Congress and many state legislatures are considering expanding access to telemedicine. To inform this debate, we analyzed Medicare fee-for-service claims for the period 2004-14 to understand trends in and recent use of telemedicine for mental health care, also known as telemental health. The study population consisted of rural beneficiaries with a diagnosis of any mental illness or serious mental illness. The number of telemental health visits grew on average 45.1 percent annually, and by 2014 there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively. There was notable variation across states: In 2014 nine had more than twenty-five visits per 100 beneficiaries with serious mental illness, while four states and the District of Columbia had none. Compared to other beneficiaries with mental illness, beneficiaries who received a telemental health visit were more likely to be younger than sixty-five, be eligible for Medicare because of disability, and live in a relatively poor community. States with a telemedicine parity law and a pro-telemental health regulatory environment had significantly higher rates of telemental health use than those that did not.
Only a small proportion of individuals with a substance use disorder (SUD) receive treatment. The shortage of SUD providers, particularly in rural areas, is an important driver of this treatment gap. Telemedicine could be a means of expanding access to SUD treatment. However, several key regulatory and reimbursement barriers to greater tele-SUD use exist, and both the Congress and the states are considering or have recently passed legislation to address these barriers. To inform these efforts, we describe how tele-SUD is currently being used. Using 2010–2017 claims data from a large commercial insurer, we identify characteristics of tele-SUD users and examine how tele-SUD is being used in conjunction with in-person SUD care. Despite a rapid increase in tele-SUD over the period, we find low use rates overall, particularly relative to the growth in tele-mental health. Tele-SUD is primarily being used as a complement to in-person care and is disproportionately used by those with relatively severe SUD. Given the severity of the opioid epidemic, the low-rates of tele-SUD use that we observe represent a missed opportunity. As availability of tele-SUD is expanded, it will be important to monitor closely which tele-SUD delivery models are being deployed and their impact on access and outcomes.
This study has several limitations. Claims data could not show how often AWVs were performed by nonphysicians under physician supervision, and the extent to which AWVs represent delivery of additional visits vs substitution for other visits remains unclear. More research is needed on whether AWVs increase use of preventive care or mitigate health risks.
In 2011 Medicare introduced the annual wellness visit to help address the health risks of aging adults. The visit also offers primary care practices an opportunity to generate revenue, and may allow practices in accountable care organizations to attract healthier patients while stabilizing patient-practitioner assignments. However, uptake of the visit has been uneven. Using national Medicare data for the period 2008-15, we assessed practices' ability and motivation to adopt the visit. In 2015, 51.2 percent of practices provided no annual wellness visits (nonadopters), while 23.1 percent provided visits to at least a quarter of their eligible beneficiaries (adopters). Adopters replaced problem-based visits with annual wellness visits and saw increases in primary care revenue. Compared to nonadopters, adopters had more stable patient assignment and a slightly healthier patient mix. At the same time, visit rates were lower among practices caring for underserved populations (for example, racial minorities and those dually enrolled in Medicaid), potentially worsening disparities. Policy makers should consider ways to encourage uptake of the visit or other mechanisms to promote preventive care in underserved populations and the practices that serve them.
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