Abstract
Little is known about how telemedicine use was evolving before the broad changes that occurred during the COVID-19 pandemic in 2020. Understanding prepandemic patterns of telemedicine use can inform ongoing debates on the future of telemedicine policy. To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine. This was a cross-sectional study and descriptive analysis of telemedicine utilization by 10.4 million fee-for-service Medicare beneficiaries from 2010 to 2019. Data analysis was performed from June 6, 2019, to July 30, 2020. Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine. Of 10.4 million rural Medicare beneficiaries, telemedicine was used by 91 483 individuals (age ≥65 years, 47 135 [51.5%]; women, 51 476 [56.3%]; and White, 76 467 [83.6%] individuals) in 2019. In 2010 to 2019, telemedicine visits grew by 23.1% annually. A total of 0.9% of all fee-for-service rural beneficiaries had a telemedicine visit in 2019 compared with 0.2% in 2010. In 2019, there were 257 979 telemedicine visits or 34.8 visits per 1000 rural beneficiaries and most (75.9%) of these visits were for mental health conditions. Patients with bipolar disorder or schizophrenia (3.0% of rural beneficiaries) received 40% of all telemedicine visits in 2019. Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89). In 2010 to 2019, telemedicine for mental health conditions shifted away from psychiatrists (71.2% to 35.8% of all telemedicine visits) to nonphysician clinicians, eg, nurse practitioners, psychologists, and social workers (21.4% to 57.2%). There was wide variation in telemedicine utilization in 2019 across counties: median (IQR), 16.0 (2.5-51.4) telemedicine users per 1000 beneficiaries). In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019. In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians. The prepandemic model of telemedicine provided in local health care settings may be a viable modality to maintain in rural communities.
Highlights
Telemedicine, the provision of clinical care via remote audiovisual telecommunications may increase access to care[1,2] and improve health care quality,[3] for people living in rural and underresourced settings.[4,5,6] During the COVID-19 pandemic, telemedicine use for office-based visits has surged.[7,8,9] This growth has been facilitated by temporary regulatory and payment changes that have expanded coverage of telemedicine in the Medicare program.[10]
Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89)
In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019. In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians
Summary
Telemedicine, the provision of clinical care via remote audiovisual telecommunications may increase access to care[1,2] and improve health care quality,[3] for people living in rural and underresourced settings.[4,5,6] During the COVID-19 pandemic, telemedicine use for office-based visits has surged.[7,8,9] This growth has been facilitated by temporary regulatory and payment changes that have expanded coverage of telemedicine in the Medicare program.[10]. Before the pandemic there were many restrictions on the use of telemedicine within the Medicare program, such as requiring beneficiaries to receive telemedicine care via live (real time) videoconference (ie, no audio-only visits) and at a clinic or hospital in a rural area (ie, no home-based visits).[12] These facilities providing the technology and space for telemedicine are known as an “originating site.”. Prior research describing utilization trends through 201715-17 found that outpatient telemedicine use within the Medicare program was low and predominantly used for mental health diagnoses, with the highest rates of use among beneficiaries with serious mental illness, such as bipolar or psychotic disorders
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