A Definitive Guide: How to Get Paid for Treating Patients by Text

I recently had a conversation with a head of benefits from a Fortune 100 company about the problem they’re seeing with video-based telehealth and the search for a messaging-based alternative for their employees. As this benefits leader explained over the phone, there are very few private spaces where employees feel comfortable joining a video conference for a sensitive health-related consult. Most of their employees are now back in the office, given return to work mandates post pandemic.

In 2025, many patients would be eager to chat with their care team. So why are we still so reliant on video and in-person visits? Why isn’t more care delivered via messaging, particularly in specialties where there are often a lot of lower acuity needs like dermatology, pediatrics, primary care, and general mental health?

For this piece, I teamed up with Josh Tauber, a health-tech entrepreneur and operator who’s gone deep on messaging-based care while building for a Gen Z user base. We’ll argue throughout this piece that the benefits for the patient experience are clear, particularly for younger generations of patients. Multitasking comes naturally to most of us, so existing appointments and meetings don’t need to be cancelled for patients to get access to medical treatment. Who among us hasn’t sent a few texts while sitting on a Zoom conference call? Another benefit? If a patient’s symptoms come and go, it’s possible to send progress updates or images to a care team versus relying on what can be gleaned fortuitously during a synchronous consult. There’s a reason patients so often gravitate to texting. Sending a text might feel more private and a bit more impersonal, which is comforting for patients managing sensitive or embarrassing issues. When we talk about privacy, we often discuss it in the context of security. But there’s also the emotional dimension. For many, a text feels more private because it can’t be overheard by a spouse, a child or a co-worker.

Using messaging in care delivery–and not just patient engagement or administrative tasks where we more commonly see it–may give companies an edge. But after talking to a dozen operators, we also believe it’s so complex that the companies that do it well have effectively created a moat. There are challenges related to coding and reimbursement, patient experience, compliance, benefit design, provider workflow, unit economics, legal considerations, and more. “It’s hard, but when done right, I don’t think people in this industry realize how much of a secret weapon it really is,” said Ellen DaSilva, CEO of Summer Health, a pediatrics SMS messaging service.

So it’s worth learning from those who have done it. For Second Opinion’s paid subscribers, we dug in.

Is messaging sync or async? Does it matter?

This is a huge question that tends to stir up debate, particularly amongst the telehealth lawyers in our network. But we’d argue that the meaningfulness of whether messaging is asynchronous or synchronous is a bit overstated. Where it matters most is regarding reimbursement. Synchronous care delivered over video (or audio-only) is of course often, though not always, reimbursable. That’s traditionally what we think of as “telehealth.”

But there are also well-established pathways to reimburse for truly asynchronous care. Think of traditional inbox messaging, akin to emailing, that could initiate back-and-forth communication with a provider. Alternatively, a patient may fill out an intake assessment or send images through a portal. The clinician receives a pile of files and then makes clinical determinations on the appropriate next step before communicating back to the patient. It’s worth noting here that many states prohibit providers from providing care - including prescribing - based solely on the submission of an online questionnaire. In permissible cases, ongoing back-and-forth is a type of unambiguously asynchronous messaging reimbursed by payers via a category of codes known as store and forward. However, some states (and payers), maintain that there must be some kind of real time (or even in-person!) aspect to care delivery.

Telehealth companies in the first generation essentially built around these codes because there’s an existing framework for them. Some businesses leveraged them by seeking reimbursement on the back end for the semi-invisible provision of professional medical services (the care determination), sometimes in addition to monies they obtained from patients up front - be it subscription revenues, cash payments for medications, and so on. This approach is especially common within the direct-to-consumer online health category.

A lot of the newer generation of digital health companies are using messaging in more dynamic ways. This opens a can of worms because not all messaging is truly asynchronous. The term “messaging” and “asynchronous care” are often used interchangeably. But a lot of care these days delivered via messaging is actually quite synchronous, meaning a clinician is exchanging a series of back-and-forth messages with a patient in real time. We often think of this more appropriately as “chat,” although now that term has become associated with LLMs in patients’ minds. Sometimes there might be gaps and delays as the patient steps away, but then returns to the conversation to exchange further messages or information. Or the clinician might take a few minutes to respond as they’re simultaneously managing a few conversations. DaSilva, the CEO of Summer Health, refers to that kind of care delivery as “pseudo-synchronous.” How these approaches get reimbursed on a fee-for-service basis remains a big, open question–how is a “unit of chat” even defined? More on that later.

Regardless of how synchronous it is, there’s no clearcut path to reimbursement and those who persevere must grapple with state-by-state and payer variances. And it’s hard to build a business relying on the store-and-forward codes alone, as they often provide a sub-optimal patient experience and their rates tend to be quite low.

Other codes that might be relevant are chronic care management codes, which anticipate some asynchronous contact. But generally speaking, there’s no ready-made mapping of text to an encounter.

Ultimately, as Shrenik Jain, the CEO of Marigold Health, a peer support company, put it: “reimbursement for text-based care is still in a patchwork phase.”

Managing capacity and the associated operational complexities

If this wasn’t already daunting enough, let’s dig into some of the unit economics. Consider the ways in which a clinician is typically hired: salaried, hourly employee or contractor, a per-case or eConsult fee, etc. Often there are variable incentives tied to productivity, in the form of total patients seen or RVUs. These models are all well suited to predictable, scheduled patient care. If a sync video visit is ten minutes long, then a clinician can complete six of them in one hour. If six appointments generate a company more revenue than the hourly cost of that clinician, then there is a positive contribution margin.

However, this looks dramatically different in a messaging context. Messaging may: vary widely in duration, patient response timeliness, and clarity; start-and-stop often; ramp up unpredictably and concurrently; and are always susceptible to patient ghosting (a very real problem). In some cases, a clinician is ethically or legally obligated not to disengage–consider the circumstance of a patient demonstrating suicidal ideation who stops responding. Yet the clinicians remain relatively fixed-cost resources: most (high-quality) clinicians will not accept a per-message rate in the face of highly unpredictable message volumes. In theory, messaging is a way to scale the care team, as one clinician could engage in simultaneous dialogs with multiple patients at any given time, unlike a one-on-one encounter like a video call or in-person consult. But there would invariably be a lot of fluctuation. So individuals on this care team might face long stretches where they’re paid to sit there and be available to patients (in many cases, 24/7), regardless of whether any patients sign on for a chat.

Powerful intake and routing systems may be a short-term fix, but they remain significant challenges for the foreseeable future. Some companies are experimenting with AI for intake and triage to mitigate these challenges. A promising model, to be sure, yet nascent and not without its own considerable challenges.

Meanwhile, revenue for this business would typically not fluctuate based on the volume of messages being sent (unlike in video-based telehealth, where revenue can be more easily paid on the basis of a volume of encounters). More than likely, the patient would pay to access care via SMS for a subscription fee. Most people would want unlimited messaging as part of that, although we strongly advise companies to consider “tiers” where a patient might pay more or less depending on the volume of messaging they might need. Still, the revenue from these encounters is likely going to be highly variable and not tied to volume, while the clinical team is a fixed cost.

This makes the whole thing extremely operationally challenging, and far more so than a standard video-based telehealth business. For any startup, it’s often very hard to project revenue and keep costs under control with messaging-based care delivery. How can companies ensure the provider is available within minutes if a patient needs them (what most users expect these days), but also not pay for a care team to sit there? And then what are the right ways to charge patients for access?

To reimburse or not to reimburse?

Now try to layer in another dynamic typical of health insurance: patient financial responsibility. Consider typical benefit design: what happens if messaging is not covered pre-deductible? Could you imagine sending 50 or so messages with your doctor only to receive a bill months later for $500 or more because your deductible had not yet been met? There also could be co-pays, or other gnarly surprises that only arise downstream. From a revenue cycle perspective, when is there time to complete the typical “pre-visit” work - such as running eligibility, determining cost-share, collecting payment before the visit, and so forth. Unpleasant financial surprises abound.

Startups attempting to build the right model with health plans will need to find an evangelist. Most payers can find a way to pay if they want to, notes Jain from Marigold Health. Commercial payers have the broadest flexibility. There’s variable coverage for Medicaid on a state-by-state basis, and Medicare Advantage plans can layer on supplemental benefits. Jain said that for startups it’s extremely important to convince the plans that text engagement is clinically appropriate, and define what counts as an encounter. With messaging, defining what a “unit of care” means can be far more challenging than with video-based telehealth. Is it a set number of messages? Is it a fixed exchange? What if the patient’s issue seems to resolve, then resurfaces and they re-emerge? Is that one encounter or two? And how can payers mitigate “unlimited” chat utilization?

“Some states don’t allow it to be telehealth under the definition or it’s not entirely clear if it can be,” said Randi Seigel, a regulatory lawyer at Manatt.

Jain recommends spelling out service documentation standards, meaning time-tracking and auditability. If the documentation is just as good as one might expect with a synchronous consult, say a video visit, the payer may deem it to be low risk.

Another tip, per Jain, is to position text alongside other modalities like phone or video, so plans don’t worry that patients will lose touch with these higher touch options. That said, there are companies like Summer Health that advocate for pure text, and have been able to start winning over plans by showing the value in pediatrics and the strong patient preference for it. Da Silva said most of the plans she’s talking to are receptive because of ballooning costs of care and the worsening challenges with more traditional primary care delivery.

General Medicine, a primary care company founded by several members of the early PillPack team, is also one to watch because of its unique approach. Once patients click a skew, say its a UTI - the company offers patients the option to get care immediately via messenger if it’s straightforward. But they would need to pay $30 out-of-pocket for treatment. Or they can wait a few hours or even a day to get care for free by video if it’s covered via their insurance. Elliot Cohen, one of the founders, told us that patients seem to really appreciate the choice - and they’re not trying to predict what people will want. There are times when text can be frustrating, he shared, and others where it’s really convenient.

One big ongoing question: How to prove ROI? Companies can show via randomized controlled trials that their messaging-based intervention thwarted an expensive outcome, like an emergency room visit or a trip to urgent care. But these types of structured medical studies are also costly and take a long time to administer. Without them, it’s hard to prove that the message-based care made the difference, versus some other variable.

How providers feel

Some providers like messaging; but a lot are mixed on it. It can be incredibly difficult (and stressful!) paradigm for clinicians to practice within. Many clinicians report frustrations with delivering care over unstructured chat in this manner. Much can be lost in translation, context and body language cues are absent, and the lag arising from response latency - sometimes hours, sometimes days - can make things highly inefficient.

Operators we spoke to told us that they’ve seen many instances of patients disappearing for a few hours, or being very vague in their descriptions (just imagine a physician getting an emoji in response to a medical question), or otherwise neglecting to share really valuable context. We spoke with providers who told us that there are moments where getting answers via messaging can take hours, given the drip feed of information they get. Those providers said they wished they could just hop on the phone or video for a few minutes to ask direct questions and get the answers they need.

Do clinicians need to sit at their desk awaiting responses indefinitely? How can chats be transitioned effectively across the team mid-stream? Can clinicians work from their phone on the go? If so, what are the implications for privacy and security? For care quality? And how are they paid for being “on call” on nights and weekends in this context?

But again, it very much depends on the type of care offered through messaging and the patient. There’s a lot of literature and anecdotal evidence showing that patients do like to talk to a therapist or a peer through messaging. Pediatrics is another good use-case because parents tend to be very engaged when trying to get medical opinions related to their kids, and they’ll often use their phones to take photos and videos of a bad cough or concerning-looking rash.

Yet it remains a big challenge for companies to recruit high-quality care teams who want to practice in this manner. Telehealth has a reputation for that either way. That said, there will be a cohort of high quality clinicians that love this medium. So companies will need to go out of their way to recruit their natural allies.

To secure text, or not to secure text?

Messaging comes in many different forms. In a care delivery context - because a lot of companies solely use it for patient engagement and administration - we think of it in three different ways:

Pure SMS (or branded iOS chat), meaning directly messaging a care team via texting;
Messaging that is only accessible after signing in via an app that requires a secure login;
Messaging that is shared via a web link that requires patients to sign into a secure portal.

Most companies in healthcare opt for either 2) or 3), in large part because of HIPAA concerns. It’s safer to go with encrypted channels. But there are also companies doing 1) that have methods that ensure a patient is fully aware of the risks and is opting to use regular SMS without encryption or iMessage (explicit patient consent is hugely important to mitigate risk). There are paths forward with 1) but we tend to see the most innovative approaches in a cash-pay context. These companies might also bake in other medical services via SMS, including prescriptions via companies like Photon Health.

We’ve also met with founders that do a mix of these approaches. What we’re also tracking, and fascinated by, is the nascent mechanisms by which the rich clinical information being exchanged via messages will make its way, in a structured and useful format, into the patient’s medical record.

Jessica Bell van der Wal, CEO of Frame Fertility, is big on SMS for her company, which treats patients with reproductive health concerns. But she made a decision to share some messages via secure web links, namely anything that involves reproductive health information, and others via SMS directly without a login. For her, it’s related to the sensitivity of the information. And again, a lot of this comes down to the condition. Some people might feel more strongly that reproductive health information should be extremely secure, while they might not feel that way about pediatrics.

Alan Nevue is taking a similar approach with his company, Mojo Health, which aims to automate physical therapy. Mojo will share as much information via SMS as they can, but if it’s related to protected health information, they do so via a secure link. Nevue said a lot of companies in digital health are actively working to figure out where the line should be because messenger is arguably more secure than email. And patients seem to like it, with seniors increasingly warming up to the idea.

There’s also now a fourth option that’s starting to emerge, which is really more of an LLM wrapper that lets patients communicate with an AI. We expect we’ll see a lot more of that in the next few years as people have become accustomed to trading chats with an AI. The rules and regulations around AI for care delivery are still very much still being written, and we’ll continue to monitor that and the impact it might have on the trajectory of messaging-based care.

All in all, we believe that there’s an enormous opportunity in pure text because patients want it and because it’s so hard. The best companies aren’t easy to build. What we hope is that the company that succeeds here, lobbying states and winning over health plans, is also the biggest success story. But as we’ve seen in other categories of digital health, sometimes the first movers establish the path and then the more larger companies are the ones that follow (Omada Health is the example that springs to mind).

“Some trillion-dollar business will succeed in this,” said DaSilva from Summer Health. “And of course I hope it’s us.”

Not already a Second Opinion subscriber?

Get weekly insights on health‑tech delivered straight to your inbox. Join the mailing list for free

Or copy & paste this link into your browser:
https://secondopinion.media/subscribe