text messages and less like emails. No place to "sign". No need to risk it looking like fraud. As for awkward conversations, I'd be shocked if many people don't experience circumstances where their doctors act as if they don't remember previous in-person conversations. They're seeing 25 patients a day for 3 minutes at a time after all. The standard will evolve to something like clinic staff sending the messages which will be overseen/supervised by a medical doctor (who won't be involved in composing the messages or spend any time looking at them before or after they are sent). We'll see trials where the doctor who was supposed to be keeping an eye on the messages wasn't, and some flunky kills a patient by suggesting that drinking used engine oil will cure the sniffles. Keep in mind that the messages can be sent from anywhere too, technically no need to keep that onshore. May eventually get legislation that would guarantee that, but only after a wild west period that lasts a few years.

qudat 3y ago

> I wonder if charging for these messages will make doctors more likely to respond. Physicians won't see a dime of that money unless it's through RVUs and even then it's marginal at best. The real money is in procedures.

wighty 3y ago
There are some codes that can be used for asynchronous portal messages, but to be honest the AMA is still pretty broken as far as how much time we need to spend for things... the codes are 99421 (5-10 minutes over 7 days), 99422 (11-20 minutes), 99423 (21+). It is not clear to me how well these codes are actually paid for by private insurance. In a wRVU system a PCP may get paid like $5-13 for the first code, $15-30 for the 2nd, $24-44 for the 3rd. This is a lot less than a visit... and you must spend the minimum 5 minutes on the portal message or you are billing it fraudulently. I can cover an in person level 4 visit (99214) in 5 minutes in some cases, which pays something like $100.
- AbstractH24 3y ago
  If there are codes like this why don’t all doctors use them already?