- The pandemic as well as regulatory changes and more favorable treatment from employers created conditions in which telemedicine visits increased dramatically in March 2020.
- The Employee Benefit Research Institute (EBRI) analyzed a proprietary database containing nearly 150,000 covered lives and nearly 16 million encounters to examine trends in who uses telemedicine, which conditions patients seek to address, and whether there were factors associated with a particular visit being conducted via telemedicine.
- Telemedicine visits spiked during March 2020, when states issued stay-at-home orders and health care providers suspended nearly all in-person outpatient services. While patients’ use of telemedicine for visits decreased after April 2020 from their meteoric highs, there is evidence that telemedicine visits have remained persistently higher than their prepandemic trends.
- Telemedicine users tended to be older and disproportionately female relative to patients who do not use telemedicine. The vast majority of telemedicine users had only one or two encounters with a health care provider via telemedicine, possibly indicating that telemedicine services were used to address acute needs or were used as a bridge for patients with chronic conditions.
- Telemedicine was used more frequently for respiratory symptoms and mental health issues, while face-to face was used more frequently for musculoskeletal and connective tissue problems.
- Named policyholders were more likely to seek care via telemedicine than their spouses or dependents, perhaps indicating that named policyholders were more comfortable seeking care for themselves via telemedicine, were more familiar with their employer’s telemedicine offerings, or were better-informed at work about the cost benefits and availability of telemedicine services.
This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, ICUBA, JP Morgan Chase, Pfizer, and PhRMA.
Figure 6 Frequency of Telemedicine Visits by Patients, by Type of Visit Figure 4 The c W Wha St ould a et us find g rindic t oup a s a tM ha a of ake tna t ete he m a m e s k p c d now loy om a V polic e p le rosi s is d y g fr hold tit e ion o m ga a e of w p rTe , hic w tw eale le h th he s a m m rls e eis d d o e pic e dicin aine a op ss taoc le b v a ia is cse e ov it te s c d e w V ra ha w e is s p d itnge it h a bop y ? d tula highe he som t e m da e r int in p w lik ha r eod lih olic t a uc ood s t ye hold he d of a e p a tr a e ’nde s p le a p m rla tm e ic n dic ula ic a ine p rr e r og vuna is prla it e w ss tb for a e er ing d e m . t It ha c n p o ond tt he a the ruc tir ic y tw ula e td or oo rov k , e a ve r ris s r e it s Jake Spiegel is a Research Associate at the Employee Benefit Research Institute (EBRI). This Issue Brief was written Who, What, When, Whe Telr em e ed, icine a as n F a d igure Med W ium 3hy: TTren elemedicined ass a S i ervn ice Telemedicine 12,000 Average Age of Telemedicine-as-a-Service (TaaS), Telemedicine-as-a-Medium (TAM), 2 The list of approved telemedicine codes as well as billing modifiers is referenced by Gross (2020) and Yeramosu et al. on a t for e ble le a m m tte e o rnt ia dtic a l ak ine b l d e a si is a . s in 201 d or In p vd ae nt a rs v r a T tg ic el 8 e ia ula . emed of A TA rft ,te e M crlont ie ci inc tm he n r e rollin e d e p -ic a as rsed og ine g - a rfor a -ser in Ser m ot rv w eic v he la aie s w ce ts. riv v e (T e a ll p raaS) i-op a rb eul c le ea siv an r , it e ty he d d b T b e lik y el g w e emed inn lih oring ood ker ici s, t in A of nhe ea p - r as y p il a ,r- rolle a a tic t - M tula d he ed itr out iout v uis m set of it t (T o be A ting he M the )rceond st pa of nde uctthe e m dir ic v , ia a nd TaaS with assistance from the Institute’s research and editorial staffs. Any views expressed in this report are those of the Given that we have observed systematic differences between patients who use either flavor of telemedicine and and Face-to-Face (F2F) Users, by Year Usage From 2016 –2020 (2019). Visits per 1,000 Enrollees, Over Time for r ee m m p a a loy ine naem d e s e t he d fr om p m olic ost 20 yhold 19 pop onw e ula r w ra ar ds d ia .150 g The nosi pd e s for a rc te ab nt TA a se hig M a he v lsis o rit td s ha iff unt n fo eril en rN t a ia ov tspouse e em s b be etrw , ow ere he d n ca en pe rre nd espir r ee nt c ae . tiv or The e yd is tlik su hre oug elih s onc ood h ae of t e ale g aa m p ine a d rbtic e icc ine ula am rp e v la tis he tfit or m Figure 5 a put atie hor nt s w and ho shd ould o not not , the ber ea sc ma ribe y ed xis to t fa the ct or offic s tha ers, t t arre us st tere ong s, or ly c ot or he rerla sponsor ted with a s of spe EBR cifi I, cE he mp aloy lth ca ee rB ee v ne isfit it bRe eing search 90 45 Figure 2 While telemedicine visits have remained persistently higher after the onset of the COVID-19 pandemic, it remains to be TaaS TAM F2F 3By Jake Spiegel, Emp Averag loye e C eh Ben arlsoe nfi C t R omo esre ba id rch I ity Inns dex titut of Pati e ents, by Mode of Delivery a p bnd r ee ing dc om acrond e ina re nt uc ce triv e ed e ad son for v ia by TA a d M, ut ocili m tor zin ea rg nw e m TA hil ot M e e, , ly p w , ea su rs ha c6h a p 4s ps ove te he rc e re nt rflect t he highe ion phone rr teha su or n if lt of via the sea v ide p sona aoc tieonfe nt l c old wra es s nc , aa ing s sh spouse te ow chnolog n b or e dlow ey p, e e nde in na Fi b nt g lin ur . g Thi e us 8. s c to ould Institute-Education and Research Fund (EBRI-ERF), or their staffs. Neither EBRI nor EBRI-ERF lobbies or takes positions c ond Inde uc ed te , d a ov Wa elrd tte ele st m fo er da ic ine struc . W tura e d l o bre not ak m coanf ke irms a c tha aus Taa t athe l S ar g tre um nd TA e nt o Mf b put ers ins istetntly ead hig aim he tr o te ele xa me mine dicine the v is faits ct or —s b— oth and TaatS he air nd Face-to-Face (In-Person) Visits per 1,000 Enrollees, Over Time 10,000 August 5, 2021 • No. 534 seen the extent to which the virtual-health-care-seeking behavior formed during the COVID-19 will persist in a post- b Me be et a a te nw r re unde flect hile, ion th rfor sta nd TA aM td na iff vis e m rite e s, r nt d p e uolic spir se y ca hold atses orye for r is s m su te e as w le y m be e er d e m ic tor ine he e .m c om ostfor cotm abm leon sed eia king gnos ca ers for e via m teost lem of edtic he ine p a for nde the mic ir, ow as sh n ne ow ed n s, TAM — remains in place after April 2020. The p-value for a Wald test for structural break in March 2020 with TaaS visits was on relaspe tivec ifi stc r epngth olicy — pr op tha osa t m ls a. yE inf BRI lue inv ncit ee ts c heo m mod me ant lity on of tc hi as r re e sought search. . We model the likelihood of a given health care visit 80 40 0.9 pandemic world. Similarly, the impact of telemedicine on patients’ health status, the downstream impact on in-person < 0.01, and it was < 0.01 for TAM visits. Following March 2020, the p-value of the Wald test for each month was greater than b or e low it could in Fi r ge ur flect e 9. t he Se vfa erca t l d tha iatg na noses, med su polic ch a yhold s gee nit rs t our ende inardy tis o su be e s a oldnd er on infeacvte ious rag e a,nd sinc pa er a dsi ep tic e nd isseue nts s low , rem ea re in ded the being conducted via telemedicine as a function of the patient’s age, gender, status as named policyholder, and type of 3,500 I he nt altr h ca oduc re sought tion , and the spending and price differences on telemedicine services relative to in-person services are 0.05. a pv ee rsi ra st ge ent aly ge m of ornon e pop -polic ulary hol ford p ea rtsie . nt Alts se erna ek tiv ing elyc, atrhis e d m ura ing y b tehe a p re aflect ndem ion th ic via a tTa the aS na tha mn e dTA polic M, c yonfir holde m ring is m the ore fin int dim ings ately Suggested citation: Spiegel, Jake, “Who, What, When, Where, and Why: Trends in Telemedicine Usage From 2016– care sought, and we include a dummy variable indicating the presence of the COVID-19 pandemic to capture the 0.795 Wh 70 o, What, When, Where, and Why: Trends in Telemedicine 35 8,000 0.8 unknown. EBRI plans to leverage this claims database to answer those questions in the future. One Mode of Delivery, Two Different Flavors The COVID-19 pandemic radically altered the consumption of he4alt 'h care services. States issued stay-at-home orders, 4 sh fam ow ilin in ar wFi ith th gure e 7 a full r bov ange e. of services covered by their health care plan and therefore may be more likely to understand 2020,” EBRI Issue Brief, no. 534 (Employee( Benefit Research I ) nstitute, August 5, 2021). si For gnifT icaa ant S v cis ha its nge , the in m mood dea l is lit ie sp s eb cifie roug d a ht s :a Pr bout ???????? b??y t = he ?????? pa|n ?? d,e ?? mic = . ?? To ?? e + xplo ?? ,r e w he wh re e t??he is r ta he vree c to wr er oe f d fa ec mo torgs m rapor hice ao nd r le ss ?? ?? ?? ?? ?? ???? Usage From 2016 –2020 3,000 ' hospit Beforea e lsxplor posting pone the d e dle em ctiv og er a su phic rges of ries, te ale nd md eoc dictine or’s offic users a es c nd losed the . tyAps a es of resu calt r, e tthe he y d e so mught and ,for it is in us -pe erful son he to draaltw h ca a re that telemedicine services are covered by their policy. ( ) treatment variables and ?? contains the error terms. Similarly, for TAM visits: Pr ???????? ?? = ?????? |?? , ?? = ?? ?? + ?? , where ?? is strongly associated with ?? a visit being conducted via TAM or TaaS, we estimate tw ?? o logistic ??reg ?? ression mod ?? els, the ?? 60 ???? 30 2 Copy0. rig 7 ht Information: This report is copyrighted by the Employee Benefit Research Institute (EBRI). You may copy, dropped precipitously. Telemedicine visits, meanwhile, exploded in popularity, in part because it represented the only a d is vt einc ctotr ion of d be emo twe ge ra n pthic wo ad nd iff e tre rea nt tme im nt ple va m ria ent ble as tions and of ?? t ce ole nta mins ed ic the ine e , rro whic r te h r rm esp . rBoth esentmo did st ein lsc a t re us e es tima cases te.d us If th ing e se clus tw teo red By Jake Spiegel, Employee Benefit Research I ?? nstitute coefficients of which are shown below in Figure 10. References Figure 8 6,000 Interestingly, a one-unit increase in a patient’s CCI had the opposite effect that might be expected given the earlier s pta rint nd, aor rd d eo rro wrs nloa . d this report solely for personal and noncommercial use, provided that all hard copies retain any and t m yp od es of e of tceale re m a ev daic ila ine bl eser for v ic m eost s a rnon e lum -em peedr g tog enc ey the he r, alt ah ca nalyses re se run t rvice he s. risk of confounding underlying trends. The first 50 2,500 25 Most Common Diagnosis Group Codes for Telemedicine-as-a-Medium Visits Over Time American Medical Association Telehealth Implementation Playbook. 2020. finding that both TaaS and TAM users had higher CCIs than F2F users. Holding all else equal, a one-unit increase in CCI all copyright and other applicable notices contained therein, and you may cite or quote small portions of the report We find several factors associated with an increased likelihood of a particular health care visit being conducted via fla 5 vor0. of 6 telemedicine, which we call telemedicine-as-a-service (TaaS), is where services are delivered via a third-party It should be noted that diagnoses for respiratory issues decreased from 2019 to 2020, from 208,624 to 179,309. However, March April May June July August September October November December A side from the stay-at-home orders, there were other factor s that contributed to the meteoric rise in telemedicine visits (i.e., going from a CCI of 2 to a CCI of 3) was a Ass T oc iatA ed wit G h a Ln 18.3 p A N e C rce E nt decrease in the likelihood of a given visit provided that you do so verbatim and with proper citation. Any use beyond the scope of the foregoing requires EBRI’s p tela letm for em dic a ine nd . in w In phic arth th icula er ,p hold atient ing ha ot s no her p vr ae ri-a eb xis les c ting onst rela ant tions , 0 .5 w 3hip e 1 fin wdit h he that a alt p h ca atiernt e p breoing vide fe rs. m a Te lela inc doc re, aD se oc d ttor he on COVID 40 -19 diagnoses accounted for 16 percent of all respiratory issue diagnoses in 2020, indicating that these results do not A shwood, J Scott, Ateev Mehrota, David Cowling, and Lori Uscher-Pines. “Direct-to-Consumer Telehealth May Increase 20 during tSy hem ppa to nm de sm , Iic ll-. Regulatory barriers were temporarily lowered as the Centers for Medicare and Medicaid Services being c 4,ond 000 ucted via TaaS and a 10 percent decrease in the likelihood of a given visit being conducted via TAM. This prior e 2,xpress 000 permission. For permissions, please contact EBRI at permissions@ebri.org. likelihood of a visit being conducted via both flavors of telemedicine. For TaaS visits, a given visit being conducted over D seeem m ato nd, b e a nd driv MD en liv bye COVID are seve -19 ra co l nc sue crh p ns.r oviders that have grown rapidly in recent years. For example, a patient seeking Respiratory 0.5 Mental Mental Mental Mental Mental Respiratory Respiratory Access to Care, But Does Not Decrease Spending.” Health Affairs. March 2017. Defined Mental Disorders (CMS) expanded the list of covered telemedicine services (Spiegel 2021). Many private insurers lowered or waived cost- could be a reflection of the fact that very ill patients prefer to — or perhaps need to, given that telemedicine is not Systm te em e ledm ice ad l c ica ine re w wa ould s 47 log .5 pin t erco ent an a mor ppelic lik ateion ly D is if t t oo rd he re ers cpeaiv tie eD nt on is o w -d rd aes em rs fe am nd aD le ca i sr ro e erd , laor e tiv rs e sc the o D d aiule s m ord a a le en rs , a ap nd point D itis w om rd ae se n rs 33 t t.5 o rpee Sy cre c s iv e te nt em cm aror e e a t Sy stem 30 • The pandemic as well as regulatory changes and more favorable treatment from employers created conditions Conditions Repo15 rt availability: This report is available on the internet at www.ebri.org sharing requirements for patients seeking care via telemedicine. Similarly, some employers nudged their workers to feasible for all types of care — access health care services in person. likely for TAM visits. An additional year of age, meanwhile, had a relatively smaller impact on a visit being conducted their convenience, from a remote health care provider they ha ve not met before. The second flavor, which we call in which telemedicine visits increased dramatically in March 2020. Barbosa, William, Kina Zhou, Emma Waddell, Taylor Myers, E. Ray Dorsey. “Improving Access to Care: Telemedicine 1, 0.500 4 see k care via telemedicine by eliminating copays for telemedicine visits entirely. 2,000 t ve ia le tm ele ed m ice ine dic ine as a . W mhil edeium the ( c TA oe M), is e fficientxe wm as st plifa ietd ist b ic ya a lly p si atgie nif ntic ut ant ili, zin the g vod ide doc s ron atio ferindic encing ateor s only rem ot a d e em m onit inim oris ing d ecrease in Symptoms, 20 Symptoms, Ill- Symptoms, Symptoms, Symptoms, Symptoms, Across Medical Domains.” 0.33 Annual Review of Public Health, 2021 42:1, 463-481 Respiratory Mental Mental Finally, we find that the pandemic dummy variable significantly increased the likelihood of a health care visit being 10 Table of Contents Ill-Deftihe ned lik • e M lih eThe nood tal D E of m iso p a rd loy v eis rs eit e b Be eing ne Dfit ec fiond n Re edsea uctr ecdh I v Illia ns -D tt ee it fle iu nt e m e d e (d Eic BIine RI ll-D ) e fa for ina n ee ly da ze ch o dI lla -D ne p e -rfy op in ee a rd ire inc tarIry lle -D d aa se etfa inin b ea da se pc aont tient aini ’s ng agene . arly 150,000 t echnologies, such as blood pressure and respiratory flow rate monitoring, to engage with a doctor with whom the System Disorders Disorders Despit 0.e 3 its growing popularity, there is still precious little empirical research into telemedicine. While trends in conducted over telemedicine. This comports with expectations, given the meteoric rise in both types of telemedicine Introduction .......................................................................................................................................................... 3 Conditions Conditions Conditions Conditions Conditions Conditions 1,000 covered lives and nearly 16 million encounters to examine trends in who uses telemedicine, which conditions G pa ross tient 10 , G aa lrre ya N dy . “ha Cod s a ing relTe ations leme hip dic, ine su cVi h a sits t s for heir P p rop rim ea r rRe y c im arb eur pseme hysicia ntn .” or C ur psy rec nt holog alleris gty, a or nd a a he sta hm lth ca a rerp eo p rr ts ov vide ol. r20 w,11 ho is telemedicine usage have been well-documented, particularly the benefits of telemedicine as a tool to improve access to visits observed as the COVID-19 pandemic hit the United States. For TaaS visits, a health care encounter occurring 5 The type of care sought by patients had statistically significant impacts on the likelihood of a visit being conducted via A 73 b. out Oc ttob he p0e aD rt ie a 20 tnt a20 ................................ s se . ek to address, and ................................ whether there were fa ................................ ctors associated with a ................................ particular visit being ...................... conducted via 3 already in the patient’s network. This flavor of telemedicine proliferated during the COVID-19 pandemic, when health Nervous underserved populations Mu la sc cu kling osk e tr le atns al,p ortation to clinics and out-of-pocket costs, other reSy levm ant pto rm esea s, rSy ch q mp ue tom stions s, Sy mptoms, during or afte1r Ma 2rch 2020 3 4 inc 5reased 6 t 7he lik 8 elih 9 ood 10 of 11 a giv 12en vi 13sit14 being 15 cond 16 uc 17ted 18 via 19 Taa 20 S by 21 279 22 pe 23 rcent 24. For 25 TAM 0.2 t elemedicine as well. Reflecting telemedicine’s apparent appeal to patients seeking to address acute health issues, all Mental 0 t R ee le sm pie ra dto icry ine . System, Respiratory Respiratory Respiratory care providers quickly pivoted to deliver care to patients who could not — or preferred not to —receive it in person One Mode of Delivery, Tw C o oD nn iff ee ctrie ve nt Flavors ................................................................................................ Ill-Defined Ill-Define ........... d Ill-D 4 e fined 500 r emain unanswered (Barbosa et al. 2021). For instance, the demographics of patients who are more likely to seek care visits, the increase in likelihood was even larger at 1,203 percent. Disord e Je e lsff rs er e ey q 0, ua Molly l,Sy a s , pta G et m a ie il D nt ’see Onofr king io, cH ay re ung forP ra ee spi k, Se rTim at nor se ot y hy issu F P es si Sy las tg tte s nif - m Mills icant , lW y Sy ill inc s ia te rm e m a E sed Soa the Sy res I slik teIe m Ilih , Ja ood son A of tH he op vpis eit , N be icing hola cs G ondeuc nets, ed ( Weiner, et al. 2021). These flavors of telemedicine stand in contrast to in-person visits, which we term face-to-face Tissue Conditions Conditions Conditions 2016 2017 2018 2019 2020 via telemedicine, and the determinants of what might increase the likelih 5 ood of a particular health care service being Source: EBRI’s Telemedicine Database Significant Modality Shifts................................ Organs ....................................................................................................... 4 B via idisha Ta • a S N Te a as tle h, w m e ae ll a nd dic s TA E ine dw M v ais r d b it y s spik R 8Me 03lni e pd e c rk d c. ur e“nt Tr ing e ands nd Ma517 rin Em ch 2020 pee rc rg e , e nt w nc , he y re n st D spe ep aca tte riv ts is m ely esu nt . e C Vi da si rst e ta s a sought y-nd at-hom H ospit fore m or ae l Adm d nt er asl he a isnd si aons in He lthe h a als lth ca o inc arlt r eh e aC sed are 0.1 (F2F). Nervsought ous via telemedicine instead of in-person are relativ Ne ely rv o unt us rodden territory. This paper aims to shed some light on providers suspended nearly all in-person outpatient services. While patients’ use of telemedicine for visits Sy the st lik em es in 5 lihood St of atae s i visn t it b he eing First cond Mont ucth es of d via the te le COVI medD ic-ine 19 ; Pa all e nde lsm e ic e q in t ual, hea US.” patie JA ntMA see Ik nt ing erna cal M re for edic m ine ent . 20 al he 20.a lth Mu 0sculoskeletal, Endocrine, Endocrine, Source: EBRI’s Telemedicine Database Who Uses Telemedicine? ........................................................................................................................................ 6 System, System, Circulatory Circulatory Circulatory Circulatory Circulatory Conclusion Unsur prisingly, patients sought different types of care via in- person, TaaS, and TAM visits. Most commonly, patients t hese relaSour tivecly e: unk EBRI’now s Teln a emedi spe cine ct Ds of atabas te elemedicine. inc reased d C e tohe cnrn e e a lik c se te iv lih de a ood fter of Ap N trhe u il 202 tri v tio isn it 0 fr , beom ing t N c he u ond tri irt im o uc ne ,t t eedor vic ia highs, th TaaS by e121 re is p e ev rc ide ent nc a end tha via t t e TA leM me bd yic a ine w hop visitps ing hav 433 e rep m ea rcine ent d. W hile the difference between telemedicine as a service vs. a medium may seem subtle at first glance, differentiating 0 Sense Sense System System System System System What Makes a Visit a Telemedicine Visit? ................................................................................................................ 11 Me sought hrot a c, aA re te for ev a ec t ut al., e r“e The spir a Im tor py a cctond of C itOVI ions v D-ia 19 Ta on aS Out , repparteie sent nt Vi ing sits in 202 nearly 38 0: Vi per si ctes R nt e of mTa aine aSd vSt isa itb s. leThi , Dse spit com ep a or L ts a tw e ith Te lemedicine Tis ha sue s long Face-to be -F eM an c e ett Us out abers oe lid c as a c M onv etab eo nie licnt Tel em and edicc ine ost -a- se -a-S ffe erv ctiicv e Us e m ers eans for hea Tlt elh ca emedirce ine p-r aov s-a- ide Medi rs t um o Ud see rsliver Vi besi tw ts for een th p ceirre c si ula tst we o tnt or ely y n a a highe b nd les us dige r t ha tst o iv n th ce ond is esu ir uc e p ts, m rreic phe ae nde a r nw am na hil ic ly e t ses , rew nds. . eTher re not e is st lik atis ely tic a a lly diff de iff re ent re nt com fop r osit teleion o medic f se ine rv v ic iseit s sough s relativ t eb y to in- Organs Organs previous research indicating that telemedicine is an effective and increasingly common way to treat acute, generally Sur ser v gic ee in C s to ap ses atie ” nt (Csom . The monw pande ealtm h Fund. ic thrus (tFe te ble rua mr ey d ic 20 ine 21 ) int o the spotlight when many providers ceased most elective in- Conclusion ........................................................................................................................................................... 12 person visitSs. ou rce: EBRI’s Telemedicine Database patients via TaaS than by TAM. Telemedicine as a service, on account of the physician lacking a formal pre-existing Nervous Nervous Nervous Nervous Nervous Source: EBRI’s Telemedicine Database EndocA rin bout e, the Data Nervous low-r •is k, Te and lem highly edicine inf us ece tiou rs ts ende respir d t ao tor be y old issu ee rs (P and or dtis noy prop etor atlion . 2016) ately. fe Otm he ale r t y re ple as of tive c to arp ea ctom ientm s w only ho sought do not in us ce lud ed person services on account of the COVID-19 pandemic. Many patients and providers who previously had not used Circulatory Respiratory Circulatory System, System, System, System, System, r Te ela letm ions edhip icine w e itnc h th ount e peartsie of nt, bm ota h va y be rie bte ie ttse d r e su crit ee ad sed to a aft de dr r etss he aA r perla il 202 tively 0 p sie m ap k, ler e aflect cuteing cond the it ion reb , ound typic aof llyin no -pte rson care References ........................................................................................................................................................... 13 Nutrition, System, Sense Patel, Sadiq Y, Ateev Mehrota, Haiden A Huskamp, Lori Uscher-Pines, Ishani Ganguli, and Michael Lawrence Barnett. The “ill-dE em finpe tloy e dle sy em em e B d pe ic tne om ine fit s,” . The Re ca sea re va rfor st ch I m the ns ajt or it ne u itr t ye v of ous sy (EtB eRI lem st ) e a em na dic ly a ine nd ze d us s e ae ns rps ha r eop orrd g ie a only tns ary , a one dnd ata c b or a ar se t ew for o ofe c tnc he laount im gs d enit ea rour s taw for ina ith a rne y he a sy rly a stlt e 15 h ca m0 , ,000 sh reo w n telemedicine Sy s bte efor m e the pandemic experieSy ncs etd e m it for the Sy s fitrest m time. Our Sen sa ena lysis indic Sensa e tes thaSe t en vsee n a fter Se stan ys-e at -home Se nse e am fte err g st ea nt y- , at su -hom ch as a e or n up ders w pere rre espir lifta etdor ayn d tr a dc oc t inf tore ’s offic ction. eIs b nde ee gd a, n tr he eop conv enin eg nie . nc In J e une of r e2c02 eiv 0, i ing n- on pe-rdson v emand isitc s ain re tv he ia Metab olic Organs “Variation in Telemedicine Use and Outpatient Care During the COVID-19 Pandemic in the United States.” HealthAffairs. Figures employees, including their spouses and dependents, of a colle ction o Org f la anrs ge emp O loy rga en rs. The s O da rg ta ab na sse cont Oa rg ins an snearly O 16 rg ans below in p Fi rov gur ide e r 7 .v ia W hil tee le m TA eM dicvine isit,s w poe ss re ibly sim indic ilarly at m ing ost tha com t tem leonl meyd ic sought ine ser for vic e re s w spir ea re tor us y ecd a rte o (a23 dd rpeess rc e ant cut ), ec ne are e d for s o r orders were lifted and health care providers resumed conducting in-person visits, telemedicine engagements remained sy danc tab hr aonous v se recov ide ere oc donfe to the renc leiv ng elsm see ay n in encour Feb arg ua e rpya 20 tie20 nts t , ao lthoug seek h in care - pfo er rson he issues t alt ha h ca t th re e yv is mit as y in subse not have q ue sought nt mon in ths Figure 10 Source:2021. EBRI’s Telemedicine Database. m me illnt ion al d he w isae or ltrh ca e d eus rsre e w d a eas nc s m a o unt uc brh mor idg ers spa e for e c nni p om ang tie mnt onl fiv s w e y y sought iteh arcshr , a onic v cia count T cA oM ning dtitha ions for n vi .ov ae Ta r $6 aS00 or m in ill-ion in perso n mod claimse c s. um Pa ula tietnt ivs se ely. eAkd ing ditio ca na relly in , above their pre-pandemic trend. This could be evidence of a transformational effect of the COVID pandemic regard3ing Fi gure 1, Descriptive Statistics of Patients and Encounters in EBRI’s Telemedicine Database, 2016–2020 ..................... 3 p re em rson aine . d P rlow evious er t ha resea n in rc 20 h 19 sug . g St eill st, st e tha lem t t eedle icm ine ed e icnc ine oun mtaeyr s r ace t m as a aine cd om pe prlim sist ee nt nt rly a thigh her teha r tn a han p dirreec-tp su ande bstm itut ic ele for vels in . - W e also observe differences in gender among TaaS, TAM, and F2F users. Both TaaS and TAM users were more likely to Logistic Regression Output From Modeling the Likelihood of a Health Care E BRI’s Telemedicine Database contains data on nearly 6.5 million prescription drug fills. Descriptive statistics illustrating person, on the other hand, most commonly sought care for musculoskeletal and connective tissue issues (22 percent). how Americans seek out and receive care. Thi pers c son he oulda rlt eh ca flectr e a v he isit sist, anc wit yh o on ne the p appaerrt fin of d ping atietnt ha s t t only o see akb in out -p e 12 rson c perca ernt e w of hil te ele tm hee d pic ande ine m vis icit c s ont sub in sue titut d e to d rfor ag ein - Portnoy, Jay, Morgan Waller, Stephen De Lurgio, Chitra Dinakar. “Telemedicine Is as Effective as in-person Visits for be female (56 percent and 55 percent, respectively) than patients who never used telemedicine (52 percent). This gap Figur •e 2, Te Fa le cm e-e to d-ic Fa ine ce w (I an s us -Pee rson) d mor Vi esi fr ts p eque er nt 1,00 ly for 0 En rerspir ollea ets, Ove ory syrm Tim ptom e ................................ s and mental health iss ................................ ues, while face-to fa... ce 5 Visit Being Conducted via Telemedicine, by Mode of Care The various ma ja or ttit ribut y of ep s of atieE nt Bs w RI’s Te ho us lee m de a dny icine ty p D ea of tabta ese lem , inc edic luding ine ha bd ot on h te ly le one me d enc icine ount us ee rr w s a ith a nd non tele-m tee le dm ice ine dic p ine rov us ide er rs, . are a Te pc err le oss son c me td he a icrine e c ount ( A vsh isit rw ys, ; ood inde me e ae tnw d a, lhil .a 2017) s C e, OVI spik . On D ed -19 in A the ca p ot ses ril 202 hespik r ha 0, ind e nd, d a w ft ice it ar h te t ing Tha le a nk m sh e sgiv d ift ic ing, ine in t he as pa m a tie od m nt ea s sought d lit ium y of , p ca a tm rie eor nt tha e s ha c t aprv a ee t ie v a ia nt p T s sought re a-aeSxis in ting . In Patients with Asthma.” Annals of Allergy and Immunology. 2016. persisted from 2018, when the group of employers rolled out their telemedicine benefit offering, until the pandemic in was used more 1frequently for musculoskeletal and connective tissue problems. Care from a health care provider with whom a patient has no preexisting relationship attracts different patients seeking TelemediciF nie g u a re s 9 a Service Telemedicine as a Medium shown below in Table 1. Differences in the frequency of visits by telemedicine modes were roughly the same. Eighty-seven percent of TaaS Figure 3, Telemedicine-as-a-Service (TaaS) and Telemedicine-as-a-Medium (TAM) Visits per 1,000 Enrollees, r D ae d ela d cit t eions ion to usin mbe hip r tha wit n in h th g te Oc e leirm t ob he ed e aic rlt in o h ca re N -as ov re- e a pm -rser ov beide v ric . A e r, lt p a ernd rov na ide it tiv tre he s lik lyr, ete fo his Te re c la m ould d aoc y b , indic e d oc bea ttor tte e’ s offic rsom suite e e d as a m for oun d a pp attt e of ie dnt b to s se eha the v e ior kC ing OVI al st he Dic - lp 19 kine in a ps as: on d nde drem ss cic eing 2020. to address diff M eo re snt t C ne om ed m s t oh na D n ia ca grn eo fr som is G ar o he up alt C h ca ode re s p fo rov r T ide ele r m we itd h w icihom ne-a s the -a- S pa etrie vint ce d V oe issi tha s O ve v e ar p Trie m ee xisting users had thr In ed e e or p e fe nw de ern et nc Vount ariab elre s with Ta Oa dS d p sr R ov aide tiors, compP> arez d to 84 pO erd cd ent s R of ati TA oM users.P> A z very small number Over Time ............................................................................................................................................... 6 Spiegel, Jake, “The Webcam Will See You Now: A Review of Telemedicine During the COVID-19 Era,” EBRI Issue Brief, b a chr c yc offe onic ustom r ing caerd et . he to These ir r ese cer iv vtic w ing e o s r fla ca ev rm e or ot v s of ia ely t, e te le su le m cm h a ee dd ic s ove ic ine ine w rm he the an it y p the hone wr F a eis ne g for u or re e a ta 7 rhr ly ttoug r tahe cth sy sy only st nc e op m hratonous v t ion, ically som dide iff ee oc us reonfe e nt rs m pa re ta ie nc ynt ing ha s v see tee c found k hnolog ing tha y, t • Named policyholders were more likely to seek care via telemedicine than their spouses or dependents, perhaps March April May June July August September October November December relationship. Patients seeking care via TaaS were dispF ro ig po urrte iona 1 tely female and older than F2F users, and they most Age 0.9899 < 0.01* 0.9954 < 0.01* of patients enthusiastically embraced telemedicine services; fewer than 1 percent of TaaS patients used TaaS services Most Common Diagnosis Group Codes, by Mode of Delivery sy t e no. he na styb e 52 lin e m nj 8 (A a goy t ic pa e a ptd ll rie il 202 y t nt e dle iff s t m e 1) o ree .d see nt ic ine he k out ’as su lth ca he pe arrlt e ior h ca se cronv v re ic e se es. nie r vic nc ee s fr , or om the pryov m ide ayr ha s w vit eh w grow hom n a tche cus y tha om de a d p to rete he xis c ting ost a re dla va tions ntaghip. es t hat On the whole, telemedicine users were slightly unhealthier than F2F users, as measured by the Charlson Comorbidity indicating that named policyholders were more comfortable seeking care for themselves via telemedicine, were Symptoms, Ill- Symptoms, Ill- Figure 4, Average Age of Telemedicine-as-a-Service (TaaS), Telemedicine-as-a-Medium (TAM), and Face-to-Face (F2F) Descriptive Statistics of Patients and Encounters Respirfr ate orq yue ntly R esough spiratorty c are for minor respiratory symptom Rs e. sp Pira attie ornt y s se Ree sk ping iratoc rya re R ve ia s pTA iratM oryw ere R esi sp m ira ila torrly y old Re es r pa irnd ato rm y ore R espiratory more than 10 Ge tim ndees, a r (F nd em fe aw lee = r t1 ha ) n 1 percent1 of .47 TA 49 M patients us < 0.e 0d 1 *TAM servic 1.e3 s m 356 ore than 12 ti < 0.m 01 es. The * re were Defined Defined som Addit eiona emp lly loy , re erg s ins ulattor itut y b ed ar . riers were lowered, making it easi er for doctors to provide services via telemedicine, and Index (CCI). The CCI is a commonly used predictor of one-year mortality rates and is often used by researchers as a more familiar with their employer’s telemedicine offerings, or were better-informed at work about the cost % of F2F Telemedicine-as-a-Service (TaaS) % of TaaS Telemedicine-as-a-Medium (TAM) % of TAM System Use Sysrts, b em y Year ................................................................ System Sy ................................ stem System ................................ System System ......... S y7s tem frequently female than F2F useirn s , E aB nd Rw I’hil s T e e the lem y a els do ic oft ine en D sought ataba rs ee spir , 2a0 tor 16 y– c2 a0 re 2, 0TAM patients also Named Policyholder 2.5044 < 0.01* 1.6388 < 0.01* Face-to-F seve Sp aie ce g r a e (F l nota l, 2J Fa) kU e bs , le e a rnd out s P lie aul F rs: C O ronst one nd itout iin. “ onslie Fu r us turee C d o of n Ta diH ta io e S na stlt o h B ade dne ress fit s in t healthe h ca Wror e k np ela ed ce s : 69 Em tim ploy es ove ers’ P r etrhe spe cc our tive se s D of ur the ing four the -year some employers waived cost-sharing arrangements for care sought via telemedicine (Spiegel 2021). As a result of the proxy for health. Patients seeking care via telemedicine of any variety had an average CCI of 0.62, compared with F2F Visits Users Visits Users Visits benefits and availability of telemedicine services. Symptoms, Ill- Symptoms, Ill- Musculoskeletal, Symptoms, Ill- Symptoms, Ill- Symptoms, Ill- Symptoms, Ill- Symptoms, Ill- Symptoms, Ill- disproportionately sought cM areea n for A g m ee nt of aEn l he ro allt leh iss e ues. 32.9 st COVI udy p D-e 19 riod CrC , isfa h isa r.” rl m s Eor o Bn RI e C t I ha o ss m n ue o arb ny Bird ie ot itfy he no. Inrd p e 51 a xt7 ( ient N ov in EB 0.e 8m 17 RI be’rs d 20 a20 tab ).a < se 0, .0 a1 nd * a differe0 nt .8 out 996 lier used TA < M 0.0 for 1* health care Figure 5, Average Charlson Comorbidity Index of Patients, by Mode of Delivery ......................................................... 8 Significant Modality Shifts Respiratory confluence of these factors, health care visits via TaaS increased 87 percent relative to February 2020, as shown in users who had an average of 0.33, perhaps reflecting a hesitancy on the part of sicker patients to seek F2F care. Defined Defined Connective Defined Defined Defined Defined Defined Defined Musculoskeletal, Connective Tissue Me 2d 1.i7 a% n Ag R ee o sp f iEn rato ro ryll e Sy estem 37.7% 31 Respiratory System 23.2% System Respiratory Issue 9.0364 < 0.01* 6.1685 < 0.01* services 70 times. However, such enthusiastic and frequent usage is rare, and the vast majority of patients use either Who Uses Telemedicine? The data in EBRI’s Telemedicine Database comport with findings from previous work that examined the impact of the CondiFi tiog nur s e 3. C Te onle dim tioe nd sicine-as-Ta is -s m ue edium, visits, however,C w one drite io 50 ns timC eo s highe nditionsr tha Cn o nin dit iFe ons bruar C yo n 20 dit20 ion sas prC ov onide ditio rs nsquick Cly on ditions D isaggregating between TaaS and TAM patients, we find that TaaS patients had a lower CCI on average than TAM Fi These gure r6, esu Frltesq ha uev nc e yim of por Tetle ant m e im dic pine lica tVi ions sits b for y e Pm atp ie loy nte s, b rs. yE Ty mp ploy e of ers w Visit ho ................................ have implemented or ................................ are considering ..... 9 Symptoms, Ill-Defined Conditions 13.4% Symptoms, Ill-Defined Co nditions 11.9% Mental Disorders 12.9% Weiner JP, Bandeian S, Hatef E, Lans D, Liu A, Lemke KW. In-Person and Telehealth Ambulatory Contacts and Costs in Share Female 47% Circulatory 0.879 0.21 1.7166 0.19 Nervfla ousv or of Mut se cle ulo m se ke dlic etine al, fewer than fiveM tu im sce us lo, sa ke s sh letalow , n b Nee rv low ous in Figure 6. Nervous Nervous C A b OVI outD 20 -19 p p ea rc nde entm of ic to he n p pa op tie ula nt tc ion in are. IE nB -p RI er’s son se Telem rveic de ics in EB ine DaRI tab ’s d ase atus abe ad se eit fe he ll p r rveacripit iation o ouslyf in A telep m re il of dicine 2020 at, som aftee r point pivoted to offering their services via videoconferencing technology and patients relied more heavily on remote- patients, at 0.531 and 0.79 Res5, pir arte ospe ry ctively, perhaps a reflection oG f e pna itto ie urnt ina s ry see king care via G eTa nita ou Sr in for ary lo w-intensity Genitourinary Respirato im ryp Sy lem ste ent ming telemedicine pl7 a.t9 for %ms for Nerv t ohe usir Sy em ste pm loy , Se ees nssh e ould Orga n bs e aware 9 tha .7% t teleSy me m dp ictine om st,e Inde ll-De df in to eda C ttr oa nc dti tip oa ntsients 12.1% a Large US Insured Cohort Before and During the COVID-19 Pandemic. JAMA Network Open. (March 2021). System, Connective Share main C po on lin c ey ch tiv o el der System, 36% System, System, Figure 7, Most Mu C som culm os on keD leia tag lnosis Group Code0s, b .25y 0 4 Mode of D< eliv 0.0 e1 ry * ................................ 0.4793 ................................ < 0.01* ....... 9 This study was conducted through the EBRI Center for Research on Health Benefits Innovation (EBRI CRHBI), System System System System b meatny we e stn 2016 ates is su and ed 20 sta 20 y-.at D-e hcom omep or osin deg r s a this nd int he o aTa lth ca aS a re nd prTA ovM idevris s p its, w ostpeone find d t m ha ost t si no mila n-e r ss preop nto iarl c tions are , of as sh patie ow ntn b s us ee low d m chr onit onic or ing cond te itcions hno log and y su viac h a TAM s p for uls c ehr oxim onice c trond y, ait ls io ons sh a ow nd n in pr eFi vegnt uriv ee 3 c . are. Nervous System, Sense Organs 7.7% Genitourinary System 7.8% Nervous System, Sense Organs 8.8% Sense Organs Tissue Tissue Sense Organs Sense Organs Sense Organs see king care for acute, low-intensity, and often self-limited needs, as evidenced by the majority of patients seeking care Share spouse 24% Mental Illness 2.2125 < 0.01* 5.3342 < 0.01* with the funding support of the following organizations: Aon, Blue Cross Blue Shield Association, ICUBA, JP e in ithe Figrur ser e 2 vic . I en ; -rpoug erson v hly 11 isit p s in EB ercentRI us ’se Te d e le itm he erd ic Ta ine aS D or a tTA aba M se atd som roppee d p oint pre cb ipit etw ousl een 20 y fro16 m ov and er 20 2620 4,00 , a0 vi nd ne sita s in Fe rly 3 bruary Endocrine, Nutrition, Metabolic 7.5% Infectious and Parasitic Skin, 5.9% MusculosN ke elre vo ta uls , Connective Tissue Nervo 5u .8 s% Figure 8, Most Common Diagnosis Group Codes for Telemedicine-as-a-Medium Visits Over Time .............................. 10 Yeramosu, Deepika, Florence Kwok, Jeremy M Kahn, and Kristin N Ray. “Validation of Use of Billing Codes for via either flavor of telemedicine only once. The growth of services sought via TAM suggests employees are willing to Genitourinary Circulatory Infectious and Infectious and Genitourinary Genitourinary Genitourinary Share dependent 40% Digestive 0.813 0.32 1.1608 < 0.01* Morgan Chase, Pfizer, and PhRMA . Subcutaneous System, System, Genitouri2020 p ne ar ry c e Sy nt to s us 21 tem e 7, d00 bot 0 in h TA Ma M rca h 20 nd Ta 20 6.a 3 , % Sb e for for M h e e e n b atot lt alh ca tD om iso ring e rd v eis out rsits .a D t igg fewing er tint hao n 149,0 demog 00 5r.a 4 p v % hic isits s in A , En padto ie pc rnt ri il 202 n s us e, N0. ing ut ri Ot ttio e he n le , r m M re e ed tse aic ba ine or lic che wr es, re 5.8% System System Parasitic Parasitic System System System Identifying Telemedicine Encounters in Administrative Data.” BMC Health Services Research, December 2019. seek care for chronic conditions via telemedicine. Also, this study shows that employees are willing to access mental Figure 9, Most Common Dia Tg onosi tal Pl s G an roup Enro Clod lee es s for in D Te atle ab m ae sd eicine-as T-ia ss -S ue ervic1 e4 Vi 7,si 6t3 s O 1 ver STim ense e ................................ Organs Sen 10 se Organs Ill-Defined Symptoms 1.6265 < 0.01* 1.7059 0.08 Circulatory System 6.0% Skin, Subcutaneous Tissue 5.0% Factors Influencing Health Status 5.7% sl ana ight lyzin ly d giff ot ehe rent EBRI r p trha o Ip ss nru ie F2 e tBri aF us ry ef d is re e arts a g.ib st Te a eses, rele d m in ha e thd ev ic U e ine . Sfound . - Pas ate- na t a - am n si de m Tr diila aum derm taus rre kn e Od rfs w fi(cJe e.e ff Ir Se rSe N m y: od 0 e8t8 e a 7st - l.1 ly 202 37 old X/0) 9e 0 . r 0 The 8t8 ha 7 -n 1C 3Ta om 7Xa /9m S 0 onw $ us .5e 0r + es (3 .a 50 lt h Fund 7 yearsfo old und, health services through telemedicine, via both TaaS and TAM. Nervous Total Encounters 15,732,265 Infectiou s and Pandemic D Cu irm culm ato yry 3.786I2 nfectious an< d 0.01* 13 M .0 e3 nt3 a8 l Infectio< u s0 a .0 nd 1 * Mental Mental Neoplasms 5.5% Factors Influencing Health Status 3.5% Genitourinary System 5.4% for and ins 36t aync eaer, s old that on in-p ae vr eson c rage,a rre espe drop ctiv pe ed ly ) ne . B aot rlyh w 60e p re e rold cent er fr tha om n it F2F s tyus pic ea rl ye s, waho rly w tre ernd e 33 be y ge inn ars ing old in l on ata ev Ma erarg ce h . The Figure 10N , eL oog plais sm tic s Regression Output Fr Nom eop la Mod smseling the Likelihood S yof stea m H , ealth Care Visit Being Conducted via Parasitic © 2021, EmploS yy ee st e B m enefit Research Institute Par - aE sitdu ic cation and ReseaD rc ish F ordeun rs d. All r Parig ash itit cs reser Dv ised. orde rs Disorders Average Encounters per Patient 106.5 Injury and Poisoning 5.5% Musculoskeletal, Connective Tissue 3.2% Circulatory System 5.0% Constant 0.001 < 0.01* 0.001 < 0.01* Sense Organs ( E aMe g ve en th hr ga ot poug a is Te e r th th oug le alm . is hly 20 e dle 21 ic p vine e e ).l o r si , st f ut by e nt Mod ili za be teion t w of eis e Cn 2016 ast re ill ................................ re la atnd ive 20 ly 19 low , , sh this ow n in could ................................ Fi g stur ill eb 4 e, ab e bfor oon e fo wide r ................................ em nin pg loy sleight rs, ly as t in 20 elem 20 ed , ............... ic pe ine rha vp iss a its 11 s Digestive System 5.2% Circulatory System 2.5% Skin, Subcutaneous Tissue 4.7% Median Encounters per Health Care User 96 Source: EBRI’s Telemed * ici In nd e iD ca a ta te ba ss e th . e coeffic ient is statistically significant from zero at a 1 percent level. a result of older patients seeking elective health care services that were not available to be administered in person. may shift patients away from potentially costly urgent care and emergency department visits. Indeed, in interviews of Source: E 1 BRI’s Telemedicine Database. Total Health Care Spending $ 615,019,177 We should note that since the database was populated by a group of employers in a particular industry, our analyses may Source: EBRI’s Telem edicine Database. benefits executives conducted by EBRI, several interviewees noted that they believed telemedicine could potentially not necessarily be generalizaS bo le u rto ce the : EB te Rle I’sme Ted le icm ine ed -is ce in ee k ing Da tp ao bp aula se.tion as a whole. lower their firm’s total health care expenditures (Spiegel and Fronstin 2020). Additionally, we find evidence that the named policyholder is more likely to seek care via telemedicine for themselves than for a spouse or dependent. 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E 5 5 5 5 5 5 5 5 5 5 5 5 5B 3 3 3 3 3 3 3 3 3 3 3 3 34 4 4 4 4 4 4 4 4 4 4 4 4 R I Education and R esearch Fund © 2021 Employee Benefit Research Institute 11 10 13 12 14 8 4 2 3 5 6 9 7 2/1/2017 2/1/2017 3/1/2017 3/1/2017 4/1/2017 4/1/2017 5/1/2017 5/1/2017 6/1/2017 6/1/2017 7/1/2017 7/1/2017 8/1/2017 8/1/2017 9/1/2017 9/1/2017 10/1/2017 10/1/2017 11/1/2017 11/1/2017 12/1/2017 12/1/2017 1/1/2018 1/1/2018 2/1/2018 2/1/2018 3/1/2018 3/1/2018 4/1/2018 4/1/2018 5/1/2018 5/1/2018 6/1/2018 6/1/2018 7/1/2018 7/1/2018 8/1/2018 8/1/2018 9/1/2018 9/1/2018 10/1/2018 10/1/2018 11/1/2018 11/1/2018 12/1/2018 12/1/2018 1/1/2019 1/1/2019 2/1/2019 2/1/2019 3/1/2019 3/1/2019 4/1/2019 4/1/2019 5/1/2019 5/1/2019 6/1/2019 6/1/2019 7/1/2019 7/1/2019 8/1/2019 8/1/2019 9/1/2019 9/1/2019 10/1/2019 10/1/2019 11/1/2019 11/1/2019 12/1/2019 12/1/2019 1/1/2020 1/1/2020 2/1/2020 2/1/2020 3/1/2020 3/1/2020 4/1/2020 4/1/2020 5/1/2020 5/1/2020 6/1/2020 6/1/2020 7/1/2020 7/1/2020 8/1/2020 8/1/2020 9/1/2020 9/1/2020 10/1/2020 10/1/2020 11/1/2020 11/1/2020 12/1/2020 12/1/2020