Primary care physicians are increasingly facing a surge of patient communications via email, a shift accelerated by the COVID-19 pandemic. Doctors report receiving messages at all hours, ranging from medication adjustments to concerns about symptoms or requests for assistance with nonmedical issues. While many physicians provide guidance or reassurance without charging, a growing number of health systems have begun billing patients and insurers for such electronic interactions.

Since 2020, approximately 500 health care organizations, including prominent clinics like the Cleveland Clinic and Mayo Clinic, have adopted new billing codes that allow charges for messages requiring medical expertise or significant physician time. According to a 2021 study by the Peterson-KFF Health System Tracker, typical insurer and patient costs for each billable email reached around $39. Advocates of this approach argue it compensates doctors for time spent outside office visits and may reduce the volume of messages received during nights and weekends.

However, some primary care physicians express concern that charging for messages could undermine the broader value of ongoing patient-doctor relationships. They note that in an era where patients have access to varied health information sources, often of uncertain quality, direct communication with a trusted primary care provider remains critical. These micro-interactions play a role in the coordination and continuity of care that defines high-quality primary care, which has been linked to better health outcomes and longer lifespans.

The primary care system itself is under strain. Fewer Americans have reliable access to a primary care physician due to declining numbers of doctors entering the field, burnout, and reductions in clinical hours. This shortage persists despite the United States’ higher overall health care spending compared to other wealthy countries. Insurers largely operate on a fee-for-service basis, reimbursing physicians per visit or procedure, which disadvantages specialties like primary care that focus heavily on cognitive work and care coordination. Fee schedules set by the Centers for Medicare and Medicaid Services (CMS) have historically favored procedural care over primary care activities, and do not typically cover essential team-based services or time spent outside of appointments.

In light of these challenges, some experts and policymakers advocate for alternative payment models that blend a fixed monthly payment per patient with traditional fee-for-service fees. In January 2025, CMS introduced Advanced Primary Care Management billing codes aimed at supporting such hybrid arrangements. The agency recently announced plans to consider expanding these models, which are also central to the bipartisan Pay PCPs legislation reintroduced in 2026. Proponents argue that stable, flexible payments would enable practices to invest in multidisciplinary teams, extend outreach efforts, and embrace digital communication, including patient emails, without imposing per-message charges.

Some physicians welcome the ability to respond to patient messages promptly before issues escalate, emphasizing that while this work requires time and expertise, attaching individual fees to communications may ultimately be counterproductive. They caution that a piecemeal billing approach fails to address the systemic financing problems facing primary care, and could deter patients from seeking timely assistance. As health systems and policymakers debate the best path forward, the balance between fair compensation for physicians and maintaining accessible, continuous care remains a central concern.