Telehealth does not raise rates of low-value primary care

Telehealth did not drive up the low-value care services, such as unnecessary scans and tests, at primary care practices, which could help mitigate lawmakers' concerns about telehealth encouraging waste in healthcare delivery, according to new research.

Published in JAMA Network Open, the study assessed whether telehealth utilization increased the delivery of low-value care. The authors noted that lawmakers have pointed out concerns about telehealth generating unnecessary or low-quality care compared with in-person care. Though prior research has shown that telehealth care quality is on par with or better than in-person care quality across several measures, the study authors stated that there is little research on how telehealth influences low-value care delivery.

The research team from the University of Michigan and Veterans Affairs Center for Clinical Management Research conducted a retrospective cohort study, analyzing Medicare fee-for-service claims data from Jan. 1, 2019, to Dec. 31, 2022. They measured practice-level telehealth use by dividing primary care practices into weighted tertiles based on the number of telehealth services per 1,000 beneficiaries used in 2022.

The study includes data for 577,928 beneficiaries attributed to 2,552 primary care practices in 2022. The mean telehealth visit rate was 194 per 1,000 beneficiaries for practices with low telehealth use, 654 per 1,000 beneficiaries for practices with medium telehealth use and 1,469 visits per 1,000 beneficiaries for practices with high telehealth use.

The researchers also identified eight low-value care services relevant to primary care. They grouped the services into four categories that might be affected by telehealth use: office-based services, laboratory-based services, imaging-based services and mixed-modality services.

The study's primary outcome was the difference in the risk-adjusted rate of low-value care services between the pre-pandemic period (2019) and the post-pandemic period (2022) at practices with differing levels of telehealth use.

Overall, the rate of patients using six of the eight low-value services studied dropped or stayed the same from the pre- to the post-pandemic periods.

Between the two periods, cervical cancer screening rates for women older than 65 and colorectal cancer screening rates for adults older than 85 decreased among all primary care practice groups, irrespective of low or high telehealth use.

However, changes in the rates of laboratory-based and imaging-based low-value care services varied. While the rates of some low-value care services, like vitamin D testing and CT sinus imaging, increased or stayed the same across all primary care practices between 2019 and 2022, others, such as low-value thyroid testing and head imaging for uncomplicated headaches, decreased over the same period.

Interestingly, for two services -- cervical cancer screening for women over 65 and ongoing blood monitoring for a thyroid hormone in people with hypothyroidism -- there was a faster drop in use at medium- and high-telehealth clinics than at low-telehealth clinics.

Thus, researchers concluded that increases in telehealth use at primary care practices were not associated with more low-value care services. This could help quell concerns regarding how telehealth affects healthcare utilization.

"Our findings are reassuring in the context of current telehealth policy decisions, because there has been concern that telehealth might be increasing access to care to a degree that leads to unnecessary visits and wasteful screening or diagnostic testing," said lead author Terrence Liu, M.D., a primary care physician at University of Michigan Health and National Clinician Scholar at the U-M Institute for Healthcare Policy and Innovation, in a press release.

Various regulatory flexibilities enacted during the COVID-19 pandemic significantly expanded access to telehealth. However, barring congressional action, these are slated to expire at the end of the year.

In February, 200 telehealth stakeholders urged Congress to take action on the flexibilities earlier in the year to "provide much needed certainty, and safeguard against this important policy getting left behind among competing priorities at the end of the year."

Though an amended version of the bipartisan Telehealth Modernization Act of 2024 has advanced out of the House Committee on Energy and Commerce and House Ways and Means Committee that would extend the flexibilities by another two years, Congress has yet to act.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.