Abstract
Background/Introduction:
Scheduled telephone follow-up visits (TFVs) are one strategy for improving access to specialty care practices, primarily because TFVs can be completed in less time with lower overhead costs than conventional office-based follow-up visits (OFVs). Beginning January 2015, scheduled TFVs were introduced in three specialty care practices at University of California San Francisco (UCSF) as a substitute for scheduled OFVs. As there is limited data on the relative advantage to patients from such a program, we conducted a survey to evaluate patient-reported outcomes associated with both TFVs and OFVs.
Materials and Methods:
All patients who completed a follow-up visit in Endocrinology, Hepatology, or Multiple Sclerosis clinics between March and May 2016 were surveyed. Primary outcomes included out-of-pocket costs associated with follow-up visits, visit duration, and satisfaction. Responses were analyzed using univariate and bivariate statistics, and both t-tests and chi-square tests were employed to determine significance.
Results:
A total of 2,741 patients were surveyed, of which 16% (n = 432) responded. Median self-reported costs associated with OFVs, including travel was $50 (interquartile range [IQR]: 20,100), and median visit duration was 240 (IQR: 150; 420) minutes. Of all TFV respondents, only one reported a cost of $15, and 99% of TFV respondents reported being satisfied with their TFV experience.
Discussion/Conclusion:
At UCSF, TFVs offer an efficient alternative to office-based visits in a manner that is both acceptable and affordable to patients. This study fills an important gap in understanding the patient's perception of telephone follow-up care, and represents a critical first step in mobilizing health plans to pay for TFVs.
Introduction
Timely access to medical care is a common priority in multispecialty health systems for improving clinical outcomes and patient satisfaction. However, with the growing imbalance between supply and demand for specialty care, patients often experience delays when seeking to schedule an office visit with their physician. 1,2 Moreover, while the opportunity costs for patients traveling to these visits are substantial, 3 they are often not appreciated as they are challenging to measure. 4 In addition, it is becoming evident that not all follow-up visits require an in-person evaluation. 5 With delays that can lead to worse outcomes and missed diagnoses, and patient out-of-pocket opportunity costs for office visits in the United States estimated to be over $50 billion dollars annually, care delivery redesign is needed to improve value for patients and to promote more patient-centered care. 3,6,7
To help address these issues, University of California San Francisco (UCSF) Health deployed a program of scheduled telephone follow-up visits (TFVs) in several specialty care practices beginning January 2015. We know that telehealth, which typically includes video, has several advantages. Studies have already demonstrated that telehealth can reduce wait times for patients, hospital admissions, and hospitalization duration. 8,9 Furthermore, the implementation of telehealth has been shown to save health care systems money and resources, 10 to be comparable to in-person visits in terms of safety, and to improve outcomes for specific chronic conditions. 11 These benefits, along with the reduction of overhead costs, time spent in waiting rooms, and exposure to other pathogens make telehealth solutions appealing. 3 The telephone modality is presumed to be comparable in this intervention for two key reasons. First, these patients were established within the practice and had a relationship with the clinical provider. Second, the patient and provider agreed during an in-person interaction that the next planned discussion could reasonably take place by phone.
To date, there is limited data on the experience of patients who participate in such a program. To inform ongoing improvement of the program, and to share the experience with payers—who do not currently provide reimbursement for telephone visits—we conducted a survey comparing patient experiences with TFVs and office-based follow-up visits (OFVs). We specifically assess self-reported out-of-pocket costs, total time spent, satisfaction, preference for future encounters, and urgent care or emergency room use following a visit.
Materials and Methods
Program Description
Like a typical OFV, TFVs were scheduled prospectively and appeared on the provider's schedule within the Electronic Health Record (Epic Systems, Inc., Verona, WI) alongside clinic visits. The duration of TFVs was significantly shorter than office-based follow-up appointments (10 min in contrast to 30 min in the practices analyzed here). In a typical 0.5-day clinic session, six TFVs would replace two office visits. These TFVs were meant to mirror a traditional office-based visit, where the provider would call the patients to assess symptoms, review results, discuss medications, and make clinical recommendations based upon their assessment. Patients received a phone call by support staff several days before their scheduled TFV to confirm their scheduled time and address potential technical difficulties.
Patient Selection for Scheduled TFVs
Physicians determined which patients were appropriate for TFVs based upon clinical condition, discussed the option with these patients, and scheduled the TFV if acceptable to the patient. For the initial program, patients were deemed appropriate for TFVs if they were ordinarily expected to have a scheduled OFV and did not require in-person evaluation or interpreter services. There was no charge to patients for TFVs, and the UCSF physician received a modest work relative value unit (wRVU) credit from UCSF Health.
Data Collection
English language surveys were offered to all patients (age ≥18 years) who completed an office or TFV in the Endocrinology, Hepatology, or Multiple Sclerosis practices between March to May 2016. Patients with an email address on file were sent the survey (Qualtrics LLC) electronically, and the remaining patients were contacted by phone. Patients contacted by phone were asked about their willingness to participate in a brief survey about their recent TFV or OFV, and then administered the survey. A single reminder e-mail or telephone call was attempted for nonresponders. All surveys were completed anonymously, and no personal health information or personally identifiable information on survey respondents were collected.
Outcome-Related Survey Content
TFV patients were asked about their out-of-pocket costs associated with their telephone visit, their satisfaction with their TFV, and intent to use TFVs in the future. Patient satisfaction was assessed with a 4-category Likert scale (1 = very unsatisfied, 4 = very satisfied). Both TFV and OFV patients were asked about their out-of-pocket costs associated with OFVs, total time of their OFV (including travel), and urgent care or emergency department (ED) use since their TFV or OFV visit between March to May 2016 to assess whether replacing some OFVs with TFVs put patients at higher risk for complications. All patients were also asked for the duration that they had been receiving care at their respective clinic as well as the total number of UCSF practices in which they receive care as a proxy for overall health and comorbidities. Lastly, all patients were asked who should pay for TFVs and whether they would be willing to pay a copay for access to TFVs in the future. TFV patients were asked a total of 29 questions, where OFV patients were asked a total of 17 questions. Specific survey questions can be found in the Appendix A1.
Data Analysis
Responses were analyzed using univariate (frequencies, means, and ranges) and bivariate statistics, and both t-tests and chi-square tests were employed to determine significance. Responses from patients who participated in TFV were directly compared with those of patients who had only had an OFV during the same time period (March–May 2016). Seven partially completed surveys were still included in analysis given they were all >90% complete. Because this survey was conducted under the direction of UCSF Health's ambulatory care operations department to evaluate its new phone visit program, it was exempt from human subject's research review and did not require IRB approval.
Results
Patient Demographics
A total of 2,741 patients were surveyed (855 TFVs, 1,886 OFVs). The response rate was 13% (n = 110) and 17% (n = 324) of patients with TFVs and OFVs, respectively. In the Endocrinology Clinic, the response rate for TFV (14%; confidence interval [CI]: 0.108–0.179) and OFV (16%; CI: 0.130–0.200) respondents were comparable. In the Hepatology Clinic, the response rate for TFV (12%; CI: 0.084–0.169) and OFV (13%; CI: 0.102–0.157) respondents were comparable. In the Multiple Sclerosis Clinic, the response rate for TFV (11%; CI: 0.073–0.165) and OFV (21%; CI: 0.181–0.238) respondents were statistically different. Respondents and nonrespondents were comparable with regard to sex and mean age. Patients who participated in TFVs had been receiving treatment from their respective TFV clinics for an average of 43 months, while patients participating in OFVs alone had been receiving treatment for an average of 76 months. Patients who participated in TFVs and those who participated only in OFV reported a comparable number of practices “as a part of their care,” 2.75 and 2.78, respectively (Table 1).
Patient Demographics
N/A, not applicable.
Out-of-Pocket Costs, Visit Duration, and Willingness to Pay
The most common out-of-pocket costs for OFVs were transportation, meal/food, loss of pay from job, copayment/deductible, hotel/lodging, and child care. Median self-reported cost for travel to UCSF for OFVs was $50 (interquartile range [IQR]: 20,100) with a median duration of 240 (IQR: 150,420) minutes for total travel plus visit time. Of all TFV respondents, only one patient reported an associated cost of $15 for time off work and phone bills.
The large majority of TFV respondents (87%) and OFV (84%) respondents agreed that “insurance companies should pay for telephone visits that substitute for an office visit,” and more than half of all respondents were “willing to pay a copayment or deductible for a telephone visit” of approximately $20 (median) if given the option (Table 2).
Patient-Reported Outcomes for Telephone and Office-Based Follow-Up Visits
Average cost of 14 cents based upon single reported cost.
Based upon % of patients who would like to utilize telephone visits in the future.
ED, emergency department; IQR, interquartile range; TFV, telephone follow-up visit.
TFV Safety, Satisfaction, and Future Use
TFV respondents reported similar rates of ED or urgent care use during the same time period as OFV respondents, 5% and 4%, respectively (p = 0.92). Among TFV respondents, the large majority (87%) reported that the TFV had “replaced their need to go to UCSF for an office visit,” and all but two TFV respondents reported being either very satisfied or satisfied with their experience.
All but one TFV respondent reported that they intended to utilize TFVs in the future where appropriate. Among OFV respondents, half expressed interest in incorporating TFVs into their future care (Table 2).
Telephone Visit Follow-Up Questions
To better understand how the decision was made to utilize TFVs, patients were asked who had decided to make their next follow-up visit a TFV. Of the TFV respondents, half reported that their provider had “decided to utilize a telephone visit,” 10% reported that they themselves had decided, and 40% reported that it was a joint decision. With regard to preference for video vs. telephone visits, 21% of patients reported that they “would have preferred to have a video connection with their provider during their last telephone visit” as this would have “improved their ability to discuss their medical problem with their provider” (Table 2).
Discussion
This evaluation of a single-site, multispecialty TFV program suggests that scheduled telephone visits provide a safe, efficient alternative for management of select patients in a manner that is both acceptable and affordable for them. To our knowledge, this is the first study to compare patient perceptions of telephone follow-up care with subspecialty physician practices. In addition to a significant reduction in out-of-pocket costs ($50) and travel time (4 h) associated with OFVs, patients reported high levels of satisfaction and intent to utilize TFVs in the future. This may suggest that patients not only enjoyed the convenience afforded by TFVs, but found TFVs necessary to their care, and the ability to speak directly with their providers valuable. While there may be concern about patient safety when utilizing telephone visits in place of office visits, it is encouraging that TFV respondents did not have increased urgent care or ED needs when compared with OFV respondents for the same time period. When appropriate, TFVs offer patients considerable flexibility and choice, and may be a safe alternative to OFVs.
Specialty practices that manage patients with chronic diseases stand to benefit by managing a greater number of patients safely while reducing wait times for OFVs. By design, this TFV program increases patient access to a specialty practice by providing a greater number of follow-up appointment slots per clinical shift—for example, increasing from 6 thirty-minute follow-up slots to 4 thirty-minute slots and 6 TFV slots (a 66% increase). The program has the potential to reduce total health care costs assuming that the wRVU resulting from TFVs is lower than for OFVs, and that there is no induced demand/increase in total number of follow-up visits for the population.
In this single-site study, there is clear patient endorsement for payers to reimburse for TFVs, with over half of all patients willing to pay a premium for such a service. While some integrated delivery systems may support providers in delivery of these services by allowing compensated time in the clinic schedule, and certain groups, such as Teladoc Health and One Medical, are reimbursed for telephone and video-based acute care services, we are aware of only one major government payer program that reimburses for telephone-based follow-up care. Due to the present coronavirus disease 2019 (COVID-19) pandemic, where providers across the country are seeing high levels of demand for telehealth and telephone visits, 12 Centers for Medicare and Medicaid Services (CMS) has recently adopted a new policy of reimbursing providers for telephone visits. 13 In light of these recent developments, CMS and other payers may also benefit from a deeper understanding of patient preference.
The results of our study should be interpreted in light of several considerations. When this survey was conducted, it was years before COVID-19 would drastically change how ambulatory care is delivered. There was no pandemic or need to social distance that compelled patients to incorporate telephone visits into their health care. While surveying patients today about their experiences with telemedicine would give us important information relevant to this ongoing crisis, the results and takeaways from this initial survey are still fundamental as they help to capture outcomes that are not influenced by the pandemic. Furthermore, as patients become more comfortable with managing their care out of the clinic using telemedicine, these findings offer additional support as to why telemedicine should be incorporated into standard follow-up care and persist in a post-COVID world.
With regard to patient demographics, the distribution of specialty clinics varied across the TFV and OFV respondents. The majority of TFV respondents were from the Endocrinology Clinics, whereas the majority of OFV respondents were from Multiple Sclerosis Clinics. This difference was likely due to the fact that telephone visits were initially rolled out in the Endocrinology Department before being implemented in Hepatology, and then Multiple Sclerosis Departments. Furthermore, almost half of all patients seen for OFVs between March and May 2016 were from the Multiple Sclerosis clinics, which likely led to a greater number of OFV respondents from those clinics. The response rate for TFV and OFV respondents were comparable in the Endocrinology and Hepatology clinics, but the response rate for OFV respondents was twice that of TFV respondents in Multiple Sclerosis Clinics.
Patients from the two groups were similar with regard to age and gender, and when asked about their experiences with OFVs, patients from both populations had comparable responses for out-of-pocket costs, total visit duration, and categorical breakdown of costs. Furthermore, patients from both groups reported that approximately three different clinics were involved in their care, which may suggest similar degrees of medical complexity between groups. However, patients from the TFV group had been receiving treatment from their respective clinics for a shorter duration than patients from the OFV group, which may reflect that providers are more comfortable referring newer patients to TFVs or that newer patients are more amenable to TFVs.
This study's results are limited to a single-site academic medical center with three specialty practices that are in a fee-for-service setting. Despite repeated attempts to contact patients, response rates remained low, which may reflect an overall decline in participation in medical surveys. 14 Additionally, it is possible that the surveys were filtered to spam mailboxes or sent to email addresses no longer being used by patients, given the number of unopened surveys. However, it is reassuring that responders and nonresponders were comparable with regards to age, sex, and clinic.
Although independent confirmation across a broader spectrum of practices is needed to fully understand the access and cost implications of a TFV program, we believe these findings should motivate health plans to consider supporting well-structured TFV programs. Furthermore, surveying physicians will also be important to evaluate workload and sustainability of such a program, especially given the increasing parity between telemedicine and office visits. It would also be of interest to survey patients who are utilizing telemedicine for urgent and emergent care, as they make up a vast majority of patients who utilize telemedicine. 15 In this study, 90% of TFV patients reported feeling that their visit had been scheduled for them, suggesting that our patient population was self-selected for those participating in regular, scheduled follow-up visits as opposed to those requiring urgent care. Lastly, in this study, only a quarter of patients who participated in the TFV program felt a video connection would have improved their ability to discuss their medical issues with their provider, suggesting that TFVs still provide the majority of patients with adequate follow-up care.
Footnotes
Acknowledgments
The authors greatly appreciate the contributions of the staff at the UCSF Continuous Process Improvement Office who aggregated data on patient visit type. The authors specially thank Lisa Deangelis, Guy Guarige, Terry Hill, MD, Susy Jeng, MD, Margaret Martin, JD, David Morgan, Amy Parekh, MD, JD, and Susan Smith, MD for their work in editing the patient surveys.
Disclosure Statement
No competing financial interests exist.
Funding Information
Supported by the UCSF Continuous Improvement Department and the UCSF School of Medicine.