When hospitals and health systems started charging patients for MyChart messages amid the pandemic, the reasoning was straightforward: Give clinicians a way to be compensated for the growing volume of medical advice flowing through patient portals, and perhaps slow that traffic down in the process.
Years later, health systems that adopted the practice say the second half of that bet hasn’t panned out — though nearly all say they’d do it again anyway.
Cleveland Clinic launched its MyChart Medical Management initiative in November 2022. Like most systems that bill for portal messages, it charges only for messages that require new medical evaluation or treatment decision-making, not for routine communications such as prescription refills or follow-up questions.
Message volume dipped briefly the following month, then resumed climbing: up 5% in 2023, 15.94% in 2024 and 18.56% in 2025, according to Sarah Hatchett, senior vice president and CIO.
“We are not changing patients’ behavior around messaging,” Ms. Hatchett said. “I think [the program] is valuable because it supports an alternative care pathway for patients while enabling providers to be reimbursed for care delivered through messaging.”
Houston Methodist has processed more than 53,000 billed messages since it began charging for certain portal communications in 2022. But the program was never designed as a standalone fix for inbox volume, said Aroub Khleif, PhD, senior director of innovation, access, billing and ambulatory clinical systems.
“We have not observed a significant change in overall message volume,” Dr. Khleif said. The benefit, she said, has been helping patients “better understand when portal messaging is appropriate and when a virtual or in-person visit may be the best option.”
At Winston-Salem, N.C.-based Novant Health, MyChart enrollment has grown 37% since the policy took effect, with overall messaging volume rising 5% year over year, according to a system spokesperson.
Seattle-based UW Medicine has seen a similar pattern. Crystal Wong, MD, a family medicine physician and associate medical director at UW Medicine Primary Care, said billing has not meaningfully changed inbox volumes, and the system hasn’t seen evidence that patients are rewording messages to avoid a charge.
The pattern lines up with limited published research on the subject. A study of San Francisco-based UCSF Health’s e-visit billing found only a 2% decline in average weekly messages after the system began charging in 2021. A separate study, also published in 2024, concluded that billing for portal messages has become more of an ongoing revenue stream for health systems than a tool for easing inbox burden.
Not every system that considered billing adopted it. Christopher Sharp, MD, chief medical information officer at Stanford Health Care in Palo Alto, Calif., said the system decided against charging for messages after watching how the policy played out elsewhere.
“We have been happy with this approach based on what we are seeing from others’ published experience to date,” Dr. Sharp said.
At Ann & Robert H. Lurie Children’s Hospital of Chicago, the goal was to create a clear pathway for clinical interactions that are better categorized as e-visits, alongside phone, video and in-person care. “As MyChart adoption has grown, messaging volume has continued to increase, so billing alone has not eliminated In Basket burden,” a Lurie Children’s spokesperson said.
None of the health systems that bill for messages reported an increase in patient complaints or help desk calls tied to the policy, and none said patients appeared to be rewording messages to avoid charges. Dr. Wong said UW Medicine would implement the policy again, though she said she would want more workflow readiness from ambulatory leadership before rolling it out a second time.
For Cleveland Clinic, the response to rising volume hasn’t been more billing. It’s been a separate set of inbox management projects, including improved message triage, prioritization tools and AI-drafted responses for clinicians to review. Ms. Hatchett said those efforts, not the billing policy itself, are where the health system expects its next real reduction in clinician burden.
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