The Future of E-Visits: Unpacking Medicare’s Digital Billing Trends 

Introduction: The Rise of Digital Health Services 

The healthcare industry is rapidly evolving, with digital health services becoming an integral part of patient care. Among these, e-visits—online consultations conducted through patient portal messages—have emerged as a key component. Beginning in 2020, the Centers for Medicare & Medicaid Services (CMS) introduced online digital evaluation and management (E&M) codes, enabling clinicians to bill for patient interactions conducted asynchronously through these portals. These e-visits, which must involve at least 5 minutes of medical decision-making by the clinician over 7 days, represent a shift toward more accessible, patient-centered care. 

However, integrating e-visits into routine practice has sparked debates about the balance between improving patient access and fairly compensating clinicians for their time. As more healthcare providers adopt this billing practice, understanding the patterns, implications, and potential challenges of e-visit billing becomes crucial. A recent study sheds light on these trends, providing valuable insights for healthcare providers navigating this evolving landscape. 

The Study: Unveiling National Trends in E-Visit Billing 

The study on national trends in billing patient portal messages as e-visit services in traditional Medicare was conducted by a team of researchers with expertise in healthcare policy, internal medicine, urology, and clinical informatics. The key contributors to this research were: 

1. Terrence Liu, M.D. 

Department of Internal Medicine, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 

Dr. Liu specializes in internal medicine and is affiliated with the Institute for Healthcare Policy and Innovation at the University of Michigan. His work focuses on the intersection of clinical care and health policy, with an emphasis on improving healthcare delivery systems. 

2. Ziwei Zhu, Ph.D. 

Department of Urology, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 

Dr. Zhu is a researcher in the field of urology and healthcare policy. Her work at the University of Michigan involves analyzing healthcare data to inform policy decisions and improve patient outcomes, particularly in the context of digital health services. 

3. A Jay Holmgren, Ph.D. 

Center for Clinical Informatics and Improvement Research, Division of Clinical Informatics and Digital Transformation, University of California, San Francisco, CA. 

Dr. Holmgren is an expert in clinical informatics and digital transformation. His work at the University of California, San Francisco, focuses on leveraging informatics to enhance healthcare quality, efficiency, and patient access, particularly through digital tools like patient portals. 

4. Chad Ellimoottil, M.D. 

Department of Urology, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI. 

Dr. Ellimoottil is a urologist and health services researcher. His work at the University of Michigan centers on healthcare delivery innovation, with a focus on telehealth and digital health services, aiming to improve access to care and streamline healthcare processes. 

This multidisciplinary team brought together expertise in clinical medicine, urology, informatics, and healthcare policy to examine the implications of e-visit billing trends in Medicare, offering insights into how these digital services are reshaping healthcare delivery. 

The study in question conducted a comprehensive analysis of e-visit billing trends within the Medicare fee-for-service population from January 1, 2020, to December 31, 2022. Traditional Medicare, which insures over 31 million Americans—primarily those aged 65 and older—has seen a notable increase in digital health interactions, particularly during the COVID-19 pandemic. This study aimed to quantify these interactions, identify which clinicians are billing for e-visits, and explore the characteristics of the patients receiving these services. 

Key Findings: A Snapshot of E-Visit Billing 

1. Trends Over Time: 

• Peak and Stabilization: The initial onset of the COVID-19 pandemic saw a surge in e-visit billing, peaking at 728 monthly encounters per 100,000 beneficiaries. This surge likely reflects the rapid pivot to telehealth services as in-person visits became challenging. However, as the pandemic progressed and healthcare systems adapted, the frequency of billed e-visits stabilized, leveling off at around 90 encounters per 100,000 beneficiaries by the end of 2022. 

• The proportion of E&M Services: Despite concerns about overuse, e-visits accounted for a minimal portion of total E&M services—ranging from 0.05% to 0.09% over the study period. This suggests that while e-visits are a valuable tool, they have not overwhelmed traditional modes of care. 

2. Specialty-Specific Billing Patterns: 

• Primary Care Dominance: The data revealed that primary care providers were the most frequent billers of e-visits, consistently accounting for over 50% of all e-visit billing. This trend likely reflects the central role of primary care in managing ongoing patient relationships and addressing a broad spectrum of health concerns. 

• Time Investment: Notably, about 30% of e-visits were billed at the highest level, requiring at least 21 minutes of clinician time. This highlights the significant time commitment involved in managing some patient portal interactions, underscoring the importance of fair compensation for these services. 

3. Patient Demographics and Diagnoses: 

• Demographic Overview: Only 0.8% of Medicare beneficiaries received billed e-visits during the study period. Among these, the demographic characteristics—such as age, sex, race, and ethnicity—were similar to those of beneficiaries who received other E&M services. However, there was a notable exception: fewer beneficiaries billed for e-visits lived in rural areas. 

• Common Diagnoses: The most frequent diagnoses addressed during e-visits were chronic conditions such as hypertension (21%), diabetes (2.3%), and COVID-19 (2%). This suggests that e-visits are often used to manage ongoing health issues, which aligns with the role of primary care in providing continuous care. 

Implications for Healthcare Providers 

The findings of this study offer important insights that can help healthcare providers understand the current state of e-visit billing and anticipate future developments. Here are some key implications: 

1. Addressing Clinician Burnout: 

• A Minimal but Growing Workload: The study’s findings that e-visits make up only a small percentage of overall E&M services may alleviate some concerns about potential overuse. However, the substantial time investment required for many e-visits, especially in primary care, highlights a critical issue: the risk of clinician burnout. 

• Primary Care Under Pressure: Primary care providers are already facing significant workloads, and the added burden of managing e-visits could exacerbate burnout. Healthcare systems must consider strategies to support primary care clinicians, such as by redistributing the workload or providing additional resources for managing digital interactions. 

2. Optimizing E-Visit Workflows: 

• Streamlining Processes: To prevent burnout and ensure efficient care, healthcare systems should focus on optimizing workflows for handling e-visits. This could involve implementing tools that help triage patient messages, standardizing protocols for responding to common inquiries or leveraging support staff to handle administrative aspects of patient portal interactions. 

• Training and Support: Providing clinicians with training on best practices for managing e-visits can also help improve efficiency and reduce the time spent on each interaction. This might include training on concise documentation, effective communication strategies for digital interactions, and the appropriate use of billing codes. 

3. Addressing Disparities in Rural Healthcare: 

• Rural vs. Urban Utilization: The study found that fewer rural beneficiaries were billed for e-visits compared to their urban counterparts. This raises concerns about the accessibility of digital health services in rural areas, where travel to in-person appointments can be particularly burdensome. 

• Barriers to E-Visit Adoption: Several factors could contribute to this disparity, including limited internet access in rural areas, a lack of familiarity with digital health tools among rural populations, or a lower propensity for rural clinicians to engage in e-visit billing. Addressing these barriers is essential to ensure that all patients, regardless of location, can benefit from the convenience of e-visits. 

• Policy and Education: Policymakers and healthcare organizations should explore initiatives to promote the adoption of e-visits in rural areas. This could involve investing in telehealth infrastructure, providing education and training for clinicians and patients in rural communities, and ensuring that rural providers are adequately reimbursed for digital health services. 

4. Ensuring Fair Compensation: 

• Balancing Patient Access with Clinician Compensation: The introduction of e-visit billing codes was a crucial step towards recognizing the time and effort clinicians invest in managing patient portal messages. However, as the study shows, e-visit billing remains relatively new, and many eligible interactions may still go unbilled. 

• Encouraging Appropriate Billing Practices: To ensure that clinicians are fairly compensated for their work, healthcare organizations should encourage the appropriate use of e-visit billing codes. This could involve providing clear guidelines on what constitutes a billable e-visit, offering training on how to document and bill for these services accurately, and regularly reviewing billing practices to identify areas for improvement. 

Future Directions: Building a Sustainable Model for Digital Health 

As e-visit billing becomes more widespread, ongoing research and policy discussions will be crucial to refining this model of care. The findings of this study provide a foundation for several future directions: 

1. Research on Clinician Workload and Burnout: 

• Quantifying the Impact: Further research is needed to quantify the impact of e-visit billing on clinician workload and burnout, particularly in primary care settings. This could involve longitudinal studies that track the volume and intensity of e-visits over time, as well as surveys that assess clinician satisfaction and stress levels. 

• Exploring Solutions: Researchers should also explore potential solutions to mitigate the risk of burnout, such as by investigating the effectiveness of different workflow optimization strategies, examining the role of team-based care in managing digital interactions, and evaluating the impact of alternative payment models that better align with the realities of digital health delivery. 

2. Understanding Patient Preferences and Outcomes: 

• Patient-Centered Care: As digital health services continue to evolve, it will be important to understand how e-visits impact patient satisfaction, engagement, and health outcomes. Research should explore whether patients find e-visits as effective as in-person or telehealth visits, which types of patients benefit most from e-visits, and how these services can be tailored to meet diverse patient needs. 

• Addressing Disparities: In particular, studies should focus on understanding and addressing the disparities in e-visit utilization among different patient populations, including those in rural areas, minority groups, and older adults who may be less familiar with digital technologies. 

3. Policy Development and Reimbursement: 

• Evolving Payment Models: Policymakers should consider how payment models can evolve to support the sustainable growth of e-visit services. This could involve revising reimbursement rates for e-visits, expanding the range of billable digital interactions, or developing new payment models that incentivize the provision of high-quality, patient-centered digital care. 

• Ensuring Equity: Policies should also focus on ensuring that all patients, regardless of geographic location or socioeconomic status, have access to the benefits of digital health services. This could involve targeted investments in telehealth infrastructure, incentives for providers to offer e-visits in underserved areas, and initiatives to educate patients about the availability and advantages of e-visits. 

The Future of E-Visit Billing 

The study on national trends in e-visit billing among Medicare beneficiaries offers a valuable snapshot of how this new form of care is being integrated into the healthcare system. While e-visits currently represent a small portion of overall E&M services, their use is likely to grow as more providers and patients become accustomed to digital health interactions. 

For healthcare providers, understanding the implications of e-visit billing is crucial for navigating this evolving landscape. By optimizing workflows, addressing potential disparities, and ensuring fair compensation, providers can leverage e-visits to enhance patient care while maintaining a sustainable and balanced workload. 

E-visit billing represents an important step toward a more flexible, accessible, and patient-centered model of care. With ongoing research, policy development, and provider engagement, the future of e-visit services holds significant promise for clinicians and patients alike.