An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor
Abstract Background The potential of virtual care as an alternative to in-person visits is promising, yet its economic impact is insufficiently understood. This evaluation represents an episode-based, cost impact analysis of virtual-first (versus in-person first) care to treat the most prevalent pri...
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2025-07-01
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| Online Access: | https://doi.org/10.1186/s12913-025-13154-1 |
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| author | Amanda L. Zaleski Xinbei Guan Kelly J. Thomas Craig Christopher Junk Arthur T. McGill Henry Gordon Dorothea J. Verbrugge Kristofer Caya |
| author_facet | Amanda L. Zaleski Xinbei Guan Kelly J. Thomas Craig Christopher Junk Arthur T. McGill Henry Gordon Dorothea J. Verbrugge Kristofer Caya |
| author_sort | Amanda L. Zaleski |
| collection | DOAJ |
| description | Abstract Background The potential of virtual care as an alternative to in-person visits is promising, yet its economic impact is insufficiently understood. This evaluation represents an episode-based, cost impact analysis of virtual-first (versus in-person first) care to treat the most prevalent primary care acute conditions among Medicare Advantage (MA) and commercial fully-insured (C-FI) members of a large national health plan in the United States. Methods Retrospective episodes-of-care and medical claims analyses identified members (N = 366,195; MA: 126,363, C-FI: 239,832) with resolved, pre-specified, acute primary care episodes (N = 455,231; MA: 141,034, C-FI: 314,197) between 1/1/2022–6/30/2022. Propensity score weighting estimated % difference in healthcare expenditures between virtual-first episodes and an adjusted cohort of in-person-first episodes. Results Within the MA cohort, 7.6% (range: 0.7–24.8%) of episodes utilized virtual-first care with observed cost-of-episode 10–24% lower than in-person-first care for 6 of 11 included conditions (all P < 0.05), including: otolaryngology disease (-24 ± 2%), rhinitis (-20 ± 4%), gastroenterology disease (-20 ± 7%), minor bacterial skin infections (-17 ± 7%), sinusitis (-14 ± 4%), and bronchitis (-11 ± 4%). Within the C-FI cohort, 12.6% (range: 2.8–40.4%) of episodes utilized virtual-first care with observed cost-of-episode 9–33% lower than in-person-first care (all P < 0.001) for 12 of 16 included conditions (all P < 0.001), including: urinary tract infection (-33 ± 5%), viral skin infection (-29 ± 6%), gastroenterology disease (-27 ± 5%), rhinitis (-28 ± 5%), otolaryngology disease (-25 ± 2%), sinusitis (-25 ± 2%), urological disease (-23 ± 9%), contact dermatitis (-19 ± 5%), viral pneumonia (-17 ± 12%), bronchitis (-15 ± 4%), fungal skin infection (-11 ± 6%), and minor bacterial skin infection (-9 ± 7%), and 4 ± 2% higher to treat exposure to infectious disease (P = 0.001). There were no between-group differences in cost-of-episode to treat: skin inflammation (MA & C-FI), urinary tract infection (MA), exposure to infectious disease (MA), fungal skin infection (MA), low back pain (C-FI), or migraine headache (C-FI) (all P > 0.081). Conclusion This real-world study of a large national sample of geographically diverse members demonstrates the potential of virtual-first care to resolve acute conditions at lower cost compared to in-person-first care. The use of episode-based analytical tools enhances the significance of these findings by enabling a proxy for clinical outcomes. |
| format | Article |
| id | doaj-art-ea5a0d032e62469b99ce227bf59e97e2 |
| institution | DOAJ |
| issn | 1472-6963 |
| language | English |
| publishDate | 2025-07-01 |
| publisher | BMC |
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| spelling | doaj-art-ea5a0d032e62469b99ce227bf59e97e22025-08-20T03:04:36ZengBMCBMC Health Services Research1472-69632025-07-012511910.1186/s12913-025-13154-1An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payorAmanda L. Zaleski0Xinbei Guan1Kelly J. Thomas Craig2Christopher Junk3Arthur T. McGill4Henry Gordon5Dorothea J. Verbrugge6Kristofer Caya7Clinical Evidence Development, Aetna® Medical Affairs, CVS Health®Analytics & Behavior Change, CVS HealthClinical Evidence Development, Aetna® Medical Affairs, CVS Health®Analytics & Behavior Change, CVS HealthAetna Network Virtual Care, CVS HealthAetna Network Virtual Care, CVS HealthClinical Evidence Development, Aetna® Medical Affairs, CVS Health®Aetna Network Virtual Care, CVS HealthAbstract Background The potential of virtual care as an alternative to in-person visits is promising, yet its economic impact is insufficiently understood. This evaluation represents an episode-based, cost impact analysis of virtual-first (versus in-person first) care to treat the most prevalent primary care acute conditions among Medicare Advantage (MA) and commercial fully-insured (C-FI) members of a large national health plan in the United States. Methods Retrospective episodes-of-care and medical claims analyses identified members (N = 366,195; MA: 126,363, C-FI: 239,832) with resolved, pre-specified, acute primary care episodes (N = 455,231; MA: 141,034, C-FI: 314,197) between 1/1/2022–6/30/2022. Propensity score weighting estimated % difference in healthcare expenditures between virtual-first episodes and an adjusted cohort of in-person-first episodes. Results Within the MA cohort, 7.6% (range: 0.7–24.8%) of episodes utilized virtual-first care with observed cost-of-episode 10–24% lower than in-person-first care for 6 of 11 included conditions (all P < 0.05), including: otolaryngology disease (-24 ± 2%), rhinitis (-20 ± 4%), gastroenterology disease (-20 ± 7%), minor bacterial skin infections (-17 ± 7%), sinusitis (-14 ± 4%), and bronchitis (-11 ± 4%). Within the C-FI cohort, 12.6% (range: 2.8–40.4%) of episodes utilized virtual-first care with observed cost-of-episode 9–33% lower than in-person-first care (all P < 0.001) for 12 of 16 included conditions (all P < 0.001), including: urinary tract infection (-33 ± 5%), viral skin infection (-29 ± 6%), gastroenterology disease (-27 ± 5%), rhinitis (-28 ± 5%), otolaryngology disease (-25 ± 2%), sinusitis (-25 ± 2%), urological disease (-23 ± 9%), contact dermatitis (-19 ± 5%), viral pneumonia (-17 ± 12%), bronchitis (-15 ± 4%), fungal skin infection (-11 ± 6%), and minor bacterial skin infection (-9 ± 7%), and 4 ± 2% higher to treat exposure to infectious disease (P = 0.001). There were no between-group differences in cost-of-episode to treat: skin inflammation (MA & C-FI), urinary tract infection (MA), exposure to infectious disease (MA), fungal skin infection (MA), low back pain (C-FI), or migraine headache (C-FI) (all P > 0.081). Conclusion This real-world study of a large national sample of geographically diverse members demonstrates the potential of virtual-first care to resolve acute conditions at lower cost compared to in-person-first care. The use of episode-based analytical tools enhances the significance of these findings by enabling a proxy for clinical outcomes.https://doi.org/10.1186/s12913-025-13154-1Primary careTelemedicineTelehealthCare delivery, virtual care |
| spellingShingle | Amanda L. Zaleski Xinbei Guan Kelly J. Thomas Craig Christopher Junk Arthur T. McGill Henry Gordon Dorothea J. Verbrugge Kristofer Caya An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor BMC Health Services Research Primary care Telemedicine Telehealth Care delivery, virtual care |
| title | An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor |
| title_full | An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor |
| title_fullStr | An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor |
| title_full_unstemmed | An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor |
| title_short | An episode-based cost analysis of virtual-first versus in-person-first care to treat common acute conditions among members of a large national payor |
| title_sort | episode based cost analysis of virtual first versus in person first care to treat common acute conditions among members of a large national payor |
| topic | Primary care Telemedicine Telehealth Care delivery, virtual care |
| url | https://doi.org/10.1186/s12913-025-13154-1 |
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