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Expansion of virtual health care—real-time video consultation with a physician via the Internet—will continue as use of mobile devices and patient demand for immediate, convenient access to care grow.
The objective of the study is to analyze the care provided and the cost of virtual visits over a 3-week episode compared with in-person visits to retail health clinics (RHC), urgent care centers (UCC), emergency departments (ED), or primary care physicians (PCP) for acute, nonurgent conditions.
A cross-sectional, retrospective analysis of claims from a large commercial health insurer was performed to compare care and cost of patients receiving care via virtual visits for a condition of interest (sinusitis, upper respiratory infection, urinary tract infection, conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, digestive symptom, or ear pain) matched to those receiving care for similar conditions in other settings. An episode was defined as the index visit plus 3 weeks following. Patients were children and adults younger than 65 years of age without serious chronic conditions. Visits were classified according to the setting where the visit occurred. Care provided was assessed by follow-up outpatient visits, ED visits, or hospitalizations; laboratory tests or imaging performed; and antibiotic use after the initial visit. Episode costs included the cost of the initial visit, subsequent medical care, and pharmacy.
A total of 59,945 visits were included in the analysis (4635 virtual visits and 55,310 nonvirtual visits). Virtual visit episodes had similar follow-up outpatient visit rates (28.09%) as PCP (28.10%,
Virtual care appears to be a low-cost alternative to care administered in other settings with lower testing rates. The similar follow-up rate suggests adequate clinical resolution and that patients are not using virtual visits as a first step before seeking in-person care.
Health care delivery is moving outside traditional settings of physician offices and emergency departments (EDs) into convenient quick-care sites [
Because telehealth and particularly virtual visits are relatively new care options, published literature is lacking, with previous studies largely focused on acceptability or patient characteristics rather than outcomes [
Virtual visits have recently become available through independent online health care delivery sites that are often covered by patients’ health plans [
To expand our understanding of the care provided and costs associated with virtual health care, we examined the care for specific acute, nonurgent conditions (eg, colds, allergies, urinary tract infections) provided by physicians via a virtual visit platform. Care provided through virtual visits, including subsequent care during a 3-week follow-up period, was compared with care delivered in the RHC, UCC, ED, and PCP office settings. This study is unique in assessing care and costs of virtual visit episodes, in contrast to previous studies of telehealth costs that have assessed structured e-visits only or have not taken into account follow-up care after the initial visit.
This cross-sectional retrospective study used data from commercially insured members receiving virtual care matched to members receiving care for similar conditions in other settings. The claims-based dataset was derived from the HealthCore Integrated Research Database (HIRD), a large administrative claims database containing medical and pharmacy claims for 14 Anthem commercial health plans geographically dispersed across the United States. The patient sample was identified from claims with service dates during the study period, January 1, 2014, through May 11, 2015. Researchers had access to a limited dataset containing no patient identifiers. This study was conducted in full compliance with the Health Insurance Portability and Accountability Act. This study was nonexperimental and was exempt from investigational review board approval.
The index date was defined as the date of the first outpatient or ED claim in a 3-week period for 11 of the most commonly diagnosed conditions through the telehealth platform: sinusitis, upper respiratory infections (URIs), urinary tract infections (UTIs), conjunctivitis, bronchitis, pharyngitis, influenza, cough, dermatitis, nausea/vomiting/diarrhea, and ear pain, based on
The study included adults younger than 65 years of age and children who had health plan eligibility for at least 6 months before and 3 weeks after the index date. Patients with serious or expensive health conditions, defined by Deyo-Charlson Comorbidity Index (DCI) scores of greater than 2, or with cystic fibrosis, transplant, end-stage renal disease, HIV, hemophilia, stroke, or respiratory failure were excluded.
Visits for conditions of interest were classified according to the setting where the visit occurred: virtual (identified by Current Procedural Terminology [CPT] code 99444 and tax ID, representing all covered telehealth visits), RHCs (identified by tax ID and National Provider Identifier [NPI] numbers), UCCs (identified by tax ID and NPI numbers; only large national UCC chains included), EDs (identified by revenue codes and CPT codes), and PCP offices (identified by CPT codes for outpatient evaluation and management visits with provider specialty noted as primary care, internal medicine, general medicine, or pediatrics).
An episode was defined as the index visit plus 3 weeks following. If patients had 2 or more potential index visits less than 3 weeks apart, only the first visit was used to identify an episode. If patients had more than 1 visit on the same day, a hierarchy was used to determine the index visit (as opposed to follow-up visit). The hierarchy was virtual > RHC > PCP > UCC > ED; this order was chosen due to likelihood of patients going to a more “urgent” care location after a different option was tried if more than 1 location was visited in a single day.
Members receiving care from RHC, UCC, ED, and PCP offices were matched to those with virtual visits in a 3:1 ratio for each location (to increase statistical power) on acute condition, quarter and year of index date, state/region of residence, and child (<18 years) or adult age group.
The primary outcome measures were care provided (utilization during and following the visit) and cost of care. The follow-up period for outcomes assessment was from the index date to 3 weeks after to allow sufficient time for most minor conditions to resolve [
Care provided was assessed by subsequent medical care after the initial visit (ie, outpatient evaluation and management visit [follow-up visit], ED visit, or inpatient hospitalization), laboratory tests performed, imaging performed, and antibiotic fill rates and use of broad-spectrum antibiotics, for patients where pharmacy data were available. Allowed cost per episode included the cost of the initial visit, subsequent medical care, and pharmacy costs.
All care and costs during the 3-week episode were included, not just those for care with the same diagnosis as the index visit, since it is difficult to determine whether subsequent care is related to the initial visit (eg, pneumonia can develop after a different infection).
The outcome measures were analyzed to determine differences between virtual visits and other locations of care. A significance level of α<.05 (2-sided) comparing each location with virtual was considered for all analyses (
A total of 4635 virtual and 55,310 in-person visits were included in the analysis (13,832 RHC; 13,757 UCC; 13,840 ED; 13,881 PCP; see
Attrition; number of virtual visits at each step.
Visits by diagnosis.
Diagnosis | Virtual, n (%) | RHCa, n (%) | UCCb, n (%) | EDc, n (%) | PCPd, n (%) |
Sinusitis | 1689 (36.44) | 5055 (36.55) | 5062 (36.80) | 5029 (36.34) | 5060 (36.45) |
Upper respiratory infection | 849 (18.32) | 2540 (18.36) | 2534 (18.42) | 2537 (18.33) | 2541 (18.31) |
Urinary tract infection | 413 (8.91) | 1240 (8.96) | 1238 (9.00) | 1236 (8.93) | 1239 (8.93) |
Bronchitis | 397 (8.57) | 1191 (8.61) | 1195 (8.69) | 1188 (8.58) | 1192 (8.59) |
Conjunctivitis | 356 (7.68) | 1070 (7.74) | 1035 (7.52) | 1071 (7.74) | 1068 (7.69) |
Pharyngitis | 285 (6.15) | 854 (6.17) | 853 (6.20) | 851 (6.15) | 853 (6.15) |
Cough | 158 (3.41) | 471 (3.42) | 473 (3.44) | 469 (3.39) | 472 (3.40) |
Contact dermatitis | 145 (3.13) | 435 (3.14) | 410 (2.98) | 432 (3.12) | 432 (3.11) |
Influenza | 140 (3.02) | 418 (3.02) | 386 (2.81) | 419 (3.03) | 417 (3.00) |
Digestive symptoms—diarrhea, nausea, vomiting | 104 (2.24) | 260 (1.88) | 310 (2.25) | 312 (2.25) | 311 (2.24) |
Ear disorders—ear pain | 99 (2.14) | 296 (2.14) | 261 (1.90) | 296 (2.14) | 296 (2.13) |
Total | 4635 (100) | 13,832 (100) | 13,757 (100) | 13,840 (100) | 13,881 (100) |
aRHC: retail health clinic.
bUCC: urgent care center.
cED: emergency department.
dPCP: primary care physician.
In the RHC, UCC, and ED groups, the highest proportion of patients were 18 to 34 years of age, whereas the highest proportion of virtual patients were 35 to 49 years, and 50 to 64 years in the PCP group (
Baseline characteristics.
Virtual, 4635 | RHCa, 13,832 | UCCb, 13,757 | EDc, 13,840 | PCPd, 13,881 | ||||||
mean (SD) / n (%) | mean (SD) / n (%) | mean (SD) / n (%) | mean (SD) / n (%) | mean (SD) / n (%) | ||||||
Age of adults, mean (SD) | 40.1 (10.8) | 39.3 (12.7) | <.001 | 37.5 (13.1) | <.001 | 38.1 (13.5) | <.001 | 42.7 (13.2) | <.001 | |
Age of children, mean (SD) | 8.4 (5.2) | 9.8 (4.7) | <.001 | 9.4 (5.1) | <.001 | 7.1 (5.4) | <.001 | 7.1 (5.1) | <.001 | |
<.001 | <.001 | <.001 | <.001 | |||||||
<18 | 557 (12.0) | 1664 (12.0) | 1622 (11.8) | 1676 (12.1) | 1675 (12.1) | |||||
18-34 | 1414 (30.5) | 4814 (34.8) | 5510 (40.1) | 5355 (38.7) | 3543 (25.5) | |||||
35-49 | 1729 (37.3) | 4248 (30.7) | 3912 (28.4) | 3784 (27.3) | 4188 (30.2) | |||||
50-64 | 935 (20.2) | 3106 (22.5) | 2713 (19.7) | 3025 (21.9) | 4475 (32.2) | |||||
Female, n (%) | 2837 (61.2) | 9143 (66.1) | <.001 | 5221 (62.1) | .31 | 8111 (58.6) | .002 | 8472 (61.0) | .83 | |
<.001 | <.001 | <.001 | <.001 | |||||||
0 | 4174 (90.1) | 12,856 (92.9) | 12,802 (93.1) | 12,828 (92.7) | 12,205 (87.9) | |||||
1 | 273 (5.9) | 540 (3.9) | 476 (3.5) | 354 (2.6) | 911 (6.6) | |||||
2 | 188 (4.1) | 436 (3.2) | 479 (3.5) | 658 (4.8) | 765 (5.5) | |||||
Diabetes mellitus | 127 (2.7) | 308 (2.2) | .05 | 288 (2.1) | .01 | 329 (2.4) | .17 | 560 (4.0) | <.001 | |
Hypertension | 390 (8.4) | 1081 (7.8) | .19 | 1147 (8.3) | .87 | 1620 (11.7) | <.001 | 1986 (14.3) | <.001 | |
Ischemic heart disease | 23 (0.5) | 91 (0.7) | .19 | 93 (0.7) | .18 | 142 (1.0) | .001 | 184 (1.3) | <.001 | |
Congestive heart failure | 4 (0.1) | 7 (0.1) | .39 | 12 (0.1) | .99 | 20 (0.1) | .34 | 14 (0.1) | .78 | |
Chronic obstructive pulmonary disease | 23 (0.5) | 30 (0.2) | .002 | 32 (0.2) | .005 | 66 (0.5) | .87 | 127 (0.9) | .01 | |
Asthma | 190 (4.1) | 380 (2.7) | <.001 | 409 (3.0) | <.001 | 443 (3.2) | .004 | 596 (4.3) | .70 |
aRHC: retail health clinic.
bUCC: urgent care center.
cED: emergency department.
dPCP: primary care physician.
e
Subsequent outpatient medical care after the initial visit was similar between virtual visits and other treatment settings. The percentage of follow-up visits within 3 weeks of the index visit, which is a potential indicator of misdiagnosis or treatment failure, was similar between the virtual (28.09%), RHC (28.59%;
Care patterns.
Virtual | RHCa | UCCb | EDc | PCPd | ||||||
n (%) | n (%) | n (%) | n (%) | n (%) | ||||||
Outpatient evaluation and management visit | 1302 (28.1) | 3955 (28.6) | .51 | 3525 (25.6) | .001 | 4732 (34.2) | <.001 | 3900 (28.1) | .99 | |
ED visit | 61 (1.3) | 223 (1.6) | .16 | 368 (2.7) | <.001 | 895 (6.5) | <.001 | 255 (1.8) | .02 | |
Inpatient visit | 7 (0.2) | 39 (0.3) | .12 | 57 (0.4) | .01 | 133 (1.0) | <.001 | 52 (0.4) | .02 | |
582 (12.6) | 5089 (36.8) | <.001 | 5367 (39.0) | <.001 | 7356 (53.2) | <.001 | 5192 (37.4) | <.001 | ||
UTI | 85 (20.6) | 1085 (87.5) | <.001 | 1189 (96.0) | <.001 | 1222 (98.9) | <.001 | 1095 (88.4) | <.001 | |
Pharyngitis | 45 (15.8) | 770 (90.2) | <.001 | 719 (84.3) | <.001 | 560 (65.8) | <.001 | 627 (73.5) | <.001 | |
Sinusitis | 185 (11.0) | 949 (18.8) | <.001 | 1243 (24.6) | <.001 | 2351 (46.8) | <.001 | 1302 (25.7) | <.001 | |
Bronchitis | 40 (10.1) | 285 (23.9) | <.001 | 271 (22.7) | <.001 | 648 (54.6) | <.001 | 308 (25.8) | <.001 | |
307 (6.6) | 826 (6.0) | .11 | 1207 (8.8) | <.001 | 5960 (43.1) | <.001 | 1563 (11.3) | <.001 | ||
Cough | 18 (11.4) | 46 (9.7) | .55 | 106 (22.4) | .003 | 397 (84.6) | <.001 | 111 (23.5) | .001 | |
Bronchitis | 34 (8.6) | 114 (9.6) | .59 | 193 (16.2) | <.001 | 844 (71.0) | <.001 | 212 (17.8) | <.001 | |
UTI | 34 (8.2) | 85 (6.9) | .35 | 132 (10.7) | .16 | 763 (61.7) | <.001 | 227 (18.3) | <.001 | |
URI | 69 (8.1) | 144 (5.7) | .01 | 203 (8.0) | .91 | 1067 (42.1) | <.001 | 236 (9.3) | .31 | |
Sinusitis | 90 (5.3) | 287 (5.7) | .59 | 358 (7.1) | .01 | 2152 (42.8) | <.001 | 497 (9.8) | <.001 | |
Any of the 6 infections below | 1918 (70.5) | 4193 (64.2) | <.001 | 4243 (67.9) | .02 | 3534 (56.7) | <.001 | 4477 (68.2) | .03 | |
Sinusitis | 971 (83.9) | 2340 (86.3) | .06 | 2084 (79.2) | .001 | 1835 (67.8) | <.001 | 2327 (82.9) | .42 | |
Pharyngitis | 130 (74.3) | 138 (29.6) | <.001 | 236 (53.8) | <.001 | 199 (46.4) | <.001 | 249 (53.7) | <.001 | |
Bronchitis | 191 (68.5) | 278 (40.8) | <.001 | 521 (76.4) | .01 | 393 (62.1) | .06 | 545 (78.1) | .002 | |
Conjunctivitis | 157 (63.8) | 463 (78.6) | <.001 | 363 (64.9) | .76 | 278 (51.8) | .002 | 373 (61.1) | .47 | |
UTI | 217 (76.4) | 628 (90.5) | <.001 | 473 (74.0) | .44 | 419 (65.6) | .001 | 415 (62.6) | <.001 | |
URI | 252 (43.5) | 346 (24.9) | <.001 | 566 (43.7) | .30 | 410 (31.9) | <.001 | 568 (43.0) | .82 | |
Broad-spectrum antibiotic as first-line treatmentg | 1219 (69.0) | 2299 (60.0) | <.001 | 2561 (66.3) | .04 | 1961 (61.9) | <.001 | 2704 (69.3) | .82 |
aED: emergency department.
bPCP: primary care physician.
cRHC: retail health clinic.
dUCC: urgent care center.
e
fSample includes patients with the condition of interest and pharmacy coverage.
gSample includes patients with antibiotics fill without history of antibiotic use in prior 60 days.
Overall laboratory tests within 3 weeks of the index date (including during the initial visit for nonvirtual visits) were lower for the virtual group (12.56%) compared with RHC (36.79%;
Overall antibiotic fills within 3 days for the 6 most commonly treated infections (excluding influenza) was somewhat higher in the virtual group (70.51%) compared with all other sites (RHC 64.18%;
Broad-spectrum antibiotics were used as first-line treatment in the virtual group (68.99%) at a similar rate to the PCP group (69.28%;
Total costs per episode were $36, $153, $1735, and $162 more expensive at RHC, UCC, ED, and PCP settings, respectively, compared with virtual visits (
Cost of retail health clinic and urgent care center visits compared with virtual visits, adjusted for age categories and baseline comorbidities.
Virtual | RHC | UCC | ||||||
n | Mean, $ | n | Mean, $ |
Relative |
n | Mean, $ |
Relative |
|
Index visit | 4635 | 49 | 13,832 | 74 |
1.52 |
13,757 | 134 |
2.75 |
Follow-up, medical | 4635 | 200 | 13,832 | 204 |
1.02 |
13,757 | 266 |
1.33 |
Pharmacy | 3182 | 90 | 7518 | 97 |
1.08 |
7188 | 92 |
1.03 |
Total (sum, estimate) | 339 | 375 | 1.11 | 492 | 1.45 |
aMean cost, adjusted to virtual visit distribution of age and comorbidities.
bRelative = ratio of how much more expensive RHC/UCC visits are compared with virtual visits after adjustments.
Cost of emergency department and primary care physician visits compared with virtual visits, adjusted for age categories and baseline comorbidities.
Virtual | ED | PCP | ||||||
n | Mean, $ | n | Mean, $ |
Relative |
n | Mean,$ |
Relative |
|
Index visit | 4635 | 49 | 13,840 | 1404 |
28.87 |
13,881 | 109 |
2.25 |
Follow-up, medical | 4635 | 200 | 13,840 | 584 |
2.92 |
13,881 | 288 |
1.44 |
Pharmacy | 3182 | 90 | 7227 | 86 |
0.96 |
7629 | 104 |
1.15 |
Total (sum, estimate) | 339 | 2074 | 6.12 | 501 | 1.48 |
aMean cost, adjusted to virtual visit distribution of age and comorbidities.
bRelative = ratio of how much more expensive ED/PCP visits are compared with virtual visits after adjustments.
As expected, the adjusted mean cost of the initial visit was lower for the virtual group ($49) than for RHC ($74;
While average episode costs differed by condition, they tended to follow a similar pattern of virtual visits having lower medical costs than care at other locations across conditions (
Follow-up medical costs, unadjusted.
This retrospective, real-world analysis demonstrated that care received through virtual visits for nonurgent conditions was comparable to that received in in-person health care settings. Patients receiving care through virtual visits had similar follow-up outpatient evaluation and management visit rates as patients using other locations. This finding suggests not only that patients using virtual visits had their health problems resolved at similar rates as patients treated at other locations but also that patients were not using virtual visits as a first step before seeking in-person care. Interestingly, follow-up visit rates for the virtual group mirrored patients’ self-reported resolution of symptoms. An informal survey administered as part of the health plan’s virtual care program found 79% of patients who used it reported complete resolution of their health care concerns (personal communication, W Adamson).
Lab testing rates, both overall and at the individual diagnosis level, were lower during virtual visits episodes than all in-person settings. Lab testing may be high at in-person locations for some conditions where it may not be needed to confirm the patient’s diagnosis [
Episodes for patients who sought care at any of the in-person settings were more expensive than similar episodes beginning with a virtual visit. In addition to the virtual visit itself being less expensive than in-person visits, follow-up medical costs were lower after virtual visits than all other locations except for RHCs. Some of the lower episode costs can be attributed to lower rates of ED or inpatient follow-up care in addition to lower laboratory and imaging rates during the episode.
A unique strength of this study was the large database allowing for a 3:1 match of episode-based care received in a number of alternative settings, but the exclusive use of claims data introduced several limitations. The accuracy of the diagnosis in claims may be a particular concern for virtual visits, where it may be more difficult for providers to diagnose a condition without a physical examination or supporting laboratory tests. Such errors not only may lead to inaccuracies in cost comparisons, but may also affect care patterns. It is not possible to determine disease severity from a diagnosis code alone, so cases seen in the ED, for example, may have been more severe, requiring more treatment than an average case handled by a virtual visit. Furthermore, claims do not provide complete information on the reasons patients chose a specific site of care. While patients may have chosen the ED because they perceived it to be the most convenient option even for a minor illness, it is also possible they believed their condition was severe and required urgent medical attention. However, the conditions included in this study tend to be relatively minor and treatable in nonurgent settings. Additionally, patients who chose virtual visits may have differed from those who chose other treatment settings in terms of their perception of the urgency of their condition, their health literacy, or their level of comfort using computers [
The rate of antibiotic prescriptions for the conditions included here may warrant additional study. Based on current guidelines and Choosing Wisely recommendations [
Virtual visits are growing rapidly, and our results indicate they are inexpensive alternatives to acute care administered at other locations. Patients receiving care through virtual visits seemed to have adequate clinical resolution compared with patients receiving care elsewhere, based on follow-up visit rates. Patients did receive additional care, such as laboratory testing or imaging, presumably when needed. Virtual visits did not appear to add to the total amount of care received as part of a care episode, as patients did not often seek care through telehealth plus another site for the same condition.
Expansion of virtual health care services is inevitable given the growing use of mobile devices, patient demand for immediate and convenient access to care, and the continuously growing demands on physicians’ time. The focus of further research on virtual health care should be about optimizing patient outcomes for conditions best suited for virtual visits and examining how virtual visits can be used by physicians who have an existing personal relationship with the patient.
International Classification of Diseases, Ninth Revision, diagnosis codes.
Adjusted mean index visit medical, follow-up medical, and pharmacy costs, by condition.
Comparing original and winsorized adjusted costs (sensitivity analysis).
Current Procedural Terminology
Deyo-Charlson Comorbidity Index
emergency department
HealthCore Integrated Research Database
International Classification of Diseases, Ninth Revision
National Provider Identifier
primary care physician
retail health clinic
urgent care center
upper respiratory infection
urinary tract infection
The authors thank D Marc Cram and Dianna Hayden for programming support and Cheryl Jones for editorial assistance. DM Cram, D Hayden, and C Jones are employees of HealthCore, Inc.
Funding for this study was provided by Anthem, Inc. The authors are solely responsible for the study design, data collection, and interpretation; approvals from Anthem were not required for submission.
A Gordon and A DeVries are employees of HealthCore, Inc, a wholly owned outcomes research subsidiary of Anthem, Inc. W Adamson is an employee of Anthem, Inc, who works on LiveHealth Online. The authors were not compensated for this study beyond their salaries.