Economics of a Health System's Direct-to-Consumer Telemedicine for Its Employees

Am J Manag Care. 2023;29(6):In Press _____ Takeaway Points The value of direct-to-consumer (DTC) telemedicine services offered by academic health systems is understudied. * DTC telemedicine services for low-acuity or minor illnesses are increasingly offered as an employee benefit, but any per-episode unit cost advantage may be offset by overuse of care. * DTC telemedicine staffed by an academic health system and offered to its employees resulted in lower per-episode unit costs for care within 7 days and only marginally increased the use of services. * DTC telemedicine staffed by an academic health system and offered directly to employees was cost-saving. _____ Employers in the United States have increasingly been offering a direct-to-consumer (DTC) telemedicine benefit for low-acuity or minor illnesses to their employees.1-3 By 2021, more than 95% of employers with 50 or more employees provided some coverage for DTC telemedicine in their largest health plan;more than 75% felt that offering telemedicine was important and nearly 20% either limited or eliminated cost sharing for telemedicine.4 Despite these trends among general employers, few health systems have directly provided DTC telemedicine to their own employees. [...]because these services are easy to access (often available immediately, around the clock, and without travel), they may induce overuse of care, especially for self-limited conditions such as viral upper respiratory infections for which the alternative to in-person care is no care at all, thus increasing the overall cost of care.5-11 Telemedicine will save money relative to in-person care if any unit price advantages are not overwhelmed by the increased use of care overall, induced by its convenience. Employers provide health insurance coverage for 158 million Americans or nearly 50% of the population. Since the COVID-19 pandemic began, telemedicine has represented a significantly larger portion of all medical claims—consistently more than 5% of all medical claims by mid-202112-15—and the estimated value of the global telemedicine industry is projected to reach a quarter of a trillion dollars by 2024.13 Yet, the future of telemedicine remains undetermined with reimbursement rates in debate,16-18 driven in large part because its economic value is understudied and uncertain. Penn Medicine is self-insured and more than 95% of employees use its only employer-sponsored plan—a preferred provider organization (PPO) plan—rather than insurance obtained individually or through a family member. Since 2017, these PPO-insured employees have been offered Penn Medicine OnDemand,19 a 24/7 DTC telemedicine benefit to employees and their adult (≥ 18 years) dependents.

Durability of SARS-CoV-2 mRNA Booster Vaccine Protection Against Omicron Among Health Care Workers with a Vaccine Mandate.

BACKGROUND: The SARS-CoV-2 Omicron Variant has spread rapidly throughout the world since being identified in South Africa in November 2021. Few studies have assessed primary series and booster vaccine effectiveness against Omicron among US health care workers. METHODS: We conducted a test-negative case-control design to estimate BNT162b2 and mRNA1273 primary vaccination and booster effectiveness against SARS-CoV-2 infection and symptomatic Covid-19 during an Omicron surge among employees of the University of Pennsylvania Health System. The study period was between 7/1/21-4/5/22. We defined the Delta period as 7/1/21-12/12/21 and the Omicron period as beginning 12/20/21. RESULTS: Our sample included 14,520 tests (2,776 [19%] positive)-7,422 (506 [7%] positive) during Delta, and 7,098 (2270 [32%] positive) during Omicron. Benchmarked against Delta, vaccine effectiveness of two vaccine doses was lower during Omicron, with no significant protection against infection. Booster doses added significant protection, although they also showed reduced effectiveness during Omicron. Compared to employees who had received two vaccine doses, three BNT162b2 doses had a relative effectiveness of 50% (95% CI 42-56%) during Omicron, relative to 78% (95% CI 63-87%) during Delta; three mRNA1273 doses had a relative effectiveness of 56% (95% CI 45-65%) during Omicron, relative to 96% (95% CI 82-99%) during Delta. Restricting the sample to symptomatic tests yielded similar results to our primary analysis. After initial waning in BNT162b2 booster protection against infection, it remained largely stable for at least 16 weeks after vaccination. DISCUSSION: Our findings provide a strong rationale for boosters among healthcare workers in the Omicron era.

Primary Care Appointment Completion Rates and Telemedicine Utilization Among Black and Non-Black Patients from 2019 to 2020.

Objective: To understand how differences in primary care appointment completion rates between Black and non-Black patients changed in 2020 within the context of the COVID-19 pandemic and when telemedicine utilization peaked. Materials and Methods: We conducted a retrospective cohort study using the electronic health record from January 1 to December 31, 2020, among all adults scheduled for a primary care appointment within a large academic medical center. We used mixed-effects logistic regression to estimate adjusted appointment completion rates for Black patients compared with those for non-Black patients in 2020 as compared with those in 2019 within four time periods: (1) prepandemic (January 1, 2020, to March 12, 2020), (2) shutdown (March 13, 2020, to June 3, 2020), (3) reopening (June 4, 2020, to September 30, 2020), and (4) second wave (October 1, 2020, to December 31, 2020). Results: Across 1,947,399 appointments, differences in appointment completion rates between Black and non-Black patients improved in all time periods: +1.4 percentage points prepandemic (95% confidence interval [CI]: +0.8 to +2.0), +11.7 percentage points during shutdown (95% CI: +11.0 to +12.3), +8.2 percentage points during reopening (95% CI: +7.8 to +8.7), and +7.1 percentage points during second wave (95% CI: +6.4 to +7.8) (all p-values <0.001). The types of conditions managed by primary care shifted during the shutdown period, but the remainder of 2020 mirrored those from 2019. Discussion: Racial differences in appointment completion rates narrowed significantly in 2020 even as the mix of disease conditions began to mirror patterns observed in 2019. Conclusions and Relevance: Telemedicine may be an important tool for improving access to primary care for Black patients. These findings should be key considerations as regulators and payors determine telemedicine's future.

Receipt of Out-of-State Telemedicine Visits Among Medicare Beneficiaries During the COVID-19 Pandemic.

Importance: Early in the COVID-19 pandemic, states implemented temporary changes allowing physicians without a license in their state to provide care to their residents. There is an ongoing debate at both the federal and state levels on whether to change licensure rules permanently to facilitate out-of-state telemedicine use. Objective: To describe out-of-state telemedicine use during the pandemic. Design, Setting, and Participants: This cross-sectional study of telemedicine visits included all patients with traditional Medicare from January through June 2021. Main Outcomes and Measures: Telemedicine visits from January through June 2021 where the patient's home address and the physician's practice address were in different states. Results: In describing which patients and specialties were using out-of-state telemedicine, we focused on the period between January to June 2021. We chose this period because it was after the turmoil of the early pandemic, when vaccines became widely available and the health care system had stabilized, but before many of the temporary licensing regulations began to lapse by mid-2021. In the first half of 2021, there were 8 392 092 patients with a telemedicine visit and, of these, 422 547 (5.0%) had 1 or more out-of-state telemedicine visits. Those who lived in a county close to a state border (within 15 miles) accounted for 57.2% of all out-of-state telemedicine visits. Among the out-of-state visits in this time period, 64.3% were with a primary care or mental health clinician. For 62.6% of all out-of-state visits, a prior in-person visit occurred between the same patient and clinician between March 2019 and the visit. The demographics and conditions treated were similar for within-state and out-of-state telemedicine visits, with several notable exceptions. Among those with a telemedicine visit, people in rural communities were more likely to receive out-of-state telemedicine care (33.8% vs 21.0%), and there was high of out-of-state telemedicine use for cancer care (9.8% of all telemedicine visits for cancer care). Conclusions and Relevance: The findings of this cross-sectional study suggest that licensure restrictions of out-of-state telemedicine would have had the largest effect on patients who lived near a state border, those in rural locales, and those who received primary care or mental health treatment.

An accelerated hospital observation pathway to reduce length of stay for patients with COVID-19.

OBJECTIVES: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message-based monitoring. STUDY DESIGN: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. METHODS: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score-matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. RESULTS: There were 44 patients in the intervention group and 83 patients in the propensity score-matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, -2.2 days; 95% CI, -3.3 to -1.1). In the intervention group, 2 patients (5%; 95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%; 95% CI, 4%-17%) in the matched cohort. CONCLUSIONS: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.

An Accelerated Hospital Observation Pathway to Reduce Length of Stay for Patients With COVID-19

Objectives: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message–based monitoring. Study Design: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. Methods: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score–matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. Results: There were 44 patients in the intervention group and 83 patients in the propensity score–matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, –2.2 days;95% CI, –3.3 to –1.1). In the intervention group, 2 patients (5%;95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%;95% CI, 4%-17%) in the matched cohort. Conclusions: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.

Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019.

Importance: Little is known about how telemedicine use was evolving before the broad changes that occurred during the COVID-19 pandemic in 2020. Understanding prepandemic patterns of telemedicine use can inform ongoing debates on the future of telemedicine policy. Objective: To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine. Design Setting and Participants: This was a cross-sectional study and descriptive analysis of telemedicine utilization by 10.4 million fee-for-service Medicare beneficiaries from 2010 to 2019. Data analysis was performed from June 6, 2019, to July 30, 2020. Main Outcomes and Measures: Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine. Results: Of 10.4 million rural Medicare beneficiaries, telemedicine was used by 91 483 individuals (age ≥65 years, 47 135 [51.5%]; women, 51 476 [56.3%]; and White, 76 467 [83.6%] individuals) in 2019. In 2010 to 2019, telemedicine visits grew by 23.1% annually. A total of 0.9% of all fee-for-service rural beneficiaries had a telemedicine visit in 2019 compared with 0.2% in 2010. In 2019, there were 257 979 telemedicine visits or 34.8 visits per 1000 rural beneficiaries and most (75.9%) of these visits were for mental health conditions. Patients with bipolar disorder or schizophrenia (3.0% of rural beneficiaries) received 40% of all telemedicine visits in 2019. Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89). In 2010 to 2019, telemedicine for mental health conditions shifted away from psychiatrists (71.2% to 35.8% of all telemedicine visits) to nonphysician clinicians, eg, nurse practitioners, psychologists, and social workers (21.4% to 57.2%). There was wide variation in telemedicine utilization in 2019 across counties: median (IQR), 16.0 (2.5-51.4) telemedicine users per 1000 beneficiaries). In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019. Conclusions and Relevance: In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians. The prepandemic model of telemedicine provided in local health care settings may be a viable modality to maintain in rural communities.

Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home.

BACKGROUND: Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE: To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN: Retrospective cohort analysis. SETTING: Mid-Atlantic academic health system in the United States. PARTICIPANTS: Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION: The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS: Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS: A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION: Observational study with the potential for unobserved confounding. CONCLUSION: Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Design, Implementation, and Validation of an Automated, Algorithmic COVID-19 Triage Tool.

OBJECTIVE: We describe the design, implementation, and validation of an online, publicly available tool to algorithmically triage patients experiencing severe acute respiratory syndrome coronavirus (SARS-CoV-2)-like symptoms. METHODS: We conducted a chart review of patients who completed the triage tool and subsequently contacted our institution's phone triage hotline to assess tool- and clinician-assigned triage codes, patient demographics, SARS-CoV-2 (COVID-19) test data, and health care utilization in the 30 days post-encounter. We calculated the percentage of concordance between tool- and clinician-assigned triage categories, down-triage (clinician assigning a less severe category than the triage tool), and up-triage (clinician assigning a more severe category than the triage tool) instances. RESULTS: From May 4, 2020 through January 31, 2021, the triage tool was completed 30,321 times by 20,930 unique patients. Of those 30,321 triage tool completions, 51.7% were assessed by the triage tool to be asymptomatic, 15.6% low severity, 21.7% moderate severity, and 11.0% high severity. The concordance rate, where the triage tool and clinician assigned the same clinical severity, was 29.2%. The down-triage rate was 70.1%. Only six patients were up-triaged by the clinician. 72.1% received a COVID-19 test administered by our health care system within 14 days of their encounter, with a positivity rate of 14.7%. CONCLUSION: The design, pilot, and validation analysis in this study show that this COVID-19 triage tool can safely triage patients when compared with clinician triage personnel. This work may signal opportunities for automated triage of patients for conditions beyond COVID-19 to improve patient experience by enabling self-service, on-demand, 24/7 triage access.

Patient Interaction Phenotypes With an Automated Remote Hypertension Monitoring Program and Their Association With Blood Pressure Control: Observational Study.

BACKGROUND: Automated texting platforms have emerged as a tool to facilitate communication between patients and health care providers with variable effects on achieving target blood pressure (BP). Understanding differences in the way patients interact with these communication platforms can inform their use and design for hypertension management. OBJECTIVE: Our primary aim was to explore the unique phenotypes of patient interactions with an automated text messaging platform for BP monitoring. Our secondary aim was to estimate associations between interaction phenotypes and BP control. METHODS: This study was a secondary analysis of data from a randomized controlled trial for adults with poorly controlled hypertension. A total of 201 patients with established primary care were assigned to the automated texting platform; messages exchanged throughout the 4-month program were analyzed. We used the k-means clustering algorithm to characterize two different interaction phenotypes: program conformity and engagement style. First, we identified unique clusters signifying differences in program conformity based on the frequency over time of error alerts, which were generated to patients when they deviated from the requested text message format (eg, ###/## for BP). Second, we explored overall engagement styles, defined by error alerts and responsiveness to text prompts, unprompted messages, and word count averages. Finally, we applied the chi-square test to identify associations between each interaction phenotype and achieving the target BP. RESULTS: We observed 3 categories of program conformity based on their frequency of error alerts: those who immediately and consistently submitted texts without system errors (perfect users, 51/201), those who did so after an initial learning period (adaptive users, 66/201), and those who consistently submitted messages generating errors to the platform (nonadaptive users, 38/201). Next, we observed 3 categories of engagement style: the enthusiast, who tended to submit unprompted messages with high word counts (17/155); the student, who inconsistently engaged (35/155); and the minimalist, who engaged only when prompted (103/155). Of all 6 phenotypes, we observed a statistically significant association between patients demonstrating the minimalist communication style (high adherence, few unprompted messages, limited information sharing) and achieving target BP (P<.001). CONCLUSIONS: We identified unique interaction phenotypes among patients engaging with an automated text message platform for remote BP monitoring. Only the minimalist communication style was associated with achieving target BP. Identifying and understanding interaction phenotypes may be useful for tailoring future automated texting interactions and designing future interventions to achieve better BP control.

Policies to Improve Substance Use Disorder Treatment With Telehealth During the COVID-19 Pandemic and Beyond.

: The COVID-19 pandemic has created an urgent need to expand access to substance use disorder (SUD) treatment through telehealth. A more permanent adoption of tele-SUD treatment options could positively alter the future of SUD treatment. We identify four steps that will help to ensure a broader transition to telehealth will be successful in improving the health outcomes of patients with SUDs. These steps are: (1) investing in telehealth infrastructure to enable health care providers and patients to use telehealth; (2) training and equipping providers to provide SUD treatment through telehealth; (3) providing patients with the financial and social support, hardware, and training necessary to use telehealth; (4) making temporary changes to telehealth law and regulation permanent. We believe these 4 steps will be critical to initiating SUD treatment for many persons that have yet to receive it, and for preserving SUD treatment continuity for millions of other patients both during and after the pandemic.

Creating Virtual Presence During a Pandemic.

This article describes ways in which telemedicine has reshaped the doctor-patient relationship, and how we may face the challenge of maintaining a clinician's presence in the virtual environment.