Telehealth Before, During, and After the Pandemic: What Have We Learned?

Timothy Lesaca MD

Psychiatrist, author, advocate.

   October 24, 2026


Abstract

The COVID-19 pandemic quickly shifted care from in-person to virtual, accelerating what would have been a slow, years-long change. This review examines telehealth before, during, and after the pandemic and discusses research on outcomes, use and cost, equity, clinician workload, and policy. Overall, telehealth works as well as in-person care for many needs and is especially effective for behavioral health, opioid use disorder, and chronic disease follow-up. However, it also brings challenges, such as missed preventive care, concerns about antibiotic use, ongoing digital gaps, and more asynchronous work that has led to clinician burnout.

Before the Pandemic: Available but Marginal

Telehealth is not new. Closed-circuit television delivered mental health care in rural Nebraska in the early 1960s, and the term "telemedicine" dates to 1971 (Ogini et al., Telemedicine and e-Health, 2025). Medicare has paid for rural beneficiaries' telehealth visits since 1996, but regulations restricted where patients could be located and which clinicians could bill, and payment was far less favorable than for in-person care. As a result, use remained low (Werner and Glied, New England Journal of Medicine, 2021).

Among commercially insured US adults, telehealth made up only 0.3% of visits in March 2019 (Hirschtritt and Kelly, JAMA, 2024). In a large academic system with over 46 million visits, telemedicine was about 1% of outpatient visits before the pandemic (Zhang et al., Journal of General Internal Medicine, 2026). Before the pandemic, studies also raised concerns that later returned: direct-to-consumer telemedicine clinicians were as likely as, or more likely than, in-person care to prescribe inappropriate antibiotics for upper respiratory infections (Ganguli et al., JAMA Internal Medicine, 2025). For nonacute issues like sinusitis, about 90% of telemedicine visits added to, rather than replaced, in-person care, which increased overall spending (Mehrotra and Uscher-Pines, New England Journal of Medicine, 2022).

During the Pandemic: The Surge

In March 2020, payers and regulators quickly removed the main barriers to telehealth. For the first time, payers paid audio-only and video visits the same as in-person visits, patients could be seen from home, and geographic limits were lifted (Mehrotra and Uscher-Pines, New England Journal of Medicine, 2022). Interestingly, many practices switched to virtual care even before payment was guaranteed, which is rare since payment usually drives practice changes (Zulman and Verghese, JAMA, 2021).

Adoption was dramatic:

Reviews showed that telehealth expanded in almost every specialty, especially in nonsurgical fields. They also noted benefits like lower exposure risk, continued care, and saving protective equipment (De Simone et al., BMC Health Services Research, 2022; Monaghesh and Hajizadeh, BMC Public Health, 2020). One review of 46 studies from the first year of the pandemic found that 40% showed better medical outcomes and 10% showed no difference compared to usual care, with none reporting lower satisfaction (Kruse and Heinemann, Journal of Medical Internet Research, 2022). Common barriers included getting used to the technology, concerns about the accuracy of remote assessments, and technical issues (Khoshrounejad et al., Frontiers in Public Health, 2021).

After the Pandemic: A New, Lower Plateau

After the pandemic, telehealth use dropped from its peak but did not return to pre-pandemic levels. At Penn Medicine, telemedicine made up 1% of visits before the pandemic, jumped to 17% in April 2020, and then settled at 4–6% from 2022 to 2024 (Zhang et al., Journal of General Internal Medicine, 2026). Among Medicare patients, 12% had at least one telehealth visit in the third quarter of 2023, down from a peak of 47% but still above 7% in early 2020 (Hirschtritt and Kelly, JAMA, 2024). National surveys show that self-reported telehealth use fell slightly from 39.0% of adults in 2022 to 34.9% in 2024. Video visits remained around 71%, and more than 75% of users said telehealth was as good as in-person care (Zhang et al., Journal of General Internal Medicine, 2026).

Use has persisted most in specialties more well suited to remote care, especially behavioral health and primary care (Werner and Glied, New England Journal of Medicine, 2021; Cutler, JAMA Health Forum, 2023). Patients mostly use telehealth for minor acute illness (32%), chronic disease management (21%), mental health or substance use (17%), and annual exams (16%) (Spaulding et al., Journal of Medical Internet Research, 2024).

Clinical Outcomes and Quality

A large review of 77 US studies from March 2020 to April 2023 found that the differences between telehealth and in-person care were usually small. Telehealth led to fewer missed visits and better medication adherence, but also to fewer up-to-date lab and other tests. The evidence was strongest for telehealth in behavioral health, but it may not work as well for general adult care or specialized pregnancy and gynecology.

Large primary care studies add more detail. At Kaiser Permanente Northern California, with 2.36 million visits in 2021 (about half virtual), 7-day return in-person visits happened after 1.3% of office visits, 6.2% of video visits, and 7.6% of phone visits. Emergency department visits were similar across groups (1.6%, 1.8%, and 2.1%). The biggest differences were for acute pain, and the smallest for mental health (Reed et al., Annals of Internal Medicine, 2023). Another study of 2.2 million primary care visits in the Midwest in 2022 also found that telemedicine led to more follow-up and hospital visits, and that phone visits led to more emergency visits (Chang et al., Journal of General Internal Medicine, 2026). Telehealth visits are less likely to include routine screenings, lab tests, or blood pressure checks (Werner and Glied, New England Journal of Medicine, 2021). Clinicians have also raised concerns that virtual visits may reduce preventive care when they replace in-person visits (Zulman and Verghese, JAMA, 2021).

Opioid use disorder is the clearest success story. Among 23,565 commercially insured patients initiating buprenorphine, telehealth initiation was associated with better treatment retention (adjusted odds ratio 1.29), more refills, and a 36% lower overdose rate than in-person initiation (Nguyen et al., Journal of General Internal Medicine, 2024). In the Veterans Health Administration, buprenorphine treatment continued to grow after the pandemic policy changes, largely through phone and video visits (Lin et al., American Journal of Psychiatry, 2022). Building on these data, a permanent federal policy adopted in December 2025 allows audio-only telehealth initiation of buprenorphine without an in-person evaluation (Landis et al., JAMA Internal Medicine, 2026).

Antibiotic Stewardship and Diagnostic Uncertainty

Antibiotic prescribing shows the challenges of remote exams. Before the pandemic, studies were mixed: 4 of 12 found higher, 5 found lower, and 3 found similar antibiotic prescribing rates in remote versus in-person visits (Han et al., Journal of Medical Internet Research, 2020). More recent data are less positive. In 2022, telemedicine primary care visits led to more antibiotic prescriptions for both video (adjusted odds ratio 1.31) and phone visits (1.22) (Chang et al., Journal of General Internal Medicine, 2026). Clinicians prescribe antibiotics more often virtually, likely because strep testing is rare and reliable remote ear exams are uncommon. Some systems now advise against diagnosing pharyngitis and ear infections virtually (Sanchez et al., Telemedicine and e-Health, 2024). The CDC has updated its antibiotic stewardship guidelines for telehealth to address these issues (Sine et al., Clinical Infectious Diseases, 2022).

Utilization, Spending, and Value

The core payer question is whether telehealth replaces or adds to in-person care. The Congressional Budget Office believes telehealth mostly adds to care (Mehrotra and Uscher-Pines, New England Journal of Medicine, 2022). The evidence, however, is mixed: some studies show telehealth replaces in-person visits, while others show it increases primary care use (Saharkhiz et al., JAMA Network Open, 2024). Telehealth might reduce unnecessary testing by removing in-person opportunities, or increase it because of diagnostic uncertainty. The overall effect on low-value care remains under study (Ganguli et al., JAMA Internal Medicine, 2025).

Telehealth helps by removing barriers like transportation, distance, and time off from work (De Simone et al., BMC Health Services Research, 2022). Early data showed big drops in missed appointments, especially for groups that often missed visits before (Werner and Glied, New England Journal of Medicine, 2021). Still, before the pandemic, 26.3% of Medicare patients lacked the home digital access needed for video visits. This was even more common among low-income people, those 85 or older, and communities of color (Roberts and Mehrotra, JAMA Internal Medicine, 2020). Post-pandemic, use remains lower among older adults and Black, Hispanic, and Asian patients relative to White patients (Zhang et al., Journal of General Internal Medicine, 2026), and digital access explains more variance in video versus audio choice than traditional sociodemographic factors (Bolbocean et al., Journal of Medical Internet Research, 2026). Because audio-only care is often the only practical option for these patients, many argue that maintaining audio-only coverage is essential to a digitally inclusive system (Hughes et al., New England Journal of Medicine, 2022; Chandrasekaran, American Journal of Public Health, 2026).

Effects on Clinicians and Clinical Work

Telehealth has offered real benefits for clinicians. Primary care doctors said working from home improved their work-life balance, gave them better insight into patients' home lives, and allowed more family members to join visits (DePuccio et al., PLoS One, 2022). Remote and hybrid work may also help retain clinicians (Hirschtritt and Kelly, JAMA, 2024). Patients have rated their experience as good as or better than in-person care, with video visits getting slightly higher marks for doctor communication in a survey of 58,500 patients (Hays and Skootsky, Journal of General Internal Medicine, 2022).

The main downside is the increase in asynchronous work volume. From 2020 to 2025, patient portal messages in Epic Cosmos grew 153% (from 0.99 to 2.50 per patient per year), while office visits rose 17% and phone calls fell by only 6%. Messaging grew alongside other visit types, not instead of them (Molina and Ross, JAMA, 2026). In the Veterans Health Administration, primary care burnout rose from 42.1% to 52.7% between 2020 and 2023. More video visits did not increase burnout, but more secure messages did (Apaydin et al., Journal of Medical Internet Research, 2025). Primary care doctors get five times as many patient messages as surgeons, and female doctors get more messages than male doctors. Most of this work is not paid under fee-for-service (Rotenstein et al., JAMA, 2023). Telemedicine can also increase time spent in the EHR by reducing staff help and making it harder to switch between remote and in-person work (Holmgren et al., JAMA Internal Medicine, 2023).

Lessons Learned

Conclusion

The pandemic showed that telehealth can be used at scale and that both patients and clinicians will use it. In the years since COVID-19, we have learned where telehealth is most useful and where it is not. It is now a permanent part of healthcare, and its value depends on using it in the right situations.

References

Zhang B, Li L, Lu Y, et al. Temporal trends and sociodemographic differences in telemedicine utilization, 2019-2024. J Gen Intern Med. 2026.

Zhang C, Zhang AD, Grobman B, et al. Trends in telehealth use and changes in associated disparities: 2022-2024 HINTS. J Gen Intern Med. 2026.

Hatef E, Wilson RF, Zhang A, et al. Effectiveness of telehealth versus in-person care during the COVID-19 pandemic: a systematic review. NPJ Digit Med. 2024.

Reed M, Huang J, Somers M, et al. Telemedicine versus in-person primary care: treatment and follow-up visits. Ann Intern Med. 2023.

Chang E, Luff A, Moen T, Fernandez E, Khatib R. Downstream healthcare use associated with primary care in-person and telemedicine visits in 2022. J Gen Intern Med. 2026.

Sanchez GV, Kabbani S, Tsay SV, et al. Antibiotic stewardship in outpatient telemedicine: adapting Centers for Disease Control and Prevention core elements to optimize antibiotic use. Telemed J E Health. 2024.

Nguyen B, Zhao C, Bailly E, Chi W. Telehealth initiation of buprenorphine for opioid use disorder: patient characteristics and outcomes. J Gen Intern Med. 2024.

Landis RK, Terplan M, Andraka-Christou B, Cantor J. Buprenorphine via telehealth—closing the gap for pregnant and postpartum women with opioid use disorder. JAMA Intern Med. 2026.

Molina M, Ross JS. National trends in patient messaging—the growing electronic inbox. JAMA. 2026.

Apaydin EA, Der-Martirosian C, Yoo C, et al. Secure messages, video visits, and burnout among primary care providers in the Veterans Health Administration: national survey study. J Med Internet Res. 2025.

Mafi JN, Vangala S, Cantor J, et al. Telemedicine adoption, US ambulatory visits, and total medical spending, 2019-2023. JAMA Netw Open. 2026.

Ganguli I, Lim C, Daley N, et al. Telemedicine adoption and low-value care use and spending among fee-for-service Medicare beneficiaries. JAMA Intern Med. 2025.

de Varge Maldonado JMS, de Paula AC, Gadelha CAG. Perception of health care providers and users on teleconsultation in times of COVID-19 in Brazil: an exploratory interview study. Telemed J E Health. 2023.

Shone HB, Cai ST, Simon K, Carnahan JL, Boustani M. Telehealth among Medicare Advantage beneficiaries with and without Alzheimer's disease and related dementias (ADRD), 2018–2024: from pandemic-era surge to post-pandemic decline. BMC Health Serv Res. 2026.

Cressman S, Stewart K, Scheuermeyer FX, et al. Changes in emergency and primary care use after adding virtual physicians to HealthLink BC's 8-1-1 program. NPJ Digit Med. 2025.

Zhang B, Li L, Lu Y, et al. Episode charges and subsequent visits after telemedicine vs in-person care. JAMA Netw Open. 2026.

Weber E, Miller SJ, Shroff N, Beyrouty M, Calman N. Recent telehealth utilization at a large federally qualified health center system: evidence of disparities even within telehealth modalities. Telemed J E Health. 2023.

Vakkalanka JP, Lund BC, Arndt S, Carter KD, Carnahan R. The association between telehealth use during buprenorphine treatment for opioid use disorder and clinical outcomes: a retrospective cohort study. Telemed J E Health. 2025.