Evaluating the association between expanded coverage of direct-to-consumer telemedicine and downstream utilization and quality of care for urinary tract infections and sinusitis

Abstract

Objective: To compare direct-to-consumer (DTC) telemedicine and in-person visits in rates of testing, follow-up health care use, and quality for urinary tract infections (UTIs) and sinusitis.

Data source: The Minnesota All Payer Claims Data provided 2008-2015 administrative claims data.

Study design: Using a difference-in-differences approach, we compared episodes of care for UTIs and sinusitis among enrollees of health plans introducing coverage for DTC telemedicine relative to those without DTC telemedicine coverage. Primary outcomes included number of laboratory tests, antibiotics filled, office and outpatient visits, emergency department (ED) visits, and standardized spending, based on standardized prices of health services.

Data collection: The study sample included non-elderly enrollees of commercial health insurance plans. We constructed 30-day episodes of care initiated by a DTC telemedicine or in-person visit.

Principal findings: The UTI and sinusitis samples were comprised of 215,134 and 624,630 episodes of care, respectively. Following the introduction of coverage for DTC telemedicine, 15.7% of UTI episodes and 8.9% of sinusitis episodes were initiated with DTC telemedicine. Compared to episodes without coverage for DTC telemedicine, UTI episodes with coverage had 0.25 fewer lab tests (95% CI: -0.33, -0.18; p < 0.001), lower standardized spending for the first UTI visit (-$11.18 [95% CI: -$21.62, -$0.75]; p < 0.05), and no change in office and outpatient visits, ED visits, antibiotics filled, or standardized medical spending. Sinusitis episodes with coverage for DTC telemedicine had fewer antibiotics filled (-0.08 [95% CI: -0.14, -0.01]; p < 0.05) and a very small increase in ED visits (0.001 [95% CI: 0.001, 0.010]; p < 0.05), but no change in lab tests, office and outpatient visits, or standardized medical spending.

Conclusions: Among commercially insured patients, coverage of DTC telemedicine was associated with reductions in antibiotics for sinusitis and laboratory tests for UTI without changes in downstream total office and outpatient visits or changes in ED visits.

Keywords: direct-to-consumer telehealth; health insurance coverage; telemedicine.

FIGURE 1

Percentage of DTC telemedicine‐initiated episodes of care in DTC coverage and comparison payers. DTC, Direct‐to‐consumer; UTI, Urinary Tract Infection. The UTI analysis includes only commercially‐insured female patients (18–64) with a primary diagnosis of urinary tract infection. The sinusitis analysis includes both male and female commercially‐insured patients (18–64) with a primary diagnosis of acute or chronic sinusitis. The DTC coverage group in our analysis included enrollees in health plans offered by two Minnesota insurers that introduced coverage of DTC telemedicine services in 2010. The comparison group included individuals enrolled in health plans that did not cover DTC telemedicine services during the study period [Color figure can be viewed at wileyonlinelibrary.com]

FIGURE 2

Adjusted differential changes in the number of follow‐up services for treatment and comparison groups in pre‐ and post‐DTC telemedicine expansion years. UTI episodes of care. Sinusitis episodes of care. All comparisons are DTC‐initiated episodes versus in‐person‐initiated episodes of care. Regressions include year and health insurer plan‐product fixed effects. All standard errors are clustered at the health plan‐product level. The UTI analysis includes only commercially‐insured female patients (18–64) with a primary diagnosis of urinary tract infection. The DTC coverage group in our analysis included enrollees in health plans offered by two Minnesota insurers that introduced coverage of DTC telemedicine services in 2010. The comparison group included individuals enrolled in health plans that did not cover DTC telemedicine services during the study period. The x‐axis represents the number of years relative to the expansion of DTC telemedicine coverage among treatment plans. Year‐to‐event coefficient estimates represent changes in the outcome and 95% confidence interval (error bars); coefficients were estimated relative to the reference period, that is the year prior to expansion. All models are adjusted for age category, ACG risk score quartile, number of comorbidities, probability of being a persistent high cost user quartile, and whether the patient resides in a rural ZIP code. The sinusitis model controlled for whether the patient was female as well.