Relative billing complexity of in-person versus telehealth outpatient encounters.

RATIONALE: Video visits became more widely available during the coronavirus disease (COVID-19) pandemic. However, the ongoing role and value of video visits in care delivery and how these may have changed over time are not well understood. AIMS AND OBJECTIVES: Compare the relative complexity of in-person versus video visits during the COVID-19 pandemic and describe the complexity of video visits over time. METHODS: We used billing data for in-person and video revisits from non-behavioural health specialities with the most video visit utilisation (≥50th percentile) at a large, urban, public healthcare system from 1 January 2021 to 31 March 2022. We used current procedural terminology (CPT) codes as a proxy for information gathering and decision-making complexity and time spent on an encounter. We compared the distribution of CPT codes 99211-99215 between in-person and video visits using Fisher's exact tests. We used Spearman correlation to test for trends between proportions of CPT codes over time for video visits. RESULTS: Ten specialities (adult primary care, paediatrics, adult dermatology, bariatric surgery, paediatric endocrinology, obstetrics and gynaecologist, adult haematology/oncology, paediatric allergy/immunology, paediatric gastroenterology, and paediatric pulmonology) met inclusion criteria. For each speciality, proportions of each CPT code for in-person visits and for video visits varied significantly, and patterns of variation differed by speciality. For example, in adult primary care, video visits had smaller proportions of moderate/high complexity visits (99214 and 99215) and greater proportions of lower complexity visits (99211-99213) compared with in-person visits (p < 0.001), but in paediatric endocrinology, the opposite was seen (p < 0.001). Trends in CPT codes over time for video visits in each speciality were also mixed. CONCLUSION: In-person and video visits had differing proportions of complexity codes (typically skewing towards lower complexity for video visits). The complexity of video visits changed over time in many specialities. Observed patterns for both phenomena varied by speciality.

Patient Characteristics Associated with Telehealth Scheduling and Completion in Primary Care at a Large, Urban Public Healthcare System.

Understanding patient characteristics associated with scheduling and completing telehealth visits can identify potential biases or latent preferences related to telehealth usage. We describe patient characteristics associated with being scheduled for and completing audio and video visits. We used data from patients at 17 adult primary care departments in a large, urban public healthcare system from August 1, 2020 to July 31, 2021. We used hierarchical multivariable logistic regression to generate adjusted odds ratios (aOR) for patient characteristics associated with having been scheduled for and completed telehealth (vs in-person) visits and for video (vs audio) scheduling and completion during two time periods: a telehealth transition period (N = 190,949) and a telehealth elective period (N = 181,808). Patient characteristics were significantly associated with scheduling and completion of telehealth visits. Many associations were similar across time periods, but others changed over time. Patients who were older (≥ 65 years old vs 18-44 years old: aOR for scheduling 0.53/completion 0.48), Black (0.86/0.71), Hispanic (0.76/0.62), or had Medicaid (0.93/0.84) were among those less likely to be scheduled for or complete video (vs audio) visits. Patients with activated patient portals (1.97/3.34) or more visits (≥ 3 scheduled visits vs 1 visit: 2.40/1.52) were more likely to be scheduled for or complete video visits. Variation in scheduling/completion explained by patient characteristics was 7.2%/7.5%, clustering by provider 37.2%/34.9%, and clustering by facility 43.1%/37.4%. Stable and dynamic associations suggest persistent gaps in access and evolving preferences/biases. Variation explained by patient characteristics was relatively low compared with that explained by provider and facility clustering.

Appointment Non-attendance for Telehealth Versus In-Person Primary Care Visits at a Large Public Healthcare System.

BACKGROUND: Appointment non-attendance has clinical, operational, and financial implications for patients and health systems. How telehealth services are associated with non-attendance in primary care is not well-described, nor are patient characteristics associated with telehealth non-attendance. OBJECTIVE: We sought to compare primary care non-attendance for telehealth versus in-person visits and describe patient characteristics associated with telehealth non-attendance. DESIGN: An observational study of electronic health record data. PARTICIPANTS: Patients with primary care encounters at 23 adult primary care clinics at a large, urban public healthcare system from November 1, 2019, to August 31, 2021. MAIN MEASURES: We analyzed non-attendance by modality (telephone, video, in-person) during three time periods representing different availability of telehealth using hierarchal multiple logistic regression to control for patient demographics and variation within patients and clinics. We stratified by modality and used hierarchal multiple logistic regression to assess for associations between patient characteristics and non-attendance in each modality. KEY RESULTS: There were 1,219,781 scheduled adult primary care visits by 329,461 unique patients: 754,149 (61.8%) in-person, 439,295 (36.0%) telephonic, and 26,337 (2.2%) video visits. Non-attendance for telephone visits was initially higher than that for in-person visits (adjusted odds ratio 1.04 [95% CI 1.02, 1.07]) during the early telehealth availability period, but decreased later (0.82 [0.81, 0.83]). Non-attendance for video visits was higher than for in-person visits during the early (4.37 [2.74, 6.97]) and later (2.02 [1.95, 2.08]) periods. Telephone visits had fewer differences in non-attendance by demographics; video visits were associated with increased non-attendance for patients who were older, male, had a primary language other than English or Spanish, and had public or no insurance. CONCLUSIONS: Telephonic visits may improve access to care and be more easily adoptable among diverse populations. Further attention to implementation may be needed to avoid impeding access to care for certain populations using video visits.