OBJECTIVES: To conduct an episode-based, cost impact analysis of virtual-first versus in-person first care to treat the most prevalent acute conditions among 126,363 Medicare Advantage members of a large national payor.

METHODS: Episode Treatment Group (ETG)® methodology was deployed to evaluate the cost impact of virtual care as the initial modality of care for treating top prevalent acute conditions (compared to in-person-first care) among Medicare Advantage members of a large national health plan. Retrospective episodes-of-care and claims analyses of members enrolled for ≥ six months prior to the episode start date (N=126,363) identified resolved acute primary care episodes (N=141,034) starting between 1/1/2022–6/30/2022. Episodes with inpatient services and/or emergency department-first visits were excluded. Propensity score weighting was used to estimate % difference in healthcare costs between virtual-first episodes (N=10,820) and a cohort of in-person-first episodes (N=130,214) matched for member characteristics and healthcare utilization.

RESULTS: Among the most commonly treated acute episodes (i.e., viral pneumonia, otolaryngology disease, infectious disease exposure, bronchitis, sinusitis, rhinitis, minor bacterial skin infections, and gastroenterology disease), 7.6% (range: 0.7-24.8%) utilized virtual-first care. When treated through virtual-first care, cost-of-episode was 10-24% lower than in-person-first care (all P<0.05) for otolaryngology disease (-24±2%), rhinitis (-21±4%), gastroenterology disease (-20±7%), minor bacterial skin infections (-16±7%), sinusitis (-13±3%), and bronchitis (-10±4%). These reductions were primarily attributed to decreased expenditures related to primary care, specialist care, and use of ancillary services.

CONCLUSIONS: This real-world study demonstrates the potential of virtual-first care as a cost-effective modality for acute conditions in a large, sample of Medicare Advantage members across the nation. The use of episode-based analytical tools enhances the significance of these findings, as this methodology provides a proxy for clinical outcomes and quality, which offers a more comprehensive understanding of the implications and benefits associated with virtual-first care for the treatment of common acute conditions.