Doctor On Demand, Harvard study finds telehealth surge driven by behavioral health, chronic illness visits

It's not surprising that the COVID-19 pandemic drove a huge surge in telehealth visits as patients avoided in-person care in favor of remote consultations.

But what is unexpected? The growth in telehealth was not fueled by COVID-19 concerns but by visits for behavioral health issues and chronic conditions, according to a new study of Doctor On Demand data.

The largest increases in telemedicine visits during the COVID-19 pandemic were attributable to scheduled behavioral health appointments, such as therapy and psychiatry visits, and chronic illness visits, according to a peer-reviewed study published in the Journal of Medical Internet Research this month.

"We see many people turning to telemedicine including a broader range of ages, urban and rural residents and lower-income households," said Ian Tong, M.D., chief medical officer at Doctor On Demand, in an exclusive interview with Fierce Healthcare about the study results.

Visit volumes for both health concerns topped visits related to COVID-19 symptoms or exposure, according to an analysis of telehealth data from Doctor On Demand before and during the COVID-19 pandemic.

Researchers from the telehealth company, Harvard Medical School and RAND Corporation studied how the number of virtual visits, reasons for visits and patients served changed over time, comparing a baseline four-month period, February through June 2019, to the same four-month period during the pandemic.

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Doctor On Demand observed a substantial increase in the volume of visits during the COVID-19 pandemic, with total visit volume up 59% above the baseline from March through April 7. Visits then declined through the week of June 2 but were still up 15% above the baseline.

The analysis looked at four categories of telehealth visits: respiratory illness (including potential COVID-19 symptoms), chronic illness, unscheduled behavioral health services (offered within the urgent care service staffed by trained primary care providers) and scheduled behavioral health services (including therapy and psychiatry). 

The study found that visits for respiratory illnesses increased through the week of March 24, with visit volume up 30% above the baseline, and then steadily declined through the week of June 2 to 65% below the baseline.

But higher relative increases were observed for unscheduled behavioral health and chronic illness visits through April, with visits up 109% and 131% above the baseline, respectively. Visits then declined through the week of June 2 to 69% and 37%, respectively—levels that were still above the baseline.

Many industry stakeholders associate telemedicine platforms like Teladoc, Amwell and Doctor On Demand with urgent care or one-time transactional care. And there has been a lot of conjecture that telehealth volume will return to pre-pandemic levels once a COVID-19 vaccine has been widely distributed and patients can safely return to in-person doctors' appointments.

But Tong said telemedicine was moving far beyond urgent care even prior to the pandemic, and patients are increasingly turning to virtual care for a diverse range of health issues.

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"We’d witnessed a steady increase in utilization for more complex, longitudinal care in the 18 months prior to the pandemic, but COVID-19 was an accelerator for much wider adoption of virtual care for behavioral health, chronic illness and primary care more broadly,” he said.

“As the peek of the pandemic wanes, we expect to continue to see high levels of utilization for these higher-acuity conditions, and as a business, will continue to invest in expanding our diverse clinical team to best support long-term patient-provider relationships," Tong said.

The study findings suggest that telemedicine may serve as a “safety valve,” addressing gaps in access to the traditional, in-person healthcare delivery system, according to the researchers, including Lori Uscher-Pines, Ph.D., from the RAND Corporation's healthcare division, and Ateev Mehrotra, M.D., associate professor of healthcare policy and medicine at Harvard Medical School.

The analysis also found a bigger uptick in telehealth visits among rural residents compared to urban residents during the pandemic. All visits among urban residents peaked at 58% above baseline, whereas visits among rural residents peaked at 64% above baseline.

Individuals residing in low-income regions (mean per capita income of less than $20,000) accounted for 47% of all visits in January and February 2020 and 50% of all visits in April 2020, the study found.

The proportion of patients new to the telehealth platform increased from 40% in February 2020 to 53% in April 2020.

"There has been substantial discussion about the 'digital divide' in health care and concerns that patients from lower-income communities may not have the necessary technology or digital literacy to participate in video-based visits. Nevertheless, it is reassuring that the proportion of telehealth visits by patients from lower-income communities was stable during the early weeks of the COVID-19 pandemic," the researchers wrote.

San Francisco-based Doctor On Demand provides on-demand and scheduled visits with U.S.-licensed healthcare providers in both medical and behavioral health. The company currently covers more than 98 million lives.

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The company more than doubled its covered lives in the past six months, propelling Doctor On Demand to 3 million virtual visits, the company said.

The study data confirm the company's vision that patients will build relationships with providers and care teams in a virtual-first care setting, Tong said.

Last year, the company teamed up with Humana to launch a new virtual primary care model. Called On Hand, the plan gives patients access to a dedicated primary care physician as well as preventive care, urgent care and behavioral health care through video visits with lower monthly premiums.

Tong said Doctor On Demand is "leaning in" to its investments in virtual care as a means to reach all patient populations and to provide high-quality care.

"We are leaning more towards prospective payment arrangements and risk-based contracts because we’ve found a much more efficient way to deliver healthcare resources and advantage that we have over brick-and-mortar facilities," Tong said.