If you wanted to talk with your doctor before the pandemic, you generally had to schedule an in-person appointment. But the sudden, rapid expansion of telehealth means patients generally can now text or email their health care providers.

"When you wanted to get a Zoom visit or an audio visit, you needed to sign up for the patient portal, and I think a lot of people became aware that they could message for the first time" during the pandemic, says A Jay Holmgren, a researcher in health care information technology at the University of California San Francisco.

Patients love that direct contact with their doctors — so much so their messages are overwhelming doctors' inboxes. Now, some patients are getting billed by hospitals or health systems for some responses to their message queries.

Holmgren tracked how doctors spent more time during the pandemic managing electronic health records. Even after lockdowns ended, doctors were fielding over 50% more patient messages than before, he notes in a research letter published in the JAMA. That compounded stress for doctors already dealing with a pandemic, then responding to emails after hours, essentially working for free.

"Physicians who receive a ton of portal messages tend to report being burned out, tend to report being more cynical about their job, tend to report that they are thinking about leaving clinical practice," Holmgren says.

Many hospitals and health systems, from Johns Hopkins to Houston Methodist and Cleveland Clinic to Veterans Affairs, now charge patients who receive clinical advice through messages. Such charges are generally covered by Medicare and Medicaid, as well as most private insurance, though patients may bear co-pays, ranging from $5 to $75, depending on the type of plan.

Holmgren says the goal of charging for these messages was both to reimburse doctors, and discourage patients from excessive emailing. In actuality, however, he says the new charges have not solved either of those problems. His research shows doctors only bill for a tiny fraction of messages — about 3%. And the move to charge for them did not cut down on email volume. The fees led to slight declines of about 2% in the number of messages.

"Uptake has not been super high amongst our clinician workforce," Holmgren says, in part because billing for messages itself is complex and time consuming. Plus, doctors don't want to alienate patients by charging them for communicating.

In short, there's still no business model to support the realities of how patients and providers now talk to each other.

But Caitlin Donovan, senior director of the nonprofit National Patient Advocate Foundation, says finding one is essential. She represents patients who are chronically ill, or live in rural areas.

"Over the last few years we've realized that telecommunications is a health issue," Donovan says, adding that the ability to email doctors was transformative for many patients: "Sometimes patients don't have the energy to make that phone call, let alone come into the office." Plus there are people who live hours away from their doctors.

Donovan hopes the ability to email doctors can remain in place, without adding major costs to patients: "We're balancing both this need to rapidly expand access and to really entice providers to make it part of their practice, with trying to make sure that it is accessible and affordable for patients."

Eve Rittenberg, a primary care doctor and assistant professor at Harvard Medical School, also wants a system that supports the relationship between doctors and patients. "For me it's an incredible privilege that my patients share their fears and their worries and their questions with me and I can talk with them directly," she says.

But it also has to be sustainable, Rittenberg argues, and what's needed are better systems to sift through the constant influx of messages, filter out administrative tasks, and allow her to focus on responding only to clinical matters.

Part of the challenge is the compensation model itself, the most common of which is what's called fee-for-service. Health care companies bill for each and every service doctors and nurses perform. Rittenberg says she wants to see payment systems instead compensate doctors for providing overall care, regardless of whether that's in an office or over email.

She says that would give doctors and patients the flexibility to decide what works best for them. "Finding ways to make clear communications sustainable is really, really important," she says.