Abstract
The COVID-19 pandemic has led to increased use of telephone and video encounters in the Veterans Health Administration and many other healthcare systems. One important difference between these virtual modalities and traditional face-to-face encounters is the different cost-sharing, travel costs, and time costs that patients face. Making the full costs of different visit modalities transparent to patients and their clinicians can help patients obtain greater value from their primary care encounters. From April 6, 2020 to September 30, 2021 the VA waived all copayments for Veterans receiving care from the VA, but since this policy was temporary it is important that Veterans receive personalized information about their expected costs so they can obtain the most value from their primary care encounters.
To test the feasibility, acceptability, and preliminary effectiveness of this approach, our team conducted a 12 week pilot project at the VA Ann Arbor Healthcare System from June–August 2021 in which we made personalized estimates of out-of-pocket, travel, and time costs available and transparent to patients and clinicians in advance of scheduled encounters and at the point of care. We found that it was feasible to generate and deliver personalized cost estimates in advance of visits, that this information was acceptable to patients, and that patients who used cost estimates during a visit with a clinician found this information helpful and would want to receive it again in the future. To achieve greater value in healthcare, systems must continue to pursue new ways to provide transparent information and needed support to patients and clinicians. This means ensuring clinical visits provide the highest levels of access, convenience, and return on patients’ healthcare-associated spending while minimizing financial toxicity.
Keywords: Price transparency, Out of pocket costs, Value, Telemedicine, Patient-centered care
Key takeaways
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COVID-19 fueled a rise in telemedicine. The COVID-19 pandemic and the rise of telemedicine modalities for ambulatory care visits provide an opportunity to consider the relative value of different care delivery approaches.
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There is a need for patient centered cost information for different visit modalities. Patients and their clinicians currently lack the personalized information about out-of-pocket, travel, and time costs to inform decision-making about visit modalities that will best meet patients' needs while considering the costs they might face.
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Health systems should provide cost estimates. Health systems and payers could provide patients and clinicians with understandable, personalized estimates of the full healthcare-associated costs (i.e., out-of-pocket, travel, and time costs) for different potential visit modalities.
1. Organizational context and challenge
The COVID-19 pandemic has transformed the delivery of ambulatory care in the U.S. via the rapid expansion of telemedicine services as a means to ensure access to needed services while protecting patients and clinicians from undue risk of exposure to COVID-19.1 , 2 For example, within the Veterans Health Administration (VHA), the early days of the COVID-19 pandemic led to an abrupt shift from mostly face-to-face visits to almost exclusively telephone and VA Video Connect (VVC) appointments. From the start of March 2020 to the end of April 2020, the amount of primary care weekly video visits rose from 1102 to 13,068 and the amount of weekly phone visits rose from an average of 327,180 to 756,195, an increase of 131%.3 By June of 2020 about 58% of outpatient visits were conducted via telemedicine compared to 14% prior to the pandemic.4 As the pandemic continues due to the rise of new variants and incomplete population vaccination, and as many patients continue to face financial challenges, health care organizations that deliver ambulatory care such as the VA Ann Arbor Healthcare System continue to grapple with how to best match patients with different modalities for care delivery (i.e., face-to-face, video visits, and telephone visits) so as to maximize the value of ambulatory encounters.5
One important difference between face-to-face, video, and telephone visits in the VHA -- which is integral to the value they produce -- is the costs that patients may face for visits that use these different modalities. When considering costs to patients, many stakeholders think first about the cost-sharing (i.e., out-of-pocket costs) patients face. Yet, patients also contend with travel and time costs when seeking care, and these less-visible costs can often exceed patients’ cost sharing.6 , 7 Such costs are particularly salient for patients who travel great distances for care because they may live in rural areas, or are facing financial constraints.8 Ambulatory visit costs are also important to the VHA as qualifying patients receive travel pay reimbursement, and previous research has shown that appropriate use of telemedicine can provide substantial savings in VHA travel payments.9
Careful consideration of these full visit costs by both Veterans and their clinicians could help align patients with visit modalities that meet their needs and preferences, potentially resulting in greater value from their ambulatory care visits. For example, when the same services can be provided by phone or VVC rather than a face-to-face visit (e.g., counseling, orders for mailed medications, referrals for future cancer screenings), the former can result in higher value for Veterans as VHA does not charge a copay for phone visits, and both travel and time costs are minimal. Similarly, when a face-to-face visit is necessary to provide appropriate care, making the relatively higher out-of-pocket, travel, and time costs of that visit transparent could help to ensure prioritization of high-value services that can only be done in person (e.g., urgent laboratory tests and immunizations or specific physical examinations).
Despite the benefits of making patient healthcare-associated costs more transparent, and national and state policy initiatives to better inform patients’ healthcare choices, Veterans and their clinicians currently lack the personalized cost information that they need to make high-value choices about ambulatory visit modalities during the COVID-19 pandemic and beyond.10, 11, 12, 13 This is especially important when virtual visits could be clinically appropriate and of lower cost than a face-to-face visit. Even if such costs were to be completely transparent to patients and clinicians, previous cost transparency initiatives have often failed to yield benefits without additional efforts to ensure patients and clinicians can use this information effectively.14 The initiatives that have fallen short include a price transparency tool offered by two large employers which had limited uptake and resulted in increased out-of-pocket spending, a price transparency tool for California public employees which also had limited impact and did not affect spending, and a transparency initiative for 4,545,809 hospital encounters for shoppable care which was found to provide an incomplete view of patient costs due to not including integral services that were billed independently from the hospital.15, 16, 17 To address these challenges, we recently conducted a pilot study in the Primary Care Clinic of the LTC Charles S. Kettles VA Medical Center in Ann Arbor, Michigan to estimate and make transparent the full costs of different types of ambulatory visits to patients with scheduled primary care appointments.
2. The goal
Our goal was to create a scalable model to help patients optimize the value of their primary care encounters via transparent estimates of the healthcare-associated costs they could expect for different possible visit modalities. To accomplish this goal, we designed a pilot study with three main objectives. The first objective was to create an automated system to generate estimates of Veterans’ healthcare-associated costs (i.e., travel costs, time costs, and out-of-pocket costs) for different types of primary care visits. The second was to develop and refine a novel behavioral intervention to help Veterans and their clinicians use information about the healthcare-associated costs to patients of different types of primary care visits in the VHA. The third was to evaluate the acceptability and feasibility of the developed intervention. The outcomes used to assess preliminary effectiveness included how helpful Veterans found the tool to be and their willingness to use the tool in the future.
3. The execution
To achieve our first objective, we used VHA administrative data to estimate key healthcare-associated costs (defined as driving costs, time costs, and cost-sharing) Veterans could experience for face-to-face visits, video visits, and telephone visits. We calculated cost-sharing by using VHA administrative data and public information on Veterans’ copay rates.18 We then estimated travel costs (defined as estimated fuel and parking costs, not driving time, based on VHA administrative data on estimated average driving time from their residence to the Ann Arbor VA) and time costs (defined as round trip driving time based on VHA administrative data plus scheduled appointment duration multiplied by the median U.S. wage from the Bureau of Labor Statistics) to Veterans.
For face-to-face visits, the total estimated healthcare-associated costs to Veterans were calculated to be the sum of estimated driving costs, time costs, and copays. For VVC and telephone visits, the estimated total costs were the estimated time costs based on the scheduled appointment duration as copays did not apply for video or telephone visits at the time of our study (Fig. 1 ).
Fig. 1.
V4V patient cost calculations.
To achieve our second objective, we exported the estimated cost information into an informational handout for Veterans and their clinicians as part of a novel behavioral intervention called Value for Veterans (V4V). The handout provided general education to Veterans and clinicians about travel, time, and out-of-pocket costs for different types of primary care visits. The handout also included personalized information about Veterans’ estimated travel, time, out-of-pocket, and full costs for different types of primary care visits. We sought early feedback on the content and design of this handout from Veteran patients via the Ann Arbor VA Center for Clinical Management Research Veterans Research Engagement Council and from VA primary care physicians. Based on this feedback, we further refined the design of the handout.
To achieve our third objective, we conducted a single-arm proof-of-concept pilot study of the V4V intervention within one Patient Aligned Care Team (PACT) in the Ann Arbor VA primary care Clinic. We first used a brief educational session to recruit ten PACT primary care clinicians. Patients of these clinicians were recruited by mailed letter and a follow-up telephone call. Patients who consented to participate were mailed personalized cost estimates in advance of a scheduled primary care visit and asked to bring their personalized cost report to that visit.
Recruitment for the pilot study provided estimates of the feasibility of recruiting clinicians and patients for a future randomized controlled trial of the V4V intervention. Patients were asked to complete a brief post-intervention telephone survey to measure the acceptability of the intervention and preliminary effectiveness of the information they received.
4. Problems
One of the big challenges the team faced was using administrative data to generate personalized estimates of cost-sharing for face-to-face encounters. At the point of care, health systems often do not have this information and rely on the applicable payor for estimates. Further, any applicable copay will depend on whether the individual has met their plan's deductible, which is often not readily available.
The VHA generally handles both the provision of care and payment for their population of patients. The VHA publicly posts copay rates for outpatient care for conditions connected to prior military service, and for certain groups of Veterans for whom copays apply. This creates a challenge because, in advance of visits, it is not always known whether the patient will be receiving care for a condition that is related to their military service (in which case a copay would not apply for that visit), or if they are currently in a group of Veterans for whom copays apply. For primary care visits, the copay is $15 per visit and $50 for specialty care. However, Veterans with a service connection level above ten percent do not have a copay. It was not always possible to consistently automate such nuances using administrative data, so caveats were added to the handouts so that Veterans could consider if a copay would likely apply to their situation. These caveats include the fact that Copay differs based on priority group, service connection and visit type. In addition, travel cost predictions do not account for the fact that a Veteran may be eligible for travel pay. Furthermore, under the American Rescue Plan, copays were waived from April 6, 2020 through September 30, 2021.
In addition, while implementing the pilot we found differing levels of clinician comfort with cost conversations. Some clinicians did not have a framework for how to discuss costs of care with patients. Others shared worries about the effects of greater cost transparency on clinical judgment, particularly the ability to prioritize clinical factors over cost considerations when necessary. Physicians who were worried about the effects of cost transparency on care decisions believed in some cases that patients with lower levels of health literacy or financial literacy might misinterpret costs and forgo necessary care due to fear of being billed for these costs at the point of care. Another concern was that transparency about travel and time costs could disincentivize care even when correctly interpreted, simply because it raises awareness of costs that the patient may not have considered.
We attempted to address these issues by creating a cost information handout that could be understood by someone who reads at about an 11th grade reading level. Additionally, we tracked how often patients canceled scheduled appointments after receiving their cost estimate and planned to conduct outreach to these patients to correct any inadvertent misunderstandings.
In addition to issues of cost and clinical appropriateness, there are convenience factors for both patients and clinicians (e.g., VVC visits may be more technically challenging for patients and clinicians compared to telephone) and relationship factors (patients and physicians who may feel more comfortable sharing information face-to-face) that should be taken into account in shared decisions about future encounters. There are also unknown factors that one cannot anticipate before the visit that may make a particular modality more suitable for the patient's needs. To address these challenges, the personalized costs estimates were framed as being supplemental information that patients and clinicians may find helpful when making decisions about future encounters.
5. The team
The VA Ann Arbor Healthcare System was composed of four physician-scientists, a project manager, a data analyst, and two research assistants.
6. Metrics
During the pilot study we collected quantitative data on estimated copay, travel, and time costs to Veterans for different visit types and telephone survey data on Veteran perceptions and use of the informational handout about estimated costs. We collected information from the patient related to the patient's perception of their primary care visit (Table 3 ) via a post-visit telephone survey to obtain feedback on the preliminary effectiveness of the patient cost information handout. We provided a five dollar gift card as an incentive for completion of the post visit survey.
Table 3.
Patient perceptions of primary care visit (n = 65).
| Survey measure | n (%) or median (IQR) |
|---|---|
| Discussed visit options at appointment (n = 64) | 39 (60.9%) |
| Visit costs discussed at appointment (n = 39) | 13 (33.3%) |
| Understanding of options for future Primary Care visitsa (n = 39) | 10.0 (0.0) |
| Ability to talk with provider about own thoughts and feelings about options for future Primary Care visitsa (n = 39) | 10.0 (2.0) |
| Recalled having received educational handout about the costs of different types of future Primary Care visits (n = 63) | 44 (69.8%) |
| Read educational handout prior to visit (n = 43) | 40 (93.0%) |
| Used educational handout during visit (n = 43) | 11 (25.6%) |
| Helpfulness of educational handouta (n = 12) | 10.0 (2.2) |
| Would want to receive educational handout again in the futurea (n = 12) | 10.0 (5.2) |
Measured on a scale of 1–10.
7. Proof-of-concept pilot study results
We recruited 96 patients with an upcoming face-to-face, telephone, or VVC appointment. The average age of these patients was 68.9 years of age and about 87.7% of these patients were male (Table 1). Nearly one in four patients (24.6%) had problems paying medical bills within the last year. To meet the first objective of our pilot study, before the appointment these Veterans were sent via mail or encrypted email the personalized handout that estimated their copay, travel, time, and total (sum of copay, travel, and time) costs for different Primary Care encounter modalities (example as Fig. 2 ). In these handouts, the median estimated total cost was $57 for F2F visits and $12 for telephone and VVC visits (Table 2). Of these 96 Veterans, 65 completed a post-visit survey. Most (44, 70%) recalled receiving the cost handout before their visit; of these individuals nearly all (40, 93%) reviewed it before their visit. Among the 40 who reviewed the handout, 11 (26%) used it during the visit. Veterans who used the handout in their visit rated highly the helpfulness and willingness to receive it in the future (median 10/10 for both) proving that the Veterans found use of the handout to be feasible and acceptable. These metrics related to the use and preliminary effectiveness of the intervention meet the second and third objectives of this pilot respectively. The 31 patients who did not complete a post-visit survey could not be contacted for the post-visit telephone survey. There were few appointment cancellations (1 patient canceled a phone visit, 2 clinics canceled in-person visits due to physician unavailability) after receipt of cost information, and none of the patients who canceled an appointment indicated that their cancellation was due to cost concerns or the cost handout they received. One patient who had a scheduled phone visit did not show up and one video appointment was canceled as the patient was already in the hospital.
Table 1.
Patient primary care visit demographics (n = 65).
| Survey Measure | Mean (SD) or n (%) |
|---|---|
| Agea | 68.9 (12) |
| Male | 57 (87.7%) |
| Education | |
| Less Than High School Degree | 3 (4.6%) |
| High School Degree/GED | 12 (18.5%) |
| Some College – College Degree | 41 (63.1%) |
| Graduate Degree or More | 9 (13.8%) |
| Race/Ethnicityb | |
| Hispanic | 2 (3.3%) |
| Non-Hispanic Black | 5 (8.2%) |
| Non-Hispanic White | 51 (83.6%) |
| Other | 3 (4.9%) |
| Federal Poverty Levelc | |
| <200% | 16 (31.4%) |
| 200%–299% | 12 (23.5%) |
| 300%–399% | 5 (9.8%) |
| 400%–499% | 6 (11.8%) |
| ≥500% | 12 (23.5%) |
| Delayed care in last 12 months due to cost | 8 (12.3%) |
| Foregone care in last 12 months due to cost | 7 (10.8%) |
| Problems paying medical bills in last 12 months | 16 (24.6%) |
| Confidence in filling out forms (scale of 1–10) | 9 (2) |
| <10% service connection ($15 copay) | 20 (30.8%) |
| >10% service connection (no copay) | 45 (69.2%) |
Age missing for 2 respondents.
Race/Ethnicity missing for 4 respondents.
Federal Poverty Level data missing for 14 respondents.
Fig. 2.
Patient handout.
Table 2.
Average estimated costs to patients for different primary care visit modalities (n = 65).
| Cost | n (%) or Median (IQR) |
|---|---|
| Face to Face Visit | |
| Copay | |
| $ 0 | 45 (69.2%) |
| $ 15 | 20 (30.8%) |
| Travel Cost ($) | 10 (7) |
| Time Cost ($) | 39 (18) |
| Total Cost ($) | 57 (26) |
| Telephone Visit | |
| Copay | |
| $ 0 | 65 (100%) |
| $ 15 | 0 (0%) |
| Travel Cost ($) | 0 (0) |
| Time Cost ($) | 12 (0) |
| Total Cost ($) | 12 (0) |
| Video Visit | |
| Copay | |
| $ 0 | 65 (100%) |
| $ 15 | 0 (0%) |
| Travel Cost ($) | 0 (0) |
| Time Cost ($) | 12 (0) |
| Total Cost ($) | 12 (0) |
*$0 and $15 reflect copay for each visiting modality.
8. Limitations
Our pilot project at the VA Ann Arbor Medical Center had a few limitations including the degree of personalization that could be achieved through administrative data, factors beyond cost that influence care modality use and variability in time waiting for appointments, receiving care, and potential follow-up care that could not be accounted for in this pilot. With regards to patient travel cost estimation, we were not able to incorporate how this cost may change for Veterans who are eligible for travel pay because whether travel pay would apply for a particular visit was not knowable ex ante with a high degree of validity and reliability. We hope to explore other strategies for prospectively estimating travel pay in future work so as to provide Veterans with the most precise data regarding their estimated costs. In addition, we were not able to personalize time costs for each veteran based on their labor force participation and other factors that may impact how individuals value their time. Additionally, there are numerous factors beyond cost that influence which modalities patients use. These factors include access to broadband/phone and competency regarding how to use audio and video modalities, as well as benefits to the individual of different possible visit modalities. We hope that future access to tools and skills regarding how to use these resources will remove confounding factors outside of cost with regards to Veteran modality choice. For time costs, waiting time in the clinic can be variable so it was not possible to account for these costs in the time costs. There are also costs that can be incurred during video and phone visits due to necessary follow-up care stemming from the virtual visit including imaging and lab collections. Since we do not know if there will be a need for follow-up services until a visit is completed we were not able to incorporate this into the cost estimates.
9. Lessons for the field
For other health systems looking to help patients and clinicians maximize the value of patients' spending on health care for ambulatory visits, the first step would be creation of an automated system to determine the patient's total cost associated with in-person, video, and telephone visits. The next step involves creating educational information for patients and clinicians that provide a side-by-side cost comparison of different types of outpatient visits. This information should first provide an overview of how travel, time, and out-of-pocket costs are calculated and how these add up to key health care-associated costs for patients. Additionally, patients should be provided information about the type of services that can be provided through virtual versus face-to-face visits. The final step should involve evaluation of how transparent cost information influences patient-clinician conversations and decisions about future healthcare encounters, including care-seeking behavior through modalities that are appropriate for clinical needs.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Jeffrey Kullgren reports a relationship with SeeChange Health that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with HealthMine that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with Kaiser Permanente Washington Health Research Institute that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with Donaghue Foundation that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with AbilTo that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with Kansas City Area Life Sciences Institute Inc that includes: consulting or advisory. Jeffrey Kullgren reports a relationship with American Diabetes Association that includes: consulting or advisory. Victor Agbafe reports a relationship with Third Culture Capital that includes: consulting or advisory.
Footnotes
Funding and support from the Ann Arbor VA Center for Clinical Management Research.
Data availability
Data will be made available on request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data will be made available on request.