Telemedicine May Reduce Low-Value Testing and Related Costs in Medicare Beneficiaries

Telemedicine helps facilitate patient access to physician visits, but it may also reduce the use of low-value tests and related costs and harms, according to a study published today in JAMA Internal Medicine.1

Low-value care refers to medical tests and services offered in annual check-ups, symptom-based visits, and preoperative visits that provide minimal benefit but can lead to direct and cascading harms2; this persistent issue worsens patient outcomes. Therefore, the researchers noted that low-value care contributes to excess medical spending and diverts resources from high-value care.1

Although low-value care use declined early in the COVID-19 pandemic, it remains unclear whether telemedicine played a role in this reduction. Telemedicine may reduce low-value care use by introducing barriers to completing certain services, particularly tests usually completed at the point of care. Conversely, clinical uncertainty in telemedicine visits due to the lack of a physical examination may lead clinicians to order more low-value diagnostic tests.

Previous research on telemedicine and low-value care is mixed and limited. The researchers highlighted the need for national evidence to guide policy decisions on telemedicine reimbursement and regulation, especially for fee-for-service (FFS) Medicare beneficiaries, who are at a high risk for low-value care. Consequently, the researchers aimed to quantify the association between telemedicine adoption and low-value care among FFS Medicare beneficiaries.

Higher telemedicine adoption among Medicare beneficiaries was associated with a slight increase in total visits but a reduction in certain low-value tests and related spending. | Image Credit: rh2010 - stock.adobe.com

They analyzed 100% FFS Medicare claims data from 2019 to 2022, categorizing US health systems into quartiles based on their telemedicine adoption in 2020. Using a difference-in-differences (DiD) framework, the researchers conducted beneficiary-level linear regression to compare low-value test and visit outcomes in 2022 vs 2019 for beneficiaries continuously enrolled in Medicare Parts A and B in high (top quartile) vs low (bottom quartile) telemedicine-adopting health systems.

The primary outcomes were low-value care use and spending. They calculated the total visits per beneficiary, both in person and virtual, annually. Also, the researchers examined 20 low-value tests that are usually ordered in the context of a physician’s visit, provided either at a point of care or scheduled at a later date, and have been associated with high direct or downstream cascade spending. These included screening, preoperative, chronic condition management, and acute diagnostic tests.

After refining and operationalizing established, claims-based measures based on sex, age, diagnoses, and procedure codes, the researchers calculated the proportion of eligible beneficiaries who received each service within a given year. Lastly, they analyzed spending per service-eligible beneficiary for each service, total spending across all low-value tests, and overall spending on visits.

Of the 6,520,377 eligible beneficiaries, 1,382,033 were attributed to 143 high-telemedicine systems (mean [SD] age, 71.6 [10.5] years; 58.8% female) and 999,051 to 143 low-telemedicine systems (mean [SD] age, 71.8 [10.0] years; 57.0% female). From 2019 to 2022, following telemedicine adoption, there was a small differential rise in total visits among beneficiaries in high-telemedicine systems (DiD visits per beneficiary, 0.12; 95% CI, 0.03-0.21).

Additionally, among this cohort, there were differential decreases in the use of 7 low-value services: screening electrocardiograms (DiD, –1.30 percentage points [pp]; 95% CI, –1.96 to –0.65), cervical cancer screening in women older than 65 years (DiD, –0.45 pp; 95% CI, –0.72 to –0.17), screening metabolic panels (DiD, –1.84 pp; 95% CI, –2.87 to –0.80), preoperative complete blood cell counts (DiD, –0.64 pp; 95% CI, –1.06 to –0.22), preoperative metabolic panels (DiD, –1.35 pp; 95% CI, –1.91 to –0.80), total or free triiodothyronine level testing for hypothyroidism (DiD, –0.90 pp; 95% CI, –1.38 to –0.41), and early back imaging for nonspecific low back pain (DiD, –1.66; 95% CI, –2.35 to –0.98).

Also, there were statistically significant differential decreases in spending per beneficiary for 2 of 20 services, namely cervical cancer screening (–$0.56; 95% CI, –$0.89 to –$0.23; 27% spending reduction) and preoperative blood cell counts (–$0.15; 95% CI, –$0.24 to –$0.06; 7% reduction). However, there was no differential change in total low-value care spending per beneficiary across all beneficiaries eligible for 1 or more low-value services (–$0.15; 95% CI, –$2.62 to $2.33).

The researchers acknowledged their study’s limitations, including that findings may not be generalizable to those enrolled in Medicare Advantage or other plans. Despite their limitations, they expressed confidence in their discoveries.

“As CMS and private payers evaluate telemedicine reimbursement policies, such as the extension of Medicare’s temporary allowance of broad telemedicine coverage beyond 2024, these results suggest potential benefits of telemedicine and mitigate concerns about telemedicine contributing to increased Medicare spending,” the authors concluded.

References

1. Ganguli I, Lim C, Daley N, Cutler D, Rosenthal M, Mehrotra A. Telemedicine adoption and low-value care use and spending among fee-for-service Medicare beneficiaries. JAMA Intern Med. Published online February 24, 2025. doi:10.1001/jamainternmed.2024.8354
2. Low-value care. V-BID Center. Accessed February 24, 2024. https://vbidcenter.org/initiatives/low-value-care/