Many older adults send their doctors portal messages, but who pays?

When today’s older adults were growing up, the only way to get information to your doctor or their clinic was a phone call. And getting more than a simple answer probably meant going in for an appointment.

But a study suggests that people in their 50s and older have embraced the ability to send and receive secure medical messages with their doctors and other providers, through the digital patient portals that most health systems and medical offices now offer.

The study also suggests that some older adults – including those with very low incomes – find themselves getting billed for these digital interactions.

In all, 76% of people aged 50 and older say they have at least one patient portal account, the researchers from the University of Michigan Institute for Healthcare Policy and Innovation write in the paper in JAMA Health Forum. 

Of them, 65% have sent a portal message in the past year, though the percentage was much higher among those covered by veterans’ or military benefits, at 75%.

And of all those who sent at least one portal message in the past year, 13% report ever having to pay a co-pay or other charge for sending portal messages.

In general, insurance allows health care providers to bill if their reply involves five minutes or more of medical decision-making. This billing for asynchronous messaging is part of the telehealth flexibility that went into effect with the start of the COVID-19 pandemic and recently received a temporary extension from Congress.

The data for the new study came from the National Poll on Healthy Aging, based at IHPI and supported by AARP and Michigan Medicine, U-M’s academic medical center. The poll was conducted in late winter 2024, to build on previous poll findings about older adults and patient portals published in 2023.

Differences by insurance status

The new study shows that 17% of older adults who have private insurance had gotten billed for a patient portal exchange, as were 16% of those covered by Medicaid alone or by Medicaid and another health insurance plan, which means they have incomes and assets near or below the poverty line.

The percentage of older adults who had paid for a patient portal message was somewhat lower among those with Medicare Advantage (11.3%) or traditional Medicare with supplemental coverage (9.7%), and lowest among those with traditional Medicare without supplemental coverage (5.1%) or VA and military coverage (3.3%). 

“Even though we don’t know the exact dollar value of the charges these older adults paid, our findings raise questions about making sure out-of-pocket costs are not keeping vulnerable populations ls from using a potentially helpful technology,” said lead author Terrence Liu, M.D., M.Sc., a clinical instructor and primary care physician in the U-M Department of Internal Medicine.

“As policymakers consider the long-term future of the telehealth rules that made it possible for providers to bill for patient portal messaging, we hope our findings inform policy that considers the needs of financially vulnerable populations.”

He notes that in other types of care, state rules for Medicaid plans often set co-pays and other charges very low for people who qualify for Medicaid.

Other recent telehealth research

Liu, who recently published findings about patient portal-related billing in patients with traditional Medicare, notes that state-level price transparency policies could also help all patients understand what they might have to pay before deciding to send a patient portal message.

The study also builds on one published earlier this year by a team led by Liu’s colleague Cornelius James, M.D. 

It used National Poll on Healthy Aging data to examine the use of digital devices such as smartphones, tablets and smartwatches, and digital health technologies such as telehealth, patient portals and health-related mobile apps among older adults.

That paper, published in JAMA Network Open, showed that older adults with incomes over $60,000 were twice as likely to use a digital device and nearly three times as likely to use digital health technologies than those with incomes under $30,000.

“Portal messaging has become more common, and many patients find it useful, but we need to ensure that the cost-sharing for patients is appropriate and matches the value they get out of using portal messaging, ,” said Liu.

Meanwhile, other IHPI members recently published a pair of studies in preprint form that look at telehealth use trends and post-visit costs for participants in traditional Medicare.

Learn more about the National Poll on Healthy Aging, including methodology.

Additional authors: In addition to Liu, the authors of the new study on patient portal messaging are senior author Tammy Chang, M.D., M.P.H., M.S., a family physician who leads the National Clinician Scholars Program at IHPI, in which Liu trained, as well as poll team members Matthias Kirch, M.S., Erica Solway, Ph.D., M.S.W., M.P.H., Dianne Singer, M.P.H., J. Scott Roberts, Ph.D. and poll director Jeffrey Kullgren, M.D., M.S., M.P.H.

Kullgren is senior author of the paper led by James, which also includes co-authors Tanima Basu, M.S., M.A. and Brahmajee Nallamothu, M.D., M.P.H.

Funding/disclosures: The team received funding from IHPI as part of its Policy Sprint initiative.

Papers cited:

"Use of Patient Portal Messaging and Self-Reported Copays Among US Adults 50 Years or Older," JAMA Health Forum. DOI: 10.1001/jamahealthforum.2025.0168 

"Use of Digital Health Technologies by Older US Adults," JAMA Network Open. DOI: 10.1001/jamanetworkopen.2024.54727

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