Direct to Consumer Telemedicine

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The direct to consumer (DTC) model of telemedicine differentiates itself from other forms of telehealth by allowing the patient to initiate the encounter. In other forms of telemedicine encounters, such as Telestroke or Teledermatology, a physician initiates the consultation. 24/7, on-demand access to a clinician - once thought to be a futuristic feat, is now readily available to patients, anywhere and anytime. Patients can enter the virtual front door of a number of private entities such as MDLive, Teladoc, or Dr. on Demand, or turn to a local healthcare system with a similar offering. The burgeoning sector of medicine, a $270 million industry in 2019, is expected to continue to grow past $320 million by 2025 as the industry becomes more mature.[1]

Delivering DTC Care

Further information about terminology and types of telemedicine visits and terminology can be found here.

Synchronous DTC Visits

Similar to other types of synchronous telemedicine, the patient initiates a live encounter with a clinician with audio or video conferencing. The widespread availability of computers, tablets, and cell phones with video capabilities enables this two-way interaction to reach the masses. The entities listed above (MDLive, Teladoc, Dr. on Demand) are all examples of companies specializing in synchronous direct to consumer visits.

Asynchronous DTC Visits

There is also a growing market for asynchronous telemedicine visits, where a structured interface leads a patient through questions to gather a medical history. Some of these systems rely on forms of artificial intelligence (AI) and branching logic to guide these patient encounters. This information can be synthesized to present the clinician with a suspected diagnosis, and even prepare a note. is one such offering.[2] Whether these responses are always reviewed by a human can vary between different company offerings, as well as each state's requirements that govern telemedicine which vary from no requirement, to a video or phone consultation.[3]

A number of companies have applied this approach to specific medical conditions, such as:
  • hims - Erectile Dysfunction
  • hers - Birth Control, Skincare
  • roman - Erectile Dysfunction, Cold Sores
  • kick - Anxiety
  • LemonAid Health - Variety of Medical Conditions

Scope of Conditions

The constraints of a virtual visit with respect to physical exam, ability to accurately record vital signs, etc somewhat limit the types of conditions that are amenable to such evaluations. Almost all commercial DTC offerings describe their ability to address straightforward or simple, acute problems that bode well to such virtual evaluations such as:
  • Ear, Nose, and Throat complaints (allergies, pink eye, runny nose, sore throat, ear pain)
  • Skin complaints (rashes, small cuts, abrasions, insect bites)
  • Cold and Flu complaints (fever, cough, body aches)
  • GI complaints (upset stomach, diarrhea, nausea)
  • Urinary complaints (urgency, dysuria)
  • Musculoskeletal complaints (without preceding trauma)
  • Mild respiratory complaints (without increased work of breathing)
  • Urgent medication refills
An analysis of one pediatric telemedicine program described a similar scope of complaints, recording mostly skin complaints, URI symptoms, fevers, and GI issues. [4]
Table 1. Chief Complaints of the Patients Seen on Nemours CareConnect
Chief Complaints # of Calls, N(%), (N=1,000)
Skin-related symptoms 186 (18.7%)
URI Symptoms 174 (17.5%)
Fever 151 (15.2%)
GI-related Symptoms 97 (9.7%)
Hospital/ER Follow-Up 91 (9.1%)
Eye-related symptoms 79 (7.9%)
Ear-related symptoms 56 (5.6%)
Injury-related issues 25 (2.5%)
Asthma and breathing concerns 17 (1.7%)
Other 119 (12.0%)

DTC Telemedicine Concerns

While the benefits of telemedicine are often easily identifiable, there have also been concerns raised about whether this increase in convenience for the patient comes at the cost of lower-quality care. A JAMA editorial explores these issues, specifically with the aforementioned asynchronous types of visits, where the authors describe that questionnaire type offerings may not identify the best treatment for the individual, but rather screen for those who should NOT be taking the medication being marketed.[5]


There have been a variety of methods to assess the quality of care delivered via telemedicine, including adherence to Healthcare Effectiveness Data and Information Set (HEDIS) measures[6], antibiotic prescribing[7], and "secret-shoppers."[8] Another novel way to assess quality was to use follow-up visits as a rough proxy for clinical resolution, though the study found that patients visiting the Teladoc virtual care solution were less likely to have follow-up visits to any setting when compared to those that visited the office.[9] A study using the "secret shopper" method with standardized patients whom presented the same complaint to a variety of commercial DTC virtual vitis demonstrated significant variability in care provided.[10] Despite these findings, consumers appear to think highly of virtual visits as described by J.D. Power, with a satisfaction score of 851/1000.[11] J.D. Power also notes that this score is among the highest of all healthcare, insurance, and financial service industry studies they conducted, finding that only direct banking customer satisfaction ranked higher.

Regulation & Reimbursement

Legislature and regulation governing telemedicine is highly variable from state to state. Some states restrict DTC telemedicine to encounters where the patient already had an existing physician-patient relationship. A common Medicaid limitation surrounds where the patient is located, termed the "originating site," such as a rural area or type of facility (a patient's home is often not an eligible site). Other restrictions include the specialty that telehealth services can be provided for, types of CPT codes that can be reimbursed, and types of providers that can be reimbursed.[12] The 2020 CPT book includes CPT codes for online digital E/M services, broken down by time.[13] The 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily lifted a number of restrictions and raised reimbursement to the same level as in-office visits.[14]


  1. At 4.3 % CAGR, Direct To Consumer Telehealth Services Market Size will reach 322.7 million USD by 2025. (2020, February 4). Retrieved April 25, 2020, from
  2. raises $8M for AI-powered remote healthcare service with 'virtual physician assistant'. (n.d.). Retrieved April 25, 2020, from
  3. State Telehealth Laws & Reimbursement Policies, The Center for Connected Health Policy,
  4. Vyas, S., Murren-Boezem, J., & Solo-Josephson, P. (2018). Analysis of a Pediatric Telemedicine Program. Telemedicine and e-Health, 24(12), 993–997. doi: 10.1089/tmj.2017.0281
  5. Jain, T., Lu, R. J., & Mehrotra, A. (2019). Prescriptions on Demand. Jama, 322(10), 925. doi: 10.1001/jama.2019.9889
  6. Uscher-Pines, L., Mulcahy, A., Cowling, D., Hunter, G., Burns, R., & Mehrotra, A. (2016). Access and Quality of Care in Direct-to-Consumer Telemedicine. Telemedicine and e-Health, 22(4), 282–287. doi: 10.1089/tmj.2015.0079
  7. Uscher-Pines, L., Mulcahy, A., Cowling, D., Hunter, G., Burns, R., & Mehrotra, A. (2015). Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-Consumer Telemedicine Visits. JAMA Internal Medicine, 175(7), 1234. doi: 10.1001/jamainternmed.2015.2024
  8. Jain, T., Schwarz, E. B., & Mehrotra, A. (2019). A Study of Telecontraception. New England Journal of Medicine, 381(13), 1287–1288. doi: 10.1056/nejmc1907545
  9. Uscher-Pines, L., & Mehrotra, A. (2014). Analysis Of Teladoc Use Seems To Indicate Expanded Access To Care For Patients Without Prior Connection To A Provider. Health Affairs, 33(2), 258–264. doi: 10.1377/hlthaff.2013.0989
  10. Schoenfeld, A. J., Davies, J. M., Marafino, B. J., Dean, M., Dejong, C., Bardach, N. S., … Dudley, R. A. (2016). Variation in Quality of Urgent Health Care Provided During Commercial Virtual Visits. JAMA Internal Medicine, 176(5), 635. doi: 10.1001/jamainternmed.2015.8248
  11. 2019 U.S. Telehealth Satisfaction Study: J.D. POWER. (n.d.). Retrieved April 25, 2020, from
  12. State Telehealth Laws & Reimbursement Policies, The Center for Connected Health Policy,
  13. Nicoletti, B. (2020, April 13). New CPT® codes for online digital E/M - 99421. Retrieved from
  14. CARES Act: AMA COVID-19 pandemic telehealth fact sheet. (n.d.). Retrieved April 25, 2020, from

Submitted by Timothy Layng