The COVID-19 pandemic led to an increase in the use of telehealth services and online asynchronous health communication, commonly referred to as emails. These tools allow patients to ask their physicians and other clinicians questions regarding medication changes, symptoms, and to check in regarding management of chronic conditions. In March 2020, CMS expanded Medicare telehealth billing to include e-visits in which patients may have non-face-to-face (i.e., asynchronous) patient-initiated communication with their doctor through online portals. Many private insurers followed CMS and are now charging patients a co-pay for emails about medical advice and care.

Using HCCI's data on individuals with employer-sponsored insurance (ESI), we examined the utilization patterns of email communication between patients and providers from 2017 to 2021. 

In the early months of the pandemic, there was a rapid increase in the use of email communication, with a rate of 31 billed email communications per 100,000 enrollees in March 2020 and nearly 40 per 100,000 enrollees in April 2020, compared to a rate of 5 in April 2019, a 750% increase. This dramatic rise in the use of email coincided with CMS expansion of telehealth billing. While email visits decreased to a rate of 23 per 100,000 enrollees in May 2020, use remained well above pre-pandemic levels through 2021.

Over the full five year period, between 2017 to 2021, the rate of email visits rose more than 1000%, from 1 visit per 100,000 in January 2017 to 19 visits per 100,000 enrollees in January 2021. Moreover, we see a seasonal trend in the use of email communications in the years before and after the start of the pandemic. Email visit rates are generally higher over the winter months, especially in December and January and lower in the summer months of June and July.

Nearly three years from the start of the pandemic, telehealth practices have continued to expand with ongoing implications for billing and care. As patients continue to use asynchronous communication methods, it is important to track how many and which types of providers and health care systems are billing for these services, and implications for costs and access. While unexpected out-of-pocket costs associated with the change in billing patterns for email communications may be frustrating for patients, shifting preferences towards telehealth and asynchronous communication can put a strain on providers' time. The amount of time providers spend on non face-to-face communication with patients has increased significantly in recent years, and compensation for these services may be necessary to ensure that patients can receive timely quality responses to their questions.