A new equilibrium for telemedicine: Prevalence of in-person, video-based, and telephone-based care in the Veterans Health Administration, 2019-2023

Abstract: Background: The rapid uptake of telemedicine (that is, encounters via telephone or video) in the early phases of the COVID-19 pandemic is well documented (1–3), yet there is little published literature on the redistribution of in-person and telemedicine encounters as U.S. health care systems enter a postpandemic phase. Objective: To describe trends in clinical outpatient encounters between 1 January 2019 and 31 August 2023 that took place in person, by telephone, and by video before (before 11 March 2020), during (11 March 2020 through 10 May 2023) and after the pandemic (after 11 May 2023, defined by the end of the federal COVID-19 Public Health Emergency declaration) within the U.S. Department of Veterans Affairs (VA) health care system. Methods and Findings: We identified 277 348 286 VA clinical outpatient encounters through VA’s Corporate Data Warehouse, which tracks data for an open cohort of 9 million veterans enrolled in VA services, approximately 5.4 million of whom used VA outpatient health care services in 2019. A majority of VA patients are men (91%), 72% are White, and 65% reside in urban areas. Encounters were categorized by care service (primary care, mental health, subspecialty care) and modality (in-person, telephone, video). We tabulated the number of weekly and monthly encounters and calculated the monthly percentage of encounters delivered via each modality by care service. Analyses were completed in Stata 18 (StataCorp) and were designated as nonresearch quality improvement by the VA Office of Connected Care. On average, VA had 1.14 million primary care, subspecialty, or mental health encounters each week and 4.9 million encounters each month. At the start of the pandemic, across all services, the number of in-person encounters sharply decreased and did not return to a steady state until March 2021. Among primary care and mental health services, decreases in in-person care encounters were offset by a compensatory increase in telephone- and video-based encounters, and telephone-based care became the dominant modality. Among subspecialty care, the total number of encounters decreased and telephone-based care was briefly more common than in-person care. By May 2020, 23% of all care was provided in person, compared with 81% in February 2020. In January 2021, in-person care once again became the dominant modality among primary care services, and the pandemic-related decrease among all in-person encounters—and concomitant surge in video and telephone encounters—reversed. After May 2021, most fluctuations in telephone and video care among mental health and subspecialty services reflect typical variations in the provision of care (for example, federal holidays). Increases in in-person primary care encounters in late 2020 and 2021 correspond to availability of initial and booster vaccinations and likely reflect a combination of visits related to vaccinations and deferred in-person care. Across all services, telephone- and video-based care decreased from a peak of 79.6% of care in April 2020 to 36.7% in April 2023. This decrease was driven by fewer telephone encounters, whereas the proportion of video visits remained close to peak levels at 11% to 13%. By August 2023, video-based encounters accounted for 34.5% of mental health, 3.7% of subspecialty, and 3.5% of primary care encounters, and telephone encounters accounted for 20.3%, 34.8%, and 16.7%, respectively. Discussion: This VA study provides an updated timeline of the fluctuations in use of in-person care and telemedicine since the onset of the COVID-19 pandemic. A new equilibrium has emerged in which telephone-based care has largely returned to prepandemic levels, whereas video-based care accounts for 11% to 12% of outpatient care (2300% increase from a prepandemic level of 0.5%). The majority (55%) of mental health care continues to be provided via telemedicine, likely due to the ease of adapting mental health services to virtual platforms. Although primary care and subspecialty telemedicine is often limited by the need for in-person evaluations (for example, physical examinations), about 10% of in-person primary and subspecialty care has converted to telemedicine. The observed patterns suggest that telemedicine rates stabilized around May 2021, although telephone visits continue to decrease across all services and mental health video visits continue to increase. Notably, this stabilization occurred when vaccines were widely available—2 years before the end of the federal COVID-19 Public Health Emergency declaration. Although these nationwide trends can inform research and policy, they obscure disparities in access to and use of telemedicine that disproportionately affect older adults, individuals in rural regions, and patients from historically marginalized groups. Future research should consider evaluating quality, safety, and health outcomes of telemedicine in this new equilibrium.