Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness

Abstract

Importance: During the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized.

Objective: To compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use.

Design, setting, and participants: In this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022.

Exposure: Practice-level use of telemedicine during the first year of the COVID-19 pandemic.

Main outcomes and measures: The primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization.

Results: The pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were -0.4% (95% CI, -1.3% to 0.5%) and -0.1% (95% CI, -1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, -1.5% to 6.2%) and 2.8% (95% CI, -1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use.

Conclusions and relevance: In this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Figure 1.. Two-Year Trends in the Mean Number of Mental Health Visits per Patient According to Practices’ Use of Telemedicine

Two-year trends in unadjusted mean number of mental health visits (including video and audio-only services) for patients in the prepandemic and pandemic cohorts. Practices were categorized based on the proportion of telemental health visits provided during the first 12 months of the COVID-19 pandemic; those with the lowest telemedicine use had 0% to 49% telemental health visits, those with middle telemedicine use had 50%-89% telemental health visits, and those with highest telemedicine use had 90%-100% telemental health visits. Vertical lines separate years 1 and 2 and correspond to the start of the pandemic in March 2020 for the pandemic cohort.

Figure 2.. Differences in 2-Year Trends Between Pandemic and Prepandemic Cohorts in Mental Health Visits, Acute Care Use, and Medication Adherence According to Practices’ Use of Telemedicine

Plots show the differences in the unadjusted mean trends in mental health visits, acute care use (hospitalization and emergency department visits), and antipsychotic and mood-stabilizing medication fills between the pandemic and prepandemic cohorts. Panels A-C show absolute differences in trends between the pandemic and prepandemic cohorts (difference = pandemic − prepandemic values) according to the practice’s use of telemedicine. Practices with lowest, middle, and highest use delivered 0%-49%, 50%-89%, and 90%-100% of mental health visits, respectively, via telemedicine. Panels D-F show the differences as relative changes compared with the prepandemic cohort mean (relative change = difference/prepandemic value). Vertical lines separate years 1 and 2 and correspond to the start of the pandemic in March 2020 for the pandemic cohort. TMH indicates telemental health.

Figure 3.. Relative Change in Mental Health Visits for Practices With Highest vs Lowest Use of Telemental Health by Patient Demographic Characteristics

Boxes represent means and bars represent 95% CI. Vertical dashed line indicates overall change across the entire study population. ^aOther race includes Asian or Pacific Islander, Black, Hispanic, American Indian, Alaska Native, and unknown race and ethnicity. Because the sample size for these racial and ethnic groups was insufficient for comparisons, we grouped them into this other category.