Ishani Ganguli is an associate professor of medicine at Harvard Medical School.
The messages ping into my inbox at all hours. “Should I increase my antidepressant dose?” one of my patients wonders. “Could you write a letter to keep my hot water and electricity on?” another asks. “I’m concerned about a headache,” says a third.
The near-constant communications are a new post-pandemic reality for primary care physicians like me. For some, I order a medication or test. Occasionally, I bring the patient into the office. Often, I offer reassurance.
What I haven’t done — yet — is bill for the time I spend reading, thinking about and responding to these messages. But there is a growing movement to do just that. It is an attempt to reconcile what patients want and need with what they pay for, but it risks undercutting the benefits of primary care.
Around 500 health care groups, including some large health systems such as the Cleveland Clinic and Mayo Clinic, now charge for messages with new billing codes introduced in 2020. A typical email claim cost the insurer and patient $39 in 2021, according to a Peterson-KFF Health System Tracker study. Doctors can bill for messages that require medical expertise or more than a few minutes of their time. The idea, I’ve heard from health system leaders, was to compensate doctors but also to cut down on the number of messages, which were often answered on nights and weekends.
I struggle with a tension in this approach. Sure, not all emails are worth sending. Moral hazard — the tendency to binge when something is free — is real. And there is a meaningful toll on the primary care doctors, most with thousands of patients each, who are on the receiving end.
But at a time when patients have many other sources for health information (reputable and otherwise), these messages represent a choice to reach out to us, through a channel that is part of any 21st-century relationship. Commodifying such micro-interactions undermines the value of having a trusted personal doctor, just as many Americans are losing sight of how our strained primary care system can help them.
Studies show that primary care, when working as intended, is more than the sum of its parts. It makes people healthier and can extend their lifespans, while losing a primary care physician has the opposite effect. Your primary care doctor or team — by definition — knows you well, is the first place you turn to look after the full range of your health needs, and helps you coordinate care beyond their office. A PCP can connect seemingly unrelated symptoms to make a difficult diagnosis, offer a single medication to address your goals to quit cigarettes and lose weight, or help you navigate conflicting recommendations from specialists.
Yet many people don’t experience this high-quality primary care and have become conditioned not to expect it. Fewer Americans have reliable access to a PCP, stemming from a decline in PCPs per capita as doctors-in-training become less likely to enter the field and physicians retire or cut back on hours due to burnout. Americans end up experiencing worse health outcomes despite the United States spending more on health care than other high-income countries.
Much of the disconnect between primary care’s potential and reality is tied to how, and how much, insurers pay for this care. Doctors, by and large, are paid fee-for-service, meaning per visit or procedure. The Centers for Medicare and Medicaid Services sets these fees through a closed-door process that has historically favored procedures (ranging from skin tag removals to surgeries) over the cognitive work of specialties like primary care. These payments do not cover team members such as social workers and pharmacists, or the large share of work that takes place between appointments, forcing PCPs to prioritize billable visits over other things patients value.
Which brings me back to emails.
I’m glad that my health system does not ask me to charge for messages. It can deter patients from getting needed care, and it doesn’t pay much — only a tiny percentage of all messages typically qualify for billing. Nor does this piecemeal approach solve the underlying problems with primary care financing.
Instead, interest is growing in a hybrid strategy that combines a “Netflix model” (monthly per-patient payments) with fee-for-service charges. CMS introduced Advanced Primary Care Management billing codes as a first step toward hybrid payment in January 2025, and recently announced that it will explore the possibility of broadening this effort next year. The idea was also at the core of the bipartisan Pay PCPs bill, reintroduced in 2026.
The hope is that substantial and flexible monthly payments would allow practices to support the range of professionals and activities that make up high-quality primary care. That could mean hiring a social worker, taking time for team huddles on complex cases, or getting creative with patient outreach — for instance, via diabetes registries, group visits and yes, emails.
I want my patients to message me and my team so we can help them with problems before they escalate. This is real work, but as with much of primary care, slapping on a per-item price tag is counterproductive.
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