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A nationwide dropoff in telemedicine visits is forcing providers who raced to ramp up virtual care in the face of the pandemic to quickly recalibrate their offerings as more patients turn back to in-person appointments.

Telemedicine visits accounted for just 21% of total encounters by the middle of July, down from 69% at the early peak of the public health crisis in April, according to national data from Epic, the electronic health record company.

While telemedicine use largely remains well above pre-pandemic levels — and many still say telemedicine’s popularity is here to stay — the recent downturn in visits has created an undeniable whiplash effect. Hospitals that rushed to retrain their staff to deliver most types of care virtually in March are now trying to strike a new balance based on shifting patient preferences and needs.

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“We’re trying to right-size, but it’s really hard because during the pandemic we switched to nearly 100% virtual in some clinical areas, and we know that’s not realistic or sustainable,” said Jessie DeVito, director of virtual care at Michigan Medicine, the health system affiliated with the University of Michigan. She said the health system will end up with some empty virtual appointment slots before it finds the right mix between office and telemedicine visits in the coming weeks.

Several large health systems told STAT the shift isn’t as simple as shuffling doctors’ calendars. Rather, it requires careful consideration of which clinical circumstances should command in-person attention and which cases can be handled just as effectively — and perhaps more conveniently — with a virtual visit. Another pressing question is what combination of the two will be most cost-efficient for providers as they struggle to optimally manage both their patients and bottom lines after months of falling revenue.

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The leveling off of virtual visits may create similar challenges for large telemedicine companies that have made big bets based on the initial surge in demand. The nation’s largest provider, Teladoc, unveiled plans last month to acquire the digital health company Livongo in a $18.5 billion deal, while competitors AmWell and MDLive have declared their intentions to proceed with initial public offerings.

So far, these companies are still reporting a significant uptick in both visits and revenue compared to the same period in 2019. But there remains a question of whether they will be able to sustain those numbers as a growing number of patients return to in-person visits with their doctors.

Charles Jones, the chief executive of MDLive, said that while overall visits have declined since the peak in April, the number of new customers is continuing to increase compared to last year. “The best harbinger for understanding the future of the business is new bookings, and that is actually up 300%,” he said.

Jones also noted that visits for mental health care have shown no signs of tapering off, opening a huge lane for future growth.

Many traditional health systems, meanwhile, are exploring what the right balance of in-person and virtual care might look like — and how that combination might vary from one specialty to the next.

The University of Pittsburgh Medical Center, for example, has launched a telemedicine program to increase the availability of its specialists and evaluate optimal ways of delivering care to patients with varying conditions and needs. The program, dubbed Rapid Access Video Evaluation, is designed to help ensure patients are connected with the right specialist and determine when they should be seen remotely or in-person.

“We want to work with our specialists and primary care physicians along disease states to figure out how care should be delivered for patients who have diabetes or lupus,” said Robert Bart, a physician and chief medical information officer at the health system. “Is there an appropriate cadence of utilizing face-to-face and telemedicine in the care delivery process?”

The health system is navigating those decisions amid a seismic shift in patient preferences. Its telemedicine visits at the University of Pittsburgh have dropped from about 10,000 a day at the peak of the pandemic in April to about 4,000 in recent weeks. The current numbers still mark a dramatic increase from the roughly 250 telemedicine visits per day before the crisis.

The recent declines are not occurring across all specialities. Traditional providers are also continuing to carry out most mental health visits via phone or video, while specialists that tend to require more hands-on care, like orthopedists, are seeing more of their patients return to their offices.

At HealthPartners, a chain of hospitals and clinics in Minnesota, Wisconsin, and Northern Iowa, about 80% percent of behavioral health visits are still being carried out virtually, compared to 25 to 30% of percent primary care appointments.

“We don’t know where the sweet spot is going to be.”

Annie Ideker, family practice physician at Health Partners.

“We don’t know where the sweet spot is going to be,” said Annie Ideker, a family practice physician at HealthPartners. “Right now we’re trying to address a fairly significant volume of catch-up — in-person care that was delayed for two to three months during Covid.”

As they recalibrate, telehealth companies and traditional providers alike will also have to contend with unpredictable regulatory landscape in the months to come. The Trump administration has signaled it will continue to support telehealth use during the pandemic, but it is unclear whether government and private insurers will continue to pay for virtual visits at the same rate as in-person care over the longer term. Some private payers are already scaling back coverage and requiring customers to pay more, even in states with high Covid-19 case counts such as Texas and Arizona.

Some hospitals and other traditional providers said maintaining coverage and payment parity is crucial to preserving access to care.

“The amount of time spent on these is very similar, and I don’t buy the argument that it’s cheaper,” said Chad Ellimoottil, a urologist at Michigan Medicine who runs a telehealth research group. “Most providers are not going to get to the point where they have enough virtual care to reduce their number of employees or rent. You still need to have that in-person practice. That’s where all your costs are coming from.”

That calculus may be different for telemedicine companies, which were built to provide all their care on computers and phones and don’t rely on revenue from brick-and-mortar offices.

Even as they navigate the complexities of reimbursement rates and shifting patient preferences, many providers said it’s clear that the increased availability of telemedicine has spurred long overdue changes in American health care.

“This has created a tremendous opportunity to move us in a direction we’ve needed to go in for a long time, but we just didn’t have the impetus to do so,”said Ideker, the family physician. “We see this as a way to grow without increasing some of our bricks-and-mortar costs.”

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