key: cord-0017210-183nsnqb
authors: Marcotte, Leah M.; Reddy, Ashok; Zhou, Lingmei; Liao, Joshua M.
title: Nationwide Use of Telehealth Among Commercially Insured Individuals 2007–2017
date: 2021-05-04
journal: J Gen Intern Med
DOI: 10.1007/s11606-021-06816-3
sha: 88ce46f56d5890780dbba0030549eda7b2af4e51
doc_id: 17210
cord_uid: 183nsnqb

nan

While the potential benefits of telehealth have been long recognized, 1,2 uptake had been gradual over time until COVID-19 3, 4 . Given current provider and payer commitments, expanded telehealth is likely to persist beyond the pandemic. 5, 6 However, despite some evidence about aggregate trends in telehealth visits, 3, 4 little is known about the characteristics of patients who have historically received telehealth services. Given that certain drivers of postpandemic telehealth use will be similar to those that existed prior to the pandemic, insight about pre-pandemic trends can provide important context and reference points for telehealth use after the pandemic.

We analyzed 2007-2017 data from Truven® MarketScan, a national database of over 40 million individuals with commercial employer-sponsored insurance through approximately 100 insurers.

We assessed telehealth services using the GT modifier (indicating use of an interactive audio and video telecommunication system) to Current Procedural Terminology codes 99201-99205 (new patient visits), 99211-99215 (return patient visits), and 99241-99245 (consultant visits). We evaluated demographic data, urban (metropolitan service area) vs. nonurban setting, site of service, insurance type, and the number of telehealth visits in each year. Site of service was categorized as (1) outpatient, (2) community mental health centers, (3) urgent care, and (4) other. Consistent with prior work evaluating insurance type by deductible amount and managed care status, we categorized insurance type as (1) consumer driven health plans (CDHP) and high deductible health plans (HDHP); (2) health maintenance organization (HMO), point of service (POS), and POS with capitation plans; and (3) preferred provider organization (PPO), exclusive provider organization (EPO), and comprehensive plans.

We used Kruskal-Wallis tests to compare continuous variables. Statistical tests were two-tailed and considered significant at alpha=0.05. Analyses were performed in SAS, Version 9.4. Institutional review board approval was not obtained given the completely de-identified nature of study data.

Our sample consisted of 47,911 patients receiving 80,360 telehealth visits between 2007 and 2017 (averaging 1.7 visits per patient). The mean age was 37.6 years and 57% of patients were female. Forty-two percent of patients lived in the South, with fewer in the Midwest (25%), West (22%), and Northeast (6%). Most visits occurred in the outpatient setting (86%). The majority of patients were covered by PPO, EPO, or comprehensive plans (66%).

Telehealth use increased from 321 patients and 859 total telehealth visits in 2007 to 14,031 patients and 22,927 visits in 2017 ( Table 1 ). The average number of visits per patient decreased from 2.7 in 2007 to 1.6 in 2017 (p=0.29). Utilization varied by gender, with differences more pronounced in the latter half of the study period. The age of patients receiving telehealth services decreased over the study period from 39.5 years to 34.7 years (p<0.001).

Patients living in urban settings received the minority of telehealth services early in the study period, but this trend reversed from 2014 to 2017. Telehealth visits occurred predominantly in the outpatient setting, though the total percentage of visits in that setting decreased over time. Telehealth use increased across all insurance types (Table 2 ). This trend was most pronounced among individuals covered under CDHP or HDHP plans, with an increase from 7 to 3455 patients receiving telehealth services from 2007 to 2017.

To our knowledge, this is the first long-term description of patients receiving telehealth visits through commercial insurance. It demonstrated that telehealth visits were relatively uncommon and occurred most commonly in the outpatient setting, with increases over time and a trend toward urban settings, younger individuals and those insured through CDHP and HDHP plans. Insight about use by geographic region can help identify areas for greater telehealth investment, while information about insurance type is particularly salient given Outpatient settings include office and hospital-based outpatient, federally qualified health centers, rural health clinics 3 The "other" category included all other sites of services, the most common of which were inpatient psychiatric facility (797 total services), school (540 total services), and patient home (454 total services).

The category also included 3417 services coded in underlying data as "other/unknown" and 1793 services coded as "telehealth" with unclear site of service) *Coverage data missing for 1% (n=676) of patients during the study period the disruption the pandemic has caused to employersponsored insurance and policymaker plans to reform national insurance coverage. Study limitations included descriptive design and focus on commercially insured individuals. We lacked important patient-level data including race/ethnicity and provider-level data (e.g., primary vs. specialty care) that are potentially associated with telehealth utilization. Telehealth utilization was also low early in the study period, and both absolute and relative growth in use should be assessed contextually in future work using other sources (e.g., clinical data). Nonetheless, our findings suggest areas for additional work and provide important insight that policy and practice leaders can use to implement telehealth amid and after the pandemic. 

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