Telehealth Doctor Visits May Be Handy, But Aren't Cheaper Overall

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Telehealth takes a lot of forms these days. Virtual visits with a health care provider can take place by video, phone or text, or via the Web or a mobile app. The one commonality: You get to consult a doctor from your home, the office, Starbucks or anywhere with a wifi or mobile connection.

These appointments can be quick, and save you from having to schlep across town and sit in a waiting room, leafing through year-old Time magazine articles, as prelude to every visit with a doc.

There's no debating that telehealth appointments can be convenient — and potentially even life-saving for people who live in remote areas. But are they also cheaper than in-person visits, as the telehealth companies claim? Not necessarily, according to a study published this month by the RAND Corporation, in the journal Health Affairs.

The study found that total annual spending, which the researchers defined as costs to insurers and out-of-pocket payments by patients, was $45 more per patient for people who used telehealth to treat acute respiratory illnesses than it was for patients who saw doctors for the same conditions.

That's because 88 percent of the telehealth visits represented people who would not have gone to a doctor otherwise — what the industry calls new utilization. Just 12 percent of the telehealth sessions, the researchers concluded, amounted to a substitute for going to see the doc.

RAND health policy researcher Lori Uscher-Pines was one of the authors on the study, and says she's not surprised.

"When you make services that are convenient, it's an 'If you build it, they will come' kind of thing," says Uscher-Pines.

Most of the patients in the study who chose these virtual appointments might have stuck to home-remedies if telehealth wasn't available, she says.

"You sit at home, you watch Netflix, you take Tylenol," Uscher-Pines says. "But now, because of these kinds of services that are so easy to access, you have a visit that would not have otherwise occurred."

And patients who get advice via a virtual appointment may be more likely to be scheduled for an in-person follow-up appointment — which increases the cost of treating that episode of illness.

The RAND study is the fourth on telehealth funded by the California Health Care Foundation. Researchers examined claims data from more than 300,000 enrollees in the Blue Shield of California HMO plans offered by CalPERS, the California Public Employees' Retirement System. In 2012, CalPERS began offering the telehealth appointments to selected members through Teladoc, a Texas-based public company that contracts with independent licensed physicians to be able to offer patients a virtual consultation — 24 hours a day, 365 days a year.

The current study looked at 981 people who used the Teladoc service over 18 months in 2012-13 to seek help for acute respiratory infections, such as bronchitis, pneumonia, sinusitis or an ear infection. The researchers compared these users with patients who had their acute respiratory infections evaluated by a doctor in-person. The research team focused on respiratory ailments because they are the conditions most commonly treated by direct-to-consumer telehealth providers, the scientists say.

Teladoc, which markets its service as a cost-saver, says the information it gathered at the time of care contradicts the RAND findings. Courtney McLeod, the company's director of public relations, says just 13 percent of appointments for more than 400,000 patients with acute respiratory infections represented new health care utilization.

That is pretty much the reverse of the 88 percent new utilization that the RAND researchers found. The RAND study asserts that the discrepancies between its numbers and those of the telehealth company's could be because the company relied on surveys of patients, as opposed to actual utilization data. In other words, the patients that Teladoc surveyed may have overestimated the likelihood they would have gone to see a doctor in person if the virtual visits hadn't been available.

The RAND researchers do acknowledge that use of telehealth services for different types of medical conditions might produce more economical results.

And there could be economic benefits from having easy, virtual access to a doctor 24/7 that the study didn't capture, Uscher-Pines adds.

These services can be offering patients reassurance, she says, and a less worried patient may be more productive. It's also possible that telehealth visits initiated from a patient's work site reduce absenteeism.

Nonetheless, Uscher-Pines cautions, "You have to take this with a grain of salt when a company says we're going to prevent emergency department visits. It's unclear whether that's likely to happen, given the fact that the literature on innovations in health care delivery frequently tells us that when you increase convenience you increase utilization."

David Cowling, another author on the RAND study and a research scientist at CalPERS, says the study revealed the trade-off that telehealth presents.

"We have increased access to our members, which is a good thing," he says. "Eighty-eight percent were new utilization, so they wouldn't have gotten care previously. Our members were seeking care, and I'm sure their satisfaction with their health plan was higher."

But the RAND finding that the virtual approach to care may not save money could prompt a change in the benefit when CalPERS re-examines its benefit package, Cowling says. The benefits fund could potentially limit telehealth access to rural areas — which was one of the original aims of introducing the service — or tailor it to specific conditions.

Melissa Buckley, the director of the California Health Care Foundation's Innovation Fund, says that sort of strategic thinking may be the best bet when it comes to telehealth.

"If you use it naively you can drive up utilization," she says. "You have to use it as a more precise tool with particular populations in order to serve their needs. Don't just go into it blindly."

This story was produced by KQED's Future of You blog. Jon Brooks is a longtime KQED reporter and editor, and the blog's host.