Telehealth patients did not require more follow-up care than in-person patients, according to a new study published in JAMA Network Open—and experts suggest that these findings may help shape telehealth policies going forward.
Telehealth isn't going anywhere, so it's time to think bigger than virtual video visits
For the study, researchers analyzed data from 40.7 million U.S. adults who were insured through Blue Cross and Blue Shield Association health plans between July 1, 2019, and Dec. 31, 2020. Health care visits among participants were measured from July 1 to Dec. 31, 2020, and compared with visits during the same period in 2019. A logistical regression model was used to determine telehealth's association with care outcomes.
Overall, researchers found that all health care encounters decreased by 1%, and in-person encounters per enrollee decreased by 17% from 2019 to 2020. During that same period, telehealth encounters increased from 0.6% to 14.1%. The highest telehealth usage was among adults ages 18 to 34 (25.3%), followed by adults ages 35 to 49 (19%).
When it came to follow-up care, patients being treated for acute conditions through telehealth were as likely or slightly more likely to need a follow-up visit as patients being treated through in-person care. Telehealth patients with acute respiratory infections were more likely to require follow-up care than in-person patients, but researchers noted that this may be due to Covid-19 concerns.
In comparison, telehealth patients with chronic conditions, such as hypertension or heart failure, were less likely to require follow-up care than in-person patients.
In addition, telehealth patients had slightly higher diagnostic severity than in-person patients. Compared with 7.4% of in-person encounters, 10.1% of telehealth patients had a disease severity of 2 based on comparable 3-digit ICD-10 disease categories.
According to Modern Healthcare, these findings may help policymakers understand the efficacy of telehealth as they consider how to develop related policies after the Covid-19 pandemic ends.
"Telehealthcare is comparable to in-person care and it really is not a duplication of the service," said Elham Hatef, an assistant professor at Johns Hopkins University and one of the study's authors. "That might help policymakers to consider the continuation of insurance coverage for telehealth services."
Because the study focused on commercially insured patients, its findings may not be applicable to Medicare beneficiaries, who are typical older and less healthy. Going forward, Hatef said researchers should examine telehealth follow-up care trends for Medicare and Medicaid beneficiaries.
In addition, Hatef suggested researchers study clinical outcomes for different patient populations that used telehealth during the pandemic, as well as the rates of follow-up visits after December 2020. Since the Covid-19 vaccine became available in 2021, they may have impacted care outcomes.
According to Krista Drobac, executive director of the advocacy group Alliance for Connected Care, the study's finding that telehealth reduced the chance of a follow-up visit for patients with chronic conditions may be important for Medicare beneficiaries. Research from the Commonwealth Fund suggests that around 30% of traditional Medicare beneficiaries have six or more chronic conditions.
"What we're most interested in is impact on Medicare," Drobac said. "If the researchers found lower rates of follow up for chronic conditions, that might mean that telehealth in Medicare will yield lower overall follow up because more seniors have chronic conditions."
In March, lawmakers in Congress passed a 151-day extension on pandemic-era telehealth policies, but progress has been limited, Modern Healthcare reports. However, Sen. Joe Manchin (D-W.Va.) on Tuesday said a telehealth bill he co-authored is gaining interest.
"We're moving on that again, but it's all intertwined with internet connectivity so we have to move in that direction," Manchin said. (Goldman, Modern Healthcare, 4/26; Hatef et al., JAMA Network Open, 4/26)
What this study found reiterates two points we examined in our own analysis of telehealth claims at the beginning of 2022.
The Johns Hopkins study found that telehealth accounted for a large share of ambulatory and chronic care encounters at the peak of the pandemic and remained prevalent even after infection rates subsided. Similarly, we found that telehealth volumes have hovered around 10% of all care since September 2020. That's an increase of almost 1000% from December 2019 and a promising sign that patients will continue to choose telehealth, even when in-person visits are an option.
We also looked into telehealth's impact on overall utilization—whether it's substitutive (replaces in-person visits) or additive (in addition to in-person visits). We found that telehealth had a substitutive effect for E&M and behavioral health visits—meaning that an increase in telehealth did not lead to an increase in overall utilization. This data suggests that patients are replacing in-person visits with telehealth visits, and are not following virtual visits with additional, unnecessary in-person care.
The Johns Hopkins study saw similar results. Telehealth encounters for chronic care had similar rates of follow-up as in-person visits, and telehealth encounters for acute conditions were only slightly more likely to require follow-up care. This is a promising sign that telehealth is an effective replacement for in-person care and will not lead to overutilization and an increase in total costs, as some stakeholders have feared.
Over two years from the onset of the pandemic, we continue to learn more about telehealth utilization and its impact. But the world is still stabilizing, as is our understanding of telehealth. We encourage health care leaders to continue to push their thinking on telehealth.
We often talk about "telehealth" when we're really talking about video visits (and many analyses, including the Johns Hopkins study and our own, pull from datasets of video and audio-only visits). It's encouraging that video visits have proven to be an effective replacement for in-person visits (and oftentimes a more accessible and convenient option), but the increased use of video visits hasn't fundamentally changed health care.
And the need for health care transformation is only getting more urgent. The pandemic exacerbated issues around workforce shortages and provider burnout, at the same time that patients are getting older and have more chronic conditions. This creates a crisis situation: a growing population of sicker patients, and fewer providers to care for them.
That's why we need to start thinking about the potential of other telehealth modalities, like asynchronous platforms and remote patient monitoring (RPM) to create new and continuous streams of engagement between patients and providers that extend beyond in-person care.
It's important to recognize that this study focused on commercially insured patients. We know that telehealth utilization differs across demographic groups, such as age, language, and race. Subsequentially, we should be careful about applying the lessons of one study across patient populations. Without proper implementation designs and considerations, there's a risk of leaving behind historically underserved populations that could benefit the most from the increased access and convenience that telehealth offers.
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