Telehealth increases downstream care, study finds

Patients who used telehealth for upper respiratory infections were more likely to receive more follow-up care than those who sought in-person care, a new study found.

More than 10% of the telehealth users had an in-person visit the next week, compared with 5.9% of patients who went to a clinic, according to an analysis of around 86,000 Blue Cross and Blue Shield of Michigan claims from 2016 to 2019. While the study didn’t quantify the value of the follow-up care, University of Michigan researchers found that the telemedicine cohort had fewer (0.5% versus 0.6%) emergency department visits but more subsequent office, urgent care and telemedicine visits.

“There is a lot of potential for telehealth to improve access. It is all about optimizing telehealth—we want the good but want to limit the bad,” said Dr. Kathleen Yinran Li, lead author of the study published in Health Affairs and adjunct clinical lecturer at the University of Michigan. “The upside is there, but how do we shape policy and practice to get the best of both worlds.”

The research builds off a 2017 RAND Corp. analysis of 2011 to 2013 California Public Employees’ Retirement System claims that found that only 12% of direct-to-consumer telehealth visits replaced a visit to another provider. Even though a telemedicine appointment costs about $79 compared to $146 for a doctor’s visit and $1,734 for an ED visit, that level of redundant care would likely drive up overall healthcare costs, RAND researchers concluded.

Policymakers could consider waiving telehealth copays if the service is used as a successful triage point that refers patients to valuable care, Li said.

“If you bring someone into the healthcare system who otherwise would’ve been fine on their own, that would probably fall under low-value care,” she said. “But if you brought someone into the healthcare system via telehealth who would’ve otherwise gone to the ED, that certainly would save the system money.”

Transportation costs and no-show appointments should be factored into the cost equation, Li added.

More patients are using telehealth to connect to their primary-care doctor rather than an unfamiliar third party, which has the potential to weed out unnecessary follow-up visits. But that’s a relatively new development, Li said.

“Your doctor has access to your records and medication, so you may trust them more. So, it’s possible that increasing telehealth within that context does not necessarily lead to that much low value downstream utilization,” she said.

Patients and doctors may have less faith in a diagnosis and treatment plan rendered via telehealth, which could explain the increase in follow-up visits, said Lori Uscher-Pines, a senior policy researcher at the RAND Corp. Patients may seek care until they get antibiotics, telehealth may not resolve their complaints, or they may have never intended to replace an in-person visits with telehealth and just wanted some quick advice, she said.

Uscher-Pines recommended making it easier for telehealth providers to order diagnostic testing or remote patient monitoring devices to shore up any uncertainty.

“If telehealth visits are associated with slightly higher downstream utilization that doesn’t necessarily signal a problem,” she wrote in an email to Modern Healthcare. “Telehealth visits may be providing a service of value to patients, quickly and conveniently helping patients decide when and where to go for care. They may be providing access and reassurance that patients value.”

States and federal regulators are grappling with that value question as they explore expanding telehealth coverage. Some states have already implemented laws that broaden coverage of services administered via telehealth or ones that level the reimbursement for telehealth and in-person care.

Some industry observers argue that an increase in downstream utilization is worth heading off more serious diseases. Others claim that telehealth, similar to retail clinics, can clog an already inefficient system.

Telehealth was a lifeline during the pandemic as the country shut down. Utilization has seemingly plateaued, although it is still significantly higher than pre-pandemic levels.

Telehealth has won over many naysayers over the past year—patients and clinicians alike—given its convenience and comparable quality to in-person care. But how much telehealth care remains will likely depend on reimbursement levels.

“If a virtual visit could titrate medication to prevent decompensation and congestive heart failure, that is a valuable service and there should probably be payment parity,” Li said.


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