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. 2021 Oct 15;2(10):e213282.
doi: 10.1001/jamahealthforum.2021.3282. eCollection 2021 Oct.

Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019

Michael L Barnett  1   2 , Haiden A Huskamp  3 , Alisa B Busch  3   4 , Lori Uscher-Pines  5 , Krisda H Chaiyachati  6 , Ateev Mehrotra  3   7
Affiliations

Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019

Michael L Barnett et al. JAMA Health Forum. .

Abstract

Importance: 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.

Objective: To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine.

Design setting and participants: 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.

Main outcomes and measures: Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine.

Results: 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.

Conclusions and relevance: 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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Barnett reported grants from the National Institutes of Health (NIH) during the conduct of the study. Dr Huskamp reported grants from the National Institute of Mental Health (NIMH) during the conduct of the study. Dr Busch reported grants from the National Institute on Drug Abuse and the NIMH during the conduct of the study. Dr Chaiyachati reported grants from the National Institute on Aging, the Patient Centered Outcome Research Institute, and Independence Blue Cross, and salary support from Roundtrip Incorporated and the National Cancer Institute, all outside the submitted work. Dr Mehrotra reported grants from the NIH and Harvard Medical School during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Trends in Quarterly Telemedicine Visits for Rural Medicare Beneficiaries, 2010 to 2019
Unadjusted counts of telemedicine visits quarterly (A) or telemedicine visits per 1000 rural Medicare beneficiaries quarterly (B) in 2010 to 2019. Mental health telemedicine visits (orange) and nonmental health telemedicine visits (gray) sum to the total of all telemedicine visits.
Figure 2.
Figure 2.. Distribution of Rural Medicare Population Subgroups Compared With Their Telemedicine Visit Use in 2010, 2015, and 2019
Proportion of rural Medicare beneficiaries (left bar) and proportion of all telemedicine visits used per year (right bar) by each of the 3 mutually exclusive groups: (1) patients with an SMI, (2) patients with a mental health diagnosis but not an SMI, and (3) all others with no defined mental health condition. Abbreviation: SMI, serious mental health illness (defined by degree of functional impairment).
Figure 3.
Figure 3.. Trends in Telemedicine Visits for Rural Medicare Beneficiaries, by Clinician Specialty, 2010 to 2019
Trends in quarterly mental health (A) and nonmental health (B) telemedicine visits by clinician specialty. The Non-MD clinician category comprises care provided by nurse practitioners (NPs), mental health NPs, physician assistants, psychologists, and social workers; Specialist MD, all medical specialties other than primary care and psychiatry (most commonly sleep medicine, nephrology, and hematology-oncology); PCP, physicians specialized in internal medicine, family medicine, geriatrics, or general practice; and Other, all other practitioners (eg, dentists or unknown specialty).
Figure 4.
Figure 4.. Telemedicine Use (All Visits), by Rural Medicare Beneficiaries and by County, 2019
County-level number of telemedicine users per 1000 Medicare beneficiaries in 2019. A, Telemedicine use rates for all Medicare beneficiaries in each county. B, Use per 1000 beneficiaries with a mental illness diagnosis but not an SMI. C, Use per 1000 beneficiaries with an SMI. Data were not available for counties with 11 or fewer eligible fee-for-service Medicare beneficiaries in both cohorts because of suppression of small cell sizes. Abbreviation: SMI, serious mental health illness (defined by degree of functional impairment).
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