Online consultations with doctors are convenient for patients and produce similar health outcomes to in-person visits. But research by Amanda Dahlstrand, Nestor Le Nestour and Guy Michaels finds that deciding which patients are seen online is crucial to whether significant cost savings are made.

In today's hybrid world, many organisations need to decide whether one-to-one services, such as financial advice, tutoring or healthcare, are delivered online or in person. Although the shift to online provision can potentially lower costs and increase convenience, the nature of such meetings may change significantly when conducted through a screen. In theory, switching services to an online format could affect costs, quality, users' experience and subsequent outcomes.

Although online service delivery has become more common in recent years, there is limited evidence from direct comparisons of in-person and online oneto- one services. To be more informative for decision-makers, we need a deeper understanding of the trade-offs involved.

Choosing the appropriate delivery mode is particularly important in healthcare. For providers, including both private and public healthcare organisations and insurers, the shift to online services presents opportunities for productivity gains, which are urgently needed given the rising costs of ageing societies.

For patients, online healthcare services provide convenience, around-the-clock access, time savings, reduced risk of contagion and the potential to level the playing field between urban and rural areas as well as between richer and poorer neighbourhoods (Dahlstrand, 2022). Key to healthcare delivery are patient consultations with doctors working as primary care physicians, also known as general practitioners (GPs).

Online consultations can be more convenient for patients, but some patients may need to be seen in person later

Our research examines the impact of switching primary care consultations with doctors from in-person to online meetings on various patient outcomes and provider costs. To do so, we assemble new data on individual consultations from Sweden, where national health insurance covers both public and private providers, and both online and in-person consultations.

The primary contributor of our data is one of Europe's largest digital healthcare firms. Since 2019, this firm has provided patients who have chosen it as their primary care provider with comprehensive primary care, including both in-person and online consultations. The data encompass both consultation types and are matched with anonymised individual panel data on patient demographics, socioeconomic characteristics and numerous health outcomes from the rest of the healthcare system.

How to identify the true costs and benefits of online consultations

One challenge in comparing online and in person consultations is that similar data about patients in both modes is rare. We have such data given that the same primary care provider offers both types of consultations. Patients always start their care journey online, in the app. We only consider patients who were directed to online nurses as a first step. The nurses then determine whether the patients should consult (as soon as possible) with a doctor, and whether this consultation should be in person or online. This setup allows us to compare the differing effects of the two modes for similar patients.

A second challenge arises because nurses may sort patients into online (as opposed to in person) consultations with doctors based on factors that we cannot observe. To address this issue, we use variation in nurses' tendency to direct patients online, as measured in other patient meetings. This allows us to approximate the effects of randomly allocating patients to the two consultation modes.

Organisations offering online consultations should carefully consider which patients are best seen in person

Our method shows that causal cost savings from online consultations are lower than simpler comparisons suggest. This difference is because our method addresses a sorting problem – that, on average, those patients are sent to in person consultations are sicker than those seen online (this is a problem for identifying true effects, but in practice this sorting is good). In the following, the results will be from our method to address this sorting, which means that we compare similar patients to get at causal effects.

We find that online consultations occur sooner and are shorter overall than in person ones. Despite this difference, they yield similar within-consultation outcomes as in person ones, including rates of informative diagnosis, prescriptions, specialist referrals and patient satisfaction.

We next examine the effect of online consultations on hospitalisations, visits to accident and emergency (A&E), and new visits to the primary care provider within 30 days after the meeting with a nurse or the consultation with a doctor.

We find significant increases in doctor-booked in-person follow-up consultations in primary care and in visits to A&E. But for medium-term outcomes (more than 30 days after the consultation with a doctor), we find no significant effects on any of these.

Taken together, our estimates suggest that online consultations offer some cost savings to payers (eg national health insurance) without significant mediumterm adverse health effects on patients, but these cost savings are reduced by the increase in short-term follow-ups.

While these findings indicate that online consultations are not a cost panacea, they still provide patients with valuable advantages, such as the ability to consult doctors sooner, reduced contagion risk and greater scheduling flexibility, including availability outside regular work hours.

Different patients, different attitudes

Our estimates show relatively high follow-up rates for two reasons. First, we study patients directed to any doctor consultation, in person or online, by nurses (versus being advised by the nurse about self-care), and those patients are likely sicker and more prone to follow-ups than patients not directed to any consultation.

Second, our sample consists mostly of patients from big cities (where in-person clinics with the hybrid option were first opened), for whom travel to in-person follow-ups and A&E is less time-consuming than patients in remote areas. Thus, directing the average Swedish patient to an online consultation (as opposed to an inperson one) is likely to yield larger savings to the healthcare system than those in our sample, as fewer rural patients would likely travel to the A&E.

We also find that patients generally view online consultations as replacements for in-person ones. But older patients and immigrants are slightly more sceptical of online consultations. Given this finding and our results on sorting into online consultations, we explore the possibility that online consultations may be better suited for less vulnerable patients.

Consistent with this hypothesis, we find suggestive evidence that patients with histories of hospitalisations or visits to A&E are considerably more likely to follow up after online consultations than other patients. We also find that directing vulnerable patients to in-person consultations and less vulnerable ones to online consultations may save costs for both providers and patients. In part, this is similar to the sorting that already happens in the organisation studied.

The wider impacts of hybrid health organisations

By examining a setting where assignment to online versus in-person care occurs after patients have already requested care, we shed light on the respective causal effects of online and in-person delivery, free from concerns about the sorting of different patients (or the same patients under different symptoms) into care based on their expectations of online or in-person consultations, and from providers' sorting of patients into consultation modes.

Taken together, our findings suggest that in-person follow-ups after online provision and differences in patients' needs are important considerations for hybrid health organisations. These and other considerations may affect the organisation of other hybrid one-to-one services in a large number of providers worldwide.

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20 February 2025     Paper Number CEPCP696

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This CentrePiece article is published under the centre's Labour programme.

This publication comes under the following theme: Labour market dynamics