Impact of billing policy changes on telehealth use in Ontario: a population-based repeated cross-sectional study

Abstract As telehealth is being integrated into a regularly functioning system, policy makers have been adding some restrictions related to its use (e.g. modalities and pre-existing in-person relationship rules). We explored how the new policies impacted the levels of use across telehealth modalities and if the impact varied across sociodemographic and chronic condition groups of patients. This is a population-based repeated cross-sectional study examining all outpatient visits in Ontario, Canada on a weekly basis from the week of January 1st, 2018 until the week of December 25 th , 2023. We used linked health administrative databases of health services provided to all Ontario residents who are insured through the Ontario Health Insurance Plan (OHIP). We examined the total number of visits and the rates of in-person and telehealth visits per 1000 persons per week. Across Ontario, there were 115 046 536 telehealth visits during the study time period (26.4% of all ambulatory care). There was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth at the beginning of December 2022 when the new policies were introduced. This was in the absence of a reduction of total ambulatory visits. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. The use of video increased slightly over the study period with 1 in 4 telehealth visits occurring over video. While the policy changes led to an overall reduction in telehealth use, the total ambulatory visits did not change, suggesting a shift of care from virtual to in-person. The adoption of video increased, but future studies should focus on exploring whether there are clear benefits of using video over telephone, as certain groups of patients may be impacted more than others. Author Summary As healthcare systems returned to normal functioning after the pandemic, rules around the use of telehealth (use of telephone and video to provide care) changed. For example, in Ontario, Canada, physicians were paid on par for video visits as in-person visits, but telephone visits were paid at 85% of the rate. In addition, the government introduced requirements related to whether a patient has been seen in-person by a physician within the last two years prior to a telehealth visit. Our study explored the impact of these changes using physician billing data. Overall, there was a 6.7% reduction in telehealth and a 10% reduction in the number of physicians using telehealth when the new policies were introduced in Dec, 2022. The impact varied across medical specialties, patient age groups, rurality and chronic conditions, but seemingly not across sex or income quintiles. Overall outpatient visits were not impacted, suggesting that care shifted back to in-person. The majority of telehealth still occurred over telephone, despite a slight increase in the use of video after the policies were introduced.

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