Patient Messaging Conundrum pt. 2

Some thoughts from an academic, a behavioral scientist, a patient, and more

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I'm sending y'all a bill

Last time, I gave some thoughts on whether we should be charging for patient messaging. Then I asked you all for your thoughts, and now I am much more sympathetic to the idea that we should be charging for messaging. In fact, venmo me.

Below are a few of my favorites. All memes and notes are added by me.

Wait also btw the claims course starts soon, if you touch healthcare data or billing this course will make your life much easier. Email for group discounts, and sign up here.

‎It’s Time To Duel For Some Behavioral Economics

This is not an uncommon conundrum and something behavioral scientists love to ponder. Two things could happen…

The Wells Fargo effect: More but low quality  messages

The CEO of Wells Fargo wanted to increase the number of accounts. So they incentivized bank employees with a rewards system. But there were no checks and balances and employees created more than three million false credit card card accounts.  Translation:  Providers may create new creative ways to increase messaging.   Btw Wells could  have been prevented this with random audits on account quality (read: message quality audits)

The Daycare effect: Less messages, why bother?

Classic behavioral science paper.  Imagine you start charging parents when they are late to pick up. Before they arrived on time in order to respect the teacher. But now, you realize it only costs 3 bucks! You're fine leave the kid linger and be late.

[NK note: The abstract of the Daycare Effect -

Once we assign a value dollar to something, social norms go out the window and market norms take over. Doctors may answer LESS messages because they have more valuable ways to spend their time. A tiny fee for one response isn't worth their time!

Neither of these are ideal.

How could you design a system that pays people for time but doesn't incentivize bad behavior?

I buy that messages likely do increase health outcomes ( Is there RCT on this??!). Instead of complaining to your family about symptoms, you could complain to your doctor.  And she could change dosage or switch meds —and Boom! Just like that, you could get increased adherence due to better symptom management.

So we should actually incentive patients to use messages - and include this with most visit fee. In retail commerce, when you say "limit 2" — more people buy 2. Can we have 2 messages included in each visit. People will feel wasteful not to use them (waste aversion) Providers than get paid either way - if the patient messages or if they do not.  The assumption is that messaging actually decreases overall visits + improves outcomes (testable).   And yes, if patients abuse the system (as some will) then they need to pay more.

But of course, AI will solve all of this. So…

-Kristen Berman (behavioral scientist, Irrational Labs CEO)

[NK note: I think there’s something interesting to the idea of creating limits to messaging so that it INCENTIVIZES people to actually use those messages or they’re gone. It’s like having unlimited vacation vs. a defined set of days lol, people always use more vacation in the latter.

Deciding the number of messages is super hard - do you do it based on the complexity of the episode or the patient’s prior history with messaging? Wait did I just invent messaging benchmarking?]


Well what’s the alternative? They’ll stop responding to messages otherwise

I wrote a few of the studies you cite here, so like any good academic, I felt the need to chime in with more of a comment than a question.

First, while billing messages has generated a lot of moral controversy, there are a number of open empirical questions - who reduces messaging? What harms to health, if any, do those patients suffer? What is the impact on overall costs? We're flying somewhat blind here since billing for messaging is relatively new, the current volume of patient-initiated messages is very new, etc. The research needs time to catch up before we pass judgment.

Second, it's important to think about the counterfactual. Imagine no billing for messages - a world where clinicians are slammed with inbox work that generates negative ROI for the health system. How long do we think secure messaging lasts as an effective way to receive care in that scenario?

We've already seen some organizations pushing patients away from it. Secure messaging has skated by as an under-utilized service for a while, and I don't think the current equilibrium makes sense to maintain for health systems - many of which are not in competitive markets where they need to compete for patients. As far as solutions, the current fee-for-service billing isn't great. But on a policy level, if you can resolve an issue in a 5 minute message rather than a 15 minute appointment, at a lower cost, that is going to be a win for patients. We should think about building systems that channel patients to the correct modality of care. That's hard stuff, and likely involves a combination of team triage, patient expectation management, technology, and tweaking reimbursement. The alternative may be any clinical message gets you a canned "Please schedule a visit" response.

Finally, some of the demand for patient messaging likely reflects a lack of available supply of visits. Below is a binned scatterplot showing the number of patient-initiated messages that physicians at UCSF get per hour of delivering scheduled patient care on the Y axis, with their average clinical effort throughout that year on the X axis, controlling for physician specialty, gender (because patients love to message women docs!), and years in practice. Physicians with lower clinical FTEs get a lot more messages per hour than those with higher clinical effort! This is the "doom loop" I worry about - patients want care but can't get a visit so they send a message, docs get burnt out by messages and reduce their clinical effort, patients respond by messaging more due to reduced availability, and so forth. This is another area we should keep close tabs on.

Less visits means more messages per hour!

-A Jay Holmgren, assistant professor at UCSF

[NK note: Obviously the guy who wrote the damn study I cited schools me on it. But these are great points. One question is whether a 15 minute visit was replaced by a 5 minute one, or if it’s just net increase consumption and the same amount of 15 minute visits and docs are just pushed more.

But if docs don’t get compensated then this entire thing will be ad-hoc and people that actually need messages responded will eventually not get it.]


We should focus on whatever helps get into a flow state

A couple of not particularly well edited thoughts since we do a lot of messaging where I work (virtual + in-person primary care chain) and our payment model is value-based (essentially PMPM)

  • We have both virtual-only providers and in-person providers - The virtual only providers spend most of their time messaging, setting up sync visits when needed, and seem happy with it relative to the average provider. I think it's because they can get into a "flow" of answering messages and the messages themselves aren't really disruptive
  • The above makes me believe 2 things:
  • Some division of responsibility is helpful; having experienced it myself as a patient, having a dedicated team of virtualists whose job it is to respond thoughtfully to my more urgent messages and having a separate in-person PCP totally works. Downside of course is that it adds cost
  • If you are going to incorporate messaging into "normal" in-person primary care, I think it needs careful guardrails, like described in your quote from Michael Stillman. This is the part that I think orgs that gets ignored when messaging is turned on; something as simple as the equivalent of an email OOO auto-notification during off hours could help a lot with patient expectations
  • If you haven't checked him out already, Jay Parkinson was the mind behind Crossover's virtual model, and has a lot of published thoughts on messaging-based care. Personally I don't fully buy into his "virtual-first is the only way" approach yet, but I think he has some interesting ideas
  • On LLMs, I certainly think they will help, but part of me wonders if the same reason people message their doc is the same reason people scream "OPERATOR" when they're stuck in a phone tree; when they're confused they just want to talk to a human. If you want healthcare to be patient-centric (which is an assumption of its own) I think you will need to plan for making that human element easy to access, unless until the boomers all die off

-Ben Hughes

[NK note: First of all, I’m not yelling OPERATOR. I’m pressing 0 until my finger hurts. Operator is a word reserved for people working at healthcare startups, duh.

I don’t think this is too dissimilar from how people think about remote work during COVID. It’s much easier to bang out tasks and get into a flow state when someone isn’t coming to your desk every 10 minutes to ask you about an update on some project you’re barely even involved in. I can see this being a similar thing for doctors doing virtual visits.

But there’s also the flipside - I think a lot of people doing remote-first work feel more disconnected from the colleagues on the other side of the screens. Will docs feel worse about their jobs if it transitions to remote-first?]


For the “oh wait shit I forgot to mention” moments

I completely empathize with physician burnout (which was no doubt exacerbated by COVID-19) & the administrative burden they face. Layer in the rising physician shortage for both primary & specialty care & the situation becomes even more dire. If physicians had manageable patient panels, responding to messages wouldn't be as overwhelming.

However, I'd be curious to look at the distribution of topics discussed in portal messages, as well as the timing. In the fee-for-service model, patients get minimal face-time with their physicians. I don't know about you, but I feel rushed through my appointments, & afterwards as I'm driving home, I remember at least 2 things I meant to mention, but failed to because of the limited amount of time I had with my doctor. (I literally saw a specialist about a month ago who, at the "end" of my appointment, didn't ask me if I had any additional questions, just abruptly said "ok, come with me" & ushered me to follow her. I thought she was taking me to another exam room, but the next thing I knew, I was in the lobby & she said "well, take care!".)

[NK note: This is so savage lmaooo, if this happened to me I would never see a doctor again in my life.]

Anyways, I wonder if there's an uptick in inbound messages to physicians following brief, rushed appointments to cover the "spillover" - does maximizing visit volume (therefore shortening appointment lengths) drive message volume? Or, are the messages unnecessary/avoidable? Or, are they predominantly related to chronic illness management (therefore important from a disease maintenance perspective)? I feel like we have to understand the context, frequency, & timing to pinpoint solution(s).

Last thought - if systems are leaning toward billing for responding to messages, why not just hop on a telehealth visit (or a quick phone call) to address their concerns? Typing it all out has to be exhausting. It's like sending a dense e-mail or Slack message at work instead of just picking up the phone. I personally can't get ahold of my PCP no matter how hard I try (typically forcing us to have 15 portal message exchanges that could have been covered in a 2-min phone call) & it really doesn't build a trusting, longitudinal relationship between the physician & patient.


[NK note: it’s interesting because I much prefer typing vs. speaking on the phone, but I find anecdotally that the preference is 50-50 amongst friends. Usually divided along the lines of who is literate.

It makes sense that messaging would be a good factor for the random things you forgot to mention in the visit, and probably the ones that don’t require a full 15 minutes to address. And I’d also be curious for someone to do a study analyzing the context of the messages being sent, I’d guess it’s a lot of clarification questions about some results or asking a doctor about things like side effects or when they should come in next.]

Thinkboi out,

Nikhil aka. “don't kill the messenger, bill them”

Twitter: @nikillinit

IG: @outofpockethealth

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