Disparities in the Use of In-Person and Telehealth Primary Care Among High- and Low-Risk Medicare Beneficiaries During COVID-19

Abstract

We conducted a retrospective cohort study using a difference-in-differences design to estimate differences in primary care outpatient clinic visit utilization among high- and low-risk Medicare aging beneficiaries from an Accountable Care Organization during the COVID-19 pandemic compared to a control cohort from the previous year. High-risk was defined as having a Hierarchical Condition Category score of 2 or higher. A total of 582 101 patient-month records were analyzed. After adjusting for patient characteristics, those in the high-risk group had 339 (95% CI [333, 345]) monthly outpatient encounters (in-person and telehealth) per 1000 patients compared to 186 (95% CI [182, 190]) in the low-risk group. This represented a 22.8% and 26.5% decline from the previous year in each group, respectively. Within each group, there was lower utilization among those who were older, male, or dually eligible for Medicaid in the high-risk group and among those who were younger, male, or non-white in the low-risk group. Telehealth use was less common among patients who were older, dually eligible for Medicaid or living in rural/suburban areas compared to urban areas. All results were significant at the 95% level. We found significant disparities based on age, gender, insurance status, and non-white race in primary care utilization during the pandemic among Medicare beneficiaries. With the exception of gender, these disparities differed between high- and low-risk groups. Interventions targeting these vulnerable groups may improve health equity in the setting of public health emergencies.

Association between broadband capacity and telehealth utilization among Medicare Fee-for-service beneficiaries during the COVID-19 pandemic

“…Older patients may be more likely to face added challenges when adopting new technologies; however, they may benefit more than younger patients from using telehealth services due to challenges of transportation and costs associated with in-person visits. 44 During the COVID-19 pandemic digital access gaps among older adults may have grown in view of economic hardship and social isolation. 45 , 46 Our findings suggest that additional interventions targeting care coordination and engagement of older Medicare beneficiaries are needed to avoid increasing disparities in healthcare access.…”

Disruption to the doctor–patient relationship in primary care: a qualitative study

“… 17 International evidence confirms that older patients, those with visual, hearing, or cognitive impairment, those from ethnic minority and rural backgrounds, and the socially deprived are less likely to be reached by telehealth services, risking increasing health disparities. 18 – 21 However, in NZ a study showed that telehealth actually reduced access barriers for indigenous Māori. 22…”

“…17 International evidence confirms that older patients, those with visual, hearing or cognitive impairment, those from ethnic minority and rural backgrounds and the socially deprived are less likely to be reached by telehealth services, risking increasing health disparities. [18][19][20][21] However, in New Zealand a study showed that telehealth actually reduced access barriers for Indigenous 22 Although Starfield's definition of primary care related to system level attributes, there was evidence that the pandemic-induced changes in the general practice model reflected attempts to maintain some of these attributes at a practice level. Practices coordinated health care despite lack of support from other services.…”

The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries

“…On average, the ACO served about 21 000 to 22 000 Medicare fee-for-service beneficiaries each year, among whom 90.3% were 65 years or older. 10 , 31 …”