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A significant but underappreciated segment of the telemedicine industry -- direct-to-consumer (DTC) telemedicine services -- may hold clues to the future of telemedicine in the post-pandemic world.

The pre-pandemic DTC market was dominated by three medical issues -- urinary tract infections, erectile dysfunction, and contraception -- that together accounted for 87.1% of one DTC company's visits compared with only 2.3% of visits to primary care physicians, found Tara Jain, MD, MBA, and Ateev Mehrotra, MD, MPH, both of Brigham and Women's Hospital in Boston.

Their data reflected televisits made by one unnamed DTC company from October through December 2019, before the COVID-19 pandemic drastically transformed the telemedicine landscape. But the findings highlight issues that may predict how telehealth will find a lasting place after the pandemic wanes.

It's easy to overlook the DTC market, Mehrotra told 番茄社区app. "When we think about the future of telemedicine, there's a lot of focus on the primary care physician and the local hospital. DTC is not the typical form of telemedicine most of us think of. But this approach appeals to many people," he said.

In 2018 and 2019, DTC companies such as Teladoc and Doctor on Demand provided more than 1 million visits and were estimated to represent a $272-million market in 2019, projected to grow to $322.7 million by 2025, according to a .

In March, with the spread of COVID-19 and an from the Centers for Medicare and Medicaid Services to expand access to and coverage for telemedicine, the volume of such visits soared. After a peak in mid-April, there has been a drop in telemedicine visits, although the level remains far higher than before the pandemic.

Large questions loom for Congress and federal policymakers about telemedicine coverage post-pandemic, with huge implications for the market.

Hundreds of companies are providing DTC telemedicine, often specializing in a single or a few diagnoses, whether mental health, diabetes, or substance abuse disorder.

"We have to remember these other companies, some of which were surging before the pandemic," Mehrotra said. "We've learned that telemedicine is important to . We want doctors to do more of it, but do we want DTC companies? We've been talking a lot about coordinated, integrated care; and yet you have these DTC companies solving patients' problems more cheaply, , and in some cases with higher quality care."

His cross-sectional, patient-deidentified analysis included all the patients seen by the unnamed DTC company in that quarter -- a total of 35,131 televisits in 20 states. Comparators came from the overall population in those states and with ambulatory primary care physician visits in those states between 2013 and 2016, as compiled in the CDC's National Ambulatory Medical Care Survey.

Sociodemographic differences in the DTC patient population versus primary care visits included a much younger age (with 74.1% of the former between the ages of 18 and 44, compared with 29.4% for primary care visits), fewer reported comorbidities, residence in wealthier urban communities, accessing care outside of normal business hours, and paying out of pocket for the service.

This younger population may find online care more convenient or may feel uncomfortable receiving care for sexual issues in person, the authors suggested.

Another DTC advantage is allowing patients to when they choose. However, at the time of Jain and Mehrotra's study, the DTC company studied was not accepting insurance for patient visits, which thus were all paid out-of-pocket by the patient.

These distinctions make comparisons between DTC telemedicine and primary care physician visits difficult, said Bradley Fox, MD, director of clinical informatics for electronic health record giant Epic Systems Corporation, which also studies the market. "What kinds of visits are they talking about?"

Jain and Mehrotra acknowledged that their data were limited to a single company and to the set of services offered by that company, Fox noted.

Telemedicine can be defined in different ways, he added, some with video and synchronous conversations and some without. "Our data come through larger health care organizations and health systems, all of which are submitting claims for these services. Will DTC companies try to pivot to get into networks where more of what they do gets covered?" He also expects increasing competition with DTC business models.

Many healthcare organizations had dipped their toes into virtual care prior to 2020, but now it has become a core part of their business that's here to stay, Fox predicted.

"We don't see a world where telemedicine goes away," he said. "It will continue to grow, even though it won't replace face-to-face visits for all needs. People will seek it, more and more, both for convenience and as we learn more about the quality of this care."

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