Downstream Impact of Telehealth on Health Care Overuse

Telehealth exploded this past year and is expected to continue to make up a significant portion of health spending. Still, the overconsumption of healthcare remains a pressing concern in health policy, and it is important to consider how this new care model may combat or contribute to this issue. Patients receiving unnecessary or even potentially harmful services represents a massive waste of spending, with the National Academy of Medicine estimating that the amount spent on unnecessary care annually is $765 billion, aligning with estimates of 20 percent of health spending. Further, an estimated 30 percent of Medicare spending is from overuse. Overuse can be hard to measure because its classification differs so greatly depending on patient circumstance. Below I will detail the challenges of reducing low value care in telehealth and the potential benefits of this new care system in combating overuse.

Telehealth is Here to Stay

Telehealth and its rampant rise in use has been a central conversation throughout the pandemic. However, as vaccines are rolled out and life returns toward normal, will telehealth still have its place? To recap, in early April 2020 visits to ambulatory practices fell nearly 60 percent below  the pre-COVID-19 baseline before rebounding in mid-June and plateauing around 10 percent below baseline. Telehealth usage however saw an 80-time increase after March 15th when the pandemic began. Many regulations regarding telehealth were laxed, including waiving licensure requirements across states and ensuring payment parity. Medicare’s policies were also expanded, with nearly half of Medicare primary care visits being provided through telehealth last April.

While a lot of the changes brought by the pandemic may recede as we reach the end, it is anticipated that telehealth will have staying power. Health and Human Services (HHS), as well as physicians nationwide, estimate that around 21 percent of care will remain virtual. A report from McKinsey estimates that 250 billion (20 percent of Medicare spending) will continue to be spent on telehealth post-pandemic.

Telehealth and Overuse

One of the primary ways telehealth has the potential to combat overuse is when used as an alternative to care sites that have historically high amounts of overuse. As the pandemic began, emergency department visits fell drastically, and with this came a disproportionate decline in low-value health spending, as this is one venue where over testing and unnecessary imaging is rampant. ED visits have been slow to bounce back in COVID recovery. Telehealth has been a factor that caused declines in ED visits as patients could quickly access doctors online. ED visits are known to be drastically more expensive than receiving care at sites such as primary care or telehealth. Therefore, indirectly telehealth decreased the unnecessary imaging and lab testing done at these care sites. This is not the only care site that may be impacted. Nursing homes switching from on-call to telemedicine physician coverage during off-hours could reduce hospitalizations and therefore generate cost savings to Medicare. Studies implementing telehealth with this purpose saw the raw rate of hospitalizations declined by nearly 10 percent. Telehealth will have a downstream impact that will reduce low-value care indirectly at a variety of other care sites.

Research shows the amount of follow-up care generated by telehealth visits vary, which is unsurprising as the necessary follow-up is dependent on the nature of the initial visit. It seems that telehealth may be considered to combat overuse for certain medical concerns and contribute to overuse for others. One recent study found that around ten percent of telehealth visits for acute respiratory infection led to subsequent in person visits, making them additive rather than substitutive care. Without access to ancillary testing, it can be difficult to diagnose some conditions through telehealth which may lead to over-prescribing for conditions like ear infections. On the other hand, others found that telehealth mitigated secondary care use, such as referrals to specialists, which may be attributed to less financial incentive for providers. Additionally, there have been declines in diagnostic testing and medications prescribed by cardiologists through telehealth platforms. Telehealth is most effective for specialties such as dermatology, psychiatry, infectious disease, and pain management. Specialties where telehealth visits were considered less valuable include oncology, sports medicine, and gastroenterology.

In sum, overconsumption remains rampant and proves difficult to combat due to the challenge of accurately identifying appropriate and inappropriate care. With the rapid emergence of telehealth, the implications of this new care model on the overuse of care are important to consider. Research suggests that this new care model may open opportunities to cut back on wasteful health spending by reducing low-value care at in-person care sites as well as directing these platforms to more high-value care. However, the true role that telehealth will play, in either contributing or combatting the issue of overuse, will likely depend on which treatments and diagnosis are being sought remotely.