Much of our daily lives have been driven into the virtual world by the COVID-19 pandemic. Americans are working, attending classes and communicating with friends and family through a screen–and accessing health services in the same way.
The healthcare landscape has shifted dramatically with the emergence of the virus. In-person elective care has been put on hold. Hospitals are challenged with caring for infected patients while keeping providers and other patients at minimal risk of contracting COVID-19. Fortunately, telehealth–defined as a video, phone or online visit between a patient and a healthcare provider–allows providers to care for patients at a safe physical distance.
New policies in the U.S. are promoting telehealth as a safe alternative to office visits. The Centers for Medicare and Medicaid Services now pays providers the same rate for telehealth visits as in-person visits and has waived a previous requirement that patients see only their established providers for telehealth. CMS also now allows providers to deliver telehealth services from their own homes, without going through the traditional processes required for home-based virtual practice.
Additionally, several states have passed pro-telehealth legislation, including laws that require private insurers to pay providers the same amount for telehealth as in-person care and to waive patient cost-sharing. Major private insurers are also voluntarily changing their policies. Aetna, Blue Cross Blue Shield, and United Healthcare, among others, are temporarily waiving member co-pays for telehealth visits.
Virtual visits not only reduce the risk of spreading COVID-19, but also preserve supplies, such as personal protective equipment, for providers. Providers can use telehealth to inform patients with mild COVID-19 symptoms to stay home, while advising patients with suspected moderate or severe cases about whether to be seen in person or be hospitalized. In usual times and for patients without COVID-19 concerns, virtual visits offer convenience, especially for patients whose life circumstances prevent them from accessing care during business hours. Without access to remote care, these patients might go untreated, which could put some of at risk for more acute health problems in the future.
But how efficient and effective is telehealth? In a report commissioned by Covered California and published in 2019, researchers gathered the evidence on the cost and quality of telehealth prior to COVID-19, providing a glimpse into the effects that a greater shift to virtual care may have on payers and patients. Here’s what you need to know.
The reviews on the cost-effectiveness of telehealth are mixed. Virtual visits save money only when the cost of a virtual visit is less than an in-office visit; virtual visits are used as a substitute, not a supplement, for in-person care; and telehealth helps deter downstream costs from more extreme illnesses. A recent study of a virtual consult program in Connecticut found that patients who had an “eConsult” had average monthly costs of $84 less per patient across the episode of care than those referred for an in-office specialty visit. A similar study in Los Angeles found that 25% of patients who received an eConsult had their problems resolved without an in-person visit.
In contrast, the Covered California report cites a 2017 paper on telehealth use among patients with acute respiratory illness which examined claims from 300,000 patients between 2011-2013. It found that 12% of telehealth visits were “replacement” visits, and 88% were “new.” When patients used telehealth as a supplement rather than a substitute for in-person care, the costs of the visits were additive.
During the COVID-19 pandemic, patients are substituting in-person care with virtual visits. However, new price parity laws mean a shift to virtual care is unlikely generate cost savings on the price of the visit itself. However, telehealth–especially during a pandemic–may reduce costs long-term by safely helping patients manage chronic conditions and avoid complications.
In 2016, the Agency for Healthcare Research and Quality conducted “evidence mapping” on telehealth and patient outcomes, examining 58 systematic reviews of telehealth. AHRQ concluded that telehealth was sufficiently effective for specific uses with some types of patients (including monitoring patients with chronic conditions). Another literature review of 20 systemic reviews of telehealth, in seven clinical areas such as mental health and dermatology, found that telehealth and in-person visits were roughly equal in effectiveness.
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Not all telehealth services are created equal. While teledermatology has become a popular alternative to in-office visits to the dermatologist, one study reported consistent diagnoses between teledermatology and in-person visits. However, other research found lower diagnostic accuracy for in-person visits. For ongoing management, teledermatology and in-office dermatology were equivalent.
For mental health, telehealth outcomes for assessment and treatment of a variety of conditions were found to be equivalent to in-person care. AHRQ’s analysis also noted sufficient evidence to support teletherapy as equivalent to office visits for psychotherapy.
In 2020, many providers and patients are choosing telehealth out of necessity, not preference. Some patients who need in-person care are being triaged through telehealth until they can safely visit in person. These visits may not be equal to an office visit, where labs, imaging and hands-on assessment can be performed. For example, providers would normally give a patient presenting with a fever, cough or shortness of breath a comprehensive physical exam to assess the severity of their symptoms. Today, during a virtual visit, a provider instead uses a standard questionnaire to ask the patient a series of screening questions.
Absent physical examinations or procedures, providers are operating without a full suite of tools, and cannot perform certain services. Providers cannot record patient vitals (blood pressure, heart rate, height and weight, etc.) through telehealth unless they and their patients are set up to use self-monitoring tools that can upload data. For accurate prescribing and dosing of medications, providers need these inputs. Telehealth providers cannot run diagnostic tests and, for patients concerned that they have COVID-19, providers cannot confirm fever or evaluate the severity of shortness of breath. Broader availability of remote monitoring technology, such as “smart” thermometers and blood pressure cuffs could potentially reduce some of these assessment gaps.
Once the pandemic subsides, some patients and providers will return to in-person visits for which telehealth is not a strong substitute. However, the infrastructure will be in place, and patients who previously were not comfortable with telehealth may have become more so. Because telehealth in normal times is efficient and cost effective, the post-COVID-19 future will ideally include an appropriate mix of in-person visits for testing and physical evaluation, and virtual visits when telehealth can provide equal care.
Suzanne Delbanco, PhD, is executive director of the Catalyst for Payment Reform. Emma Wager is the project and research assistant for the Catalyst for Payment Reform.