Outcomes of In-Person and Telehealth Ambulatory Encounters during COVID-19 Within a Large Commercially Insured Cohort

Importance: Since the start of the COVID-19 pandemic, few studies have assessed the association of telehealth with outcomes of care, including patterns of health care use after the initial encounter. Objective: To assess the association of telehealth and in-person visits with outcomes of care during the COVID-19 pandemic. Design, Setting, and Participants: This cohort study assessed continuously enrolled members in private health plans of the Blue Cross and Blue Shield Association from July 1, 2019, to December 31, 2020. Main Outcomes and Measures: Main outcomes were ambulatory encounters per enrollee stratified by characteristics derived from enrollment files, practitioner claims, and community characteristics linked to the enrollee's zip code. Outcomes of care were assessed 14 days after the initial encounters and included follow-up encounters of any kind, emergency department encounters, and hospitalizations after initial telehealth or in-person encounters. Results: In this cohort study of 40739915 individuals (mean [SD] age, 35.37 [18.77] years; 20480768 [50.3%] female), ambulatory encounters decreased by 1.0% and the number of in-person encounters per enrollee decreased by 17.0% from 2019 to 2020; however, as a proportion of all ambulatory encounters, telehealth encounters increased substantially from 0.6% (n = 236220) to 14.1% (n = 5743718). For members with an initial telehealth encounter for a new acute condition, the adjusted odds ratio was 1.44 (95% CI, 1.42-1.46) for all follow-ups combined and 1.11 (95% CI, 1.06-1.16) for an emergency department encounter. For members with an initial telehealth encounter for a new chronic condition, the adjusted odds ratios were 0.94 (95% CI, 0.92-0.95) for all follow-ups combined and 0.94 (95% CI, 0.90-0.99) for in-patient admissions. Conclusions and Relevance: In this cohort study of 40.7 million commercially insured adults, telehealth accounted for a large share of ambulatory encounters at the peak of the pandemic and remained prevalent after infection rates subsided. Telehealth encounters for chronic conditions had similar rates of follow-up to in-person encounters for these conditions, whereas telehealth encounters for acute conditions seemed to be more likely than in-person encounters to require follow-up. These findings suggest a direction for future work and are relevant to policy makers, payers, and practitioners as they manage the use of telehealth during the COVID-19 pandemic and afterward.