Patterns of Virtual Care and In-Person Ambulatory Contacts During the Onset of the Pandemic

During the first four months of the COVID-19 pandemic, in-person ambulatory visits decreased while Americans gained wide access to telehealth services. A new study in JAMA Network Open documents shifts in telehealth use and ambulatory care from March to June 2020 and could have implications for the future of virtual care.

Prior to the onset of the pandemic telehealth services were not commonly used, but research has indicated that usage skyrocketed from less than 1% of visits to as much as 80% in areas with a high prevalence of COVID-19 cases. The use of telehealth as a way to deliver care at a social distance was made possible because “policy makers, payers, and practitioners eliminated almost all financial, regulatory, and technical barriers that hampered past telehealth expansion,” explained the authors.

They used data from the Blue Health Intelligence data repository, which includes complete claims files for commercial health plan members. The study compared March to June 2019 and 2020 and only analyzed ambulatory encounters with a telehealth-eligible service. They did not include inpatient and emergency department services.

The study cohort included 36,568,010 individuals with a mean age of 36 years. For this group, in-person ambulatory visits decreased by 37% between 2019 and 2020. Only 0.3% of ambulatory visits in 2019 were billed using telehealth designations, which increased sharply to 23.6% in 2020.

Patients who were between the ages of 18 and 49 and who had two or more chronic conditions used more telehealth in 2020, and states that were COVID-19 hot spots during the four months studied had higher rates of virtual care (36.0% vs 21.6%), as did urban locales compared with rural locales (24.2% vs 14.2%), and the most socially advantaged neighborhoods compared with the least (27.4% vs 19.9%).

Ambulatory visit rates were approximately 30% higher for patients who were placed in the COVID-19–related subgroup based on whether they had a diagnosis code associated with the disease, exposure to it, screening, or testing, but their telehealth use was only slightly higher (25.0% vs 23.5%).

The per member rate for behavioral visits stayed constant year over year, as did the encounter rate for addressing diabetes, hypertension, cancer, and well-child care. However, telehealth use for acute conditions was only 14.1% compared with 21.5% for chronic conditions.

“The use of telehealth for new patients and for new problems in 2020 was lower than overall rates,” the authors noted.

While total medical costs decreased from $358.32 per member per month (PMPM) to $306.04 PMPM (or approximately 15%) between 2019 and 2020, expenditures for patients with 1 or more ambulatory contacted increased slightly ($632.48 PMPM in 2019 vs $653.78 PMPM in 2020). The patients in the COVID-19–related subgroup had medical costs that were three times higher than patients in the non-COVID-19 subgroup.

The authors noted that a limitation of the study is that it was limited to the first four months of the pandemic and that further analysis is warranted “as virtual care becomes more established, as COVID-19 prevalence increases, and as coverage policies may change.” In addition, the study did not include the uninsured or patients covered by Medicare or Medicaid.

“Although some of the associations we uncovered may be unique to the COVID-19 environment, arguably the insights we gained will be relevant to the future trajectory of telehealth no matter what direction it takes,” the authors concluded.