During the COVID pandemic, in-person visits were not recommended so telemedicine rapidly evolved into an ideal way of delivering care safely and expanding access while reducing exposure to pathogens to both patients and staff. And tremendous enthusiasm exists for the continuation of such a model. There is no doubt that there is a significant enhancement to access with telemedicine, and numerous believe the total cost of care will improve when there is a replacement of virtual visits for in-person visits, thereby resulting in a lower price point. In fact, data has shown that direct-to-consumer telemedicine visits cost less per encounter than in-person and yet, they are only used as a substitution to in-person, 12% of the time while 88% of visits were actually new utilization.
A current concern with the use of telemedicine is the possible hidden costs of downstream care utilization after a visit. Since independent for-profit companies provide the majority of telemedicine, care is fragmented; therefore, follow-up is often necessary since the prescriber of care is merely providing a service at a specific point in time. Since this provider is not the patient’s primary caregiver and is quite possibly not attuned to the patient, a potentially inadequate telemedicine evaluation may lead to downstream visits.
A recent study by Li et al., published in Health Affairs, Direct-To-Consumer Telemedicine Visits For Acute Respiratory Infections Linked to More Downstream Visits, found that patients with initial visits for acute respiratory infection were more likely to obtain follow-up care within seven days after direct-to-consumer telemedicine visits (10%) than after in-person visits (6%). Though they had a slight decrease in emergency department visits, they had an increase in office, urgent care, and subsequent telemedicine visits. The overall cost of care was not calculated for these episodes.
There are numerous reasons for this finding. For instance, patients themselves might be worried that the care they received over a video by an unknown person might be inadequate; thus, they seek follow-up on their own accord. Furthermore, the same might be equally valid. The clinician might not be entirely comfortable delivering services to an unknown patient; therefore, they are more likely to suggest follow-up care. Additionally, telemedicine by its nature may increase inaccurate diagnosis and thus inappropriate care requiring additional evaluations.
A fundamental premise to primary care is the continuity of care and the relationships between patient and clinician. This model allows for a better overall understanding of the individual’s needs within the context of who they are both physiologically and psychologically. Therefore, the critical question remains, how do we implement new technology to significantly improve access, increase satisfaction, lower the cost of care, and improve affordability? We must continue to consider and contemplate using telemedicine as an extension of what works versus as a substitution. Are the issues we are seeing related to the fact that the majority of telemedicine visits are provided by independent companies versus by the consumer’s primary clinician when available? Is the lack of global access to a person’s clinical records a hindrance to better understanding? These are questions we need to continue to consider and seek to answer.
As with any new technology, we must examine all these nuances; otherwise, we will quickly digress to a situation where we begin to execute binary decisions, meaning whether something is good or bad, and if determined bad, then the need to stop using it. Technology should enhance care and lower costs. We must continuously evaluate its impact and improve on the models, always striving for enhanced value.