Allina Health this month started billing up to $49 for some emails that doctors and clinicians send to patients in reply to new medical concerns.

The Minneapolis-based provider followed Mayo Clinic in adding the billing practice amid financial pressures and rising electronic communications between patients and doctors.

Patient messages increased fivefold since 2017 and accelerated during the COVID-19 pandemic, clogging doctors' schedules and slowing their response times, said Dr. Kevin Best, Allina's vice president of medical operations for primary care. Payment will allow doctors to dedicate more time in their days to respond, which will make message exchanges more convenient and allow patients to avoid office visits for routine needs.

"I think it's a good thing, honestly," Best said. "It's probably more convenient for patients to get a lot of their care done in this kind of asynchronous way where they don't have to take time out of their day or work. ... So we don't want to discourage it, but we need to figure out how we can incorporate it into our workflow."

After Allina announced the policy Dec. 12 in emails to patients, some expressed confusion over what types of messages will trigger bills. Allina's secure email system warns patients that all messages could result in billing if they aren't related to recent clinic or hospital visits and require doctors to treat new problems.

That still leaves uncertainty for Graham Coppin, a 59-year-old self-employed consultant who emailed his doctor in the past with questions about preventive care and checkups.

"I'm going to err on the side of caution and not reach out when I probably should. This is not ideal," he said. "This is the digital equivalent of people not going to the emergency room when they should and then eventually something tragic happens."

Health insurers have set standards by which they will pay for message exchanges, which allowed providers to start billing. Mayo announced in August that it would bill up to $50 for certain messaging exchanges with patients.

Providers already bill for e-visits, by which patients enter symptoms into an online portal — such as HealthPartners' Virtuwell — and receive remote treatment recommendations and prescriptions.

The number of patient messages declined immediately when UCSF Health in California started billing, according to one of the first published studies to examine its impact. However, follow-up research suggests that patients aren't against paying if messages produce timely treatment, said Jay Holmgren, a clinical informatics researcher who led that study.

"We empirically don't know what is driving changes in patient messaging, or what the downstream impacts of reduced messaging are on health," Holmgren said. "These are important areas for future research."

The majority of messages don't result in bills, sometimes because doctors aren't certain which emails apply or don't want to bother with filing claims, research showed. Mayo this week reported that it has received 850,000 "medical advice messages" since it started billing, a 7% decrease. Of the resulting exchanges, only 0.3% produced bills — a rate that the Rochester-based health system expected.

Best said he sympathized with patients because "we don't make it easy" for them to understand when to message a doctor instead of going to the clinic or emergency room. He said he thinks patients eventually will become familiar with the messages that cost them versus those that don't.

Doctors also will take more time with billable messages to make diagnostic or clinical judgments, compared with the hectic scrambles they now face to reply, Best said. "You get done with an in-person visit, you head back to your desk, and you try to tackle as many of these as you can."

Patients shouldn't be billed when emailing about refills, vaccination schedules or follow-up instructions from recent visits or hospitalizations, he said. One example of a billable visit came this week, Best said, when a patient disclosed he was struggling with cold sores and wanted to try a prescription treatment that a friend had recommended.

Billing is the latest step by Allina to manage its rising email volume; its clinicians received 620,000 messages from patients in 2022.

The health system has diverted more messages about refills and other needs to nurses and assistants who can respond. It also hired seven regional care providers who can respond to patients while doctors are out. Clinicians are spending 10% to 15% less time on messages since these changes occurred, the health system reported.

Coppin said he intends to stay with Allina, though other providers aren't yet charging for messaging and he likes that method of communication. But, he said, he plans to be more cautious before pressing send.

"We have a great partnership, and I want to continue that," Coppin said of his doctor. "I'm willing to weather this pay-for-messages nonsense for now because I value my relationship with him. It's hard finding a good doctor."