An acutely ill patient logged in to MedStar Health’s telehealth platform in April 2020, when the COVID-19 pandemic severely limited in-person visits.

The uninsured man was worried about the cost of going to the emergency department or hospital and occupying valuable space. After some reassurance, MedStar clinicians convinced him to go to the ED, where he was diagnosed with COVID-19 and sent to the intensive care unit.

He survived, in part, thanks to the virtual consultation, said Dr. Ethan Booker, the medical director of the MedStar Telehealth Innovation Center and MedStar eVisit.

“If it wasn’t for telehealth, there’s a good chance he would’ve done nothing and could’ve died,” he said. “More patients are using a telehealth visit to navigate the system, starting with us to see if it’s appropriate to seek in-person care.”

Telehealth’s value in scenarios like those where other pathways are blocked is undeniable. But its convenience has also raised questions as to whether it’s layering extra encounters between patients and providers and leading to unnecessary treatment.

More than 30% of telehealth visits resulted in a physical office visit, according to a new survey from the commercial real estate firm JLL that polled more than 4,000 individuals in January. But the rate of telehealth to in-person referrals was much higher than MedStar’s, which was less than 15%, Booker said, echoing other experts’ observations. Notably, the survey didn’t specify if it was a new or returning patient, nor what type of treatment patients were seeking, researchers said.

Regardless, the rate of in-person referrals has increased demand for medical office space, said Jay Johnson, managing director of JLL Healthcare.

“The demand for medical office buildings is going up and the supply is not keeping pace. Rents for medical office buildings have reached highs across the US over the last couple of years,” he said, adding that leasing demand for medical office space was high before the pandemic. “The pandemic hasn’t dampened that trend and has potentially given it a boost.”

Health systems have pared down their office space for their administrative teams as more back-office employees work from home. But the long-term impact on clinical real estate has been less definitive as providers figure out how much telehealth can safely substitute in-person care.

“Telehealth is an effective substitute for certain types of care,” Booker said. “As the medical director of a telehealth group, I am clearly a believer, but even I would never suggest telehealth as a viable substitute for any type of care.”

JLL’s survey is misleading, said Krista Drobac, executive director of the Alliance for Connected Care, which lobbies for telehealth on behalf of insurers, providers, tech companies and pharmacies. It failed to specify the types of services leading to in-person referrals and whether telehealth helped patients avoid emergency or urgent care, she said.

“This kind of patient self-reported data makes the leap to over-utilization way too simplistic,” she said. “It’s also important to compare these visits to regular, in-person evaluation and management visits. Those often lead to follow-up care, so we may not be seeing any difference between in-person and telehealth for follow up to specialists, etc.”

While it’s hard to quantify the value of follow-up care stemming from a telehealth visit, there has been mixed results as to whether ease of access has significantly increased overall healthcare utilization.

More than 10% of the telehealth users had an in-person visit the next week, compared with 5.9% of patients who went to a clinic, according to an analysis of around 86,000 Blue Cross Blue Shield of Michigan claims from 2016 to 2019. University of Michigan researchers found that the telemedicine cohort had fewer (0.5%, versus 0.6%) emergency department visits, but more subsequent office, urgent care and telemedicine visits.

Telephone visits offer a convenient way to address primary care needs within ongoing patient-physician relationships without substantially higher rates of follow-up visits or hospitalizations, an analysis of more than 1 million patients who accessed telehealth from 2016 to 2018 found.

Meanwhile, only 12% of direct-to-consumer telehealth visits replaced a visit to another provider, according to a 2017 RAND Corp. study of 2011 to 2013 California Public Employees’ Retirement System claims. It should be noted that copays were waived for those claims, said Lori Uscher-Pines, senior policy researcher at the RAND Corp.

“Different studies have had different findings as to whether telehealth leads to more follow-ups than in-person care—I don’t know if the jury is out on that issue,” she said, noting that telehealth for behavioral healthcare has been unequivocally positive.

There could be several explanations for more follow-up visits: Conservative providers suggest that patients should come in, telehealth is not resolving the problem or patients don’t perceive it as high-value, Uscher-Pines added.

As for MedStar, patients who access telehealth for primary-care services tend to substitute in-person visits, Booker said.

If it wasn’t for telehealth, about 40% of the around 100,000 patients who accessed MedStar’s telehealth portal over the past two years would’ve gone to urgent care instead, while about 10% would’ve gone to the ED, he said. Overall, about 10% of the patients have been referred to urgent care and 1.3% to the ED after a telehealth visit.

“Patients and providers tend to use telehealth for lower-acuity care, while higher-complexity care is mostly delivered in person,” Booker said. “The big exception is behavioral health, where telehealth is the new norm.”