The COVID-19 pandemic accelerated medical communication as patients and doctors utilized computer technology to manage health care that was not available a decade ago.

Hospitals and doctors maintain online medical records that enable patients to access personal information about ongoing issues. “Portals” allow users to view lab tests, imaging results, pathology reports, and progress notes. The computer “message” system also enables patients to communicate with their physicians or other health care professionals.

My wife and I are seniors and have faced our share of health issues, including hospitalizations and medical office visits. However, we have utilized our marginal computer skills to navigate the sometimes complex aspects of this new technology.

When my sister-in-law in Arizona developed a life-threatening medical problem, I was surprised to find in her hospital portal this pop-up note prior to sending a message to her doctor:

“You may be billed for some messages. If your message requires medical decision-making, you or your insurance company may be billed up to $50. There is no charge for a quick medical update, provider-requested update, appointment requests, questions about scheduling an appointment, refilling a prescription, or a question about a surgery you had in the last 90 days. On average, a small percent of messages are billed.”

Coincidentally, in one of the national journals I receive every month, the Annals of Internal Medicine, from January 2025, there was an article from the same hospital system titled “Implementation of Billing for Patient Portal Messages as E-visits in a Large Integrated Health System.”

I have reviewed research papers for years to determine if the evidence supports the conclusion. The article states that the rationale for imposing a fee is that doctors have been overwhelmed with messages that require significant time to address.

However, our local health care system has not threatened patients with charges. Several years ago, ambulance services through 911 could cost patients as much as $2,000 for transportation to the hospital for emergency care. Many of my patients faced tough medical decisions about whether to call 911 or risk receiving a prohibitive bill. Therefore, would a $50 fee discourage patients from contacting their doctor with a critical, life-saving question?

The researchers aimed to answer this question. According to the collected data, when a pop-up regarding a $50 fee appeared on the portal, messages dropped by 8.8 percent. Hence, this fee discourages patients from asking questions.

Since my patients are geriatric, I focused on those who are seniors. Older adults often deal with multiple medical issues, and many suffer from chronic conditions that can lead to hospitalization or even death. Promptly addressing their symptoms could save their life.

In our local online message communications, there has consistently been a “screener,” usually a nurse or nurse practitioner, who intervenes and forwards the message to the doctor if they cannot address our question.

In my practice, if a question requires a significant medical decision-making response, I either call the patient or inform them that they need to be seen in the office or have an online visit—a simple solution instead of a pop-up.

Anecdotally, my senior patients often face “nickel and diming,” especially regarding medical bills. They all agree that the fear of a $50 charge discourages them from asking questions. These days, a medical office visit is time-limited, and seniors, even with their list of questions in hand, find they don’t have enough time to address many of their concerns.

After finishing their study, the research group sent a survey to physicians but not to patients. A survey capturing patient opinions could have clarified the potential impact of a $50 fee, which creates a barrier preventing patients from communicating with their doctor. This could adversely affect their health.

In the near future, online communication through messaging between patients and doctors will likely involve a fee.

Unfortunately, it will affect the timely health care of our patients, particularly seniors.

Gene Uzawa Dorio is an internal medicine physician who blogs at SCV Physician Report.