The explosive growth in telemedicine has been hailed by some as an important “silver lining” of the Covid pandemic, if such a thing can exist for such a vast tragedy. In the first terrifying weeks of the pandemic, most people did not go to their doctors’ offices for medical care and telemedicine quickly evolved from a fringe service to a major mode of care delivery.
The CEO of one telemedicine company described his company experiencing a decade’s worth of growth in just a few weeks.
For the nation’s older adults and other Medicare beneficiaries, telemedicine has been an essential lifeline during the pandemic. On March 17, 2020, the Centers for Medicare and Medicaid Services announced that it would reimburse all providers for telemedicine services rendered to any patient. In a blog post, then-CMS Administrator Seema Verma described how the number of Medicare fee-for-service beneficiaries using telemedicine each week increased from fewer than 15,000 at the beginning of 2020 to nearly 1.7 million by April of that year
Since Verma’s post, the pandemic has continued in waves, with a toll of more than 630,000 dead in the U.S. alone, four-fifths of whom are older adults. What has happened in older adults’ use of telemedicine during this time?
To answer that question, we analyzed medical claims for 30 million individuals who were covered by traditional Medicare. This sample included older adults; dual-eligible, low-income beneficiaries qualifying for both Medicare and Medicaid coverage; and those under 65 who entered the Medicare program due to disability.
Three findings surprised us about how telemedicine is used by Medicare beneficiaries.
Telemedicine use decreased sharply after peaking in May 2020. Despite continuing concerns about transmission of the coronavirus, the number of telemedicine visits fell steadily after peaking at about 2 million visits, comprising 42% of all visits in April and May 2020 (see chart below). By April 2021, weekly visits fell to less than 800,000, a decline of about 60%.
While telemedicine will certainly play a valuable role in health care in the years ahead, it will likely account for only a modest share of visits under current payment policies, medical practice, and technologies.
Future use depends on both government and private health plans’ policies around how — and how much — clinicians are reimbursed for providing this type of care. Clinicians and medical practices are understandably hesitant to invest in telemedicine technology platforms and make changes in their practice operations if they aren’t certain they can count on being paid for providing this kind of care. Future use will also depend on adaptations in medical practice. Home-based equipment such as oxygen monitors and the ability to do basic laboratory tests are needed so some telemedicine visits can approach in-office visits in clinical quality.
Telephone calls are the only form of telemedicine used by 1 in 10 Medicare beneficiaries. Telemedicine is seen as a high-tech approach to delivering care. But it is important to put this in perspective. Under the temporary Medicare payment policy in place during the pandemic, telemedicine includes everything from video calls to “old-fashioned” phone calls. Between Medicare’s expansion of telemedicine reimbursement in March 2020 and the end of that year, 52 million telemedicine visits were provided to Medicare fee-for-service beneficiaries. Of these, 11 million (21%) were billed as simple phone calls. Among all Medicare beneficiaries, 52% received telemedicine care through the end of 2020; a substantial minority of them, 3 million individuals (10%) received only telephone calls and this percentage was greater in older age groups, as shown in the table below.
Percentage of Medicare beneficiaries using different forms of telemedicine from March 17, 2020, through Dec. 31, 2020
|Type of telemedicine||Age 66 and under||Age 66 to 74||Age 75 to 84||Age 85 and older|
Continuing to reimburse clinicians for making telephone-only calls after the pandemic subsides has raised concerns about whether physicians can provide adequate-quality care in a telephone call and whether telephone calls might be overused. Even so, it is important to recognize that eliminating reimbursement for telephone-only calls will likely mean that 1 in 10 Medicare beneficiaries will no longer be able to use telemedicine. Research is needed to better characterize beneficiaries who can’t access video visits and find ways to increase their access to video-based telemedicine.
Telemedicine use has not varied substantially by race and ethnicity. Many commenters, including one of us (A.M.), have expressed concern that telemedicine will widen disparities of care. Surprisingly, this has not by borne out by the data. Through the end of 2020, we observed no substantive differences in the proportion of beneficiaries using telemedicine by race and ethnicity: 51% of non-Latino white beneficiaries, 55% of Black beneficiaries, and 56% for both Latino and Asian beneficiaries.
This pattern may in part reflect the fact that people of color are more likely to live in urban areas, where the use of telemedicine is higher. Beneficiaries living in large metropolitan counties were substantially more likely to use telemedicine than those living in rural areas, as shown in the table below.
Telemedicine use by Medicare beneficiaries by place of residence from March 17, 2020, through Dec. 31, 2020
|Large metropolitan area||Metropolitan area||Urban||Less urban||Rural|
*This may be an undercount of telephone calls as physicians may not always use the telephone code vs. video code.
This rural-urban difference is surprising given that the use of telemedicine was significantly higher in rural areas before the pandemic. Based on that, our expectation had been that its use would continue to be higher in rural areas during the pandemic. Persistent issues with broadband access and lack of technology in the home is likely a barrier to its adoption in rural communities. (It is worth noting that the use of telephone-only telemedicine visits in 2020 is quite similar between urban and rural areas.) Investments in broadband access, as recently proposed in the infrastructure package, are likely key to address this digital divide.
The rapid expansion of telemedicine during the pandemic made headlines. What have been overlooked are the changing patterns of its use. Which older adults used telemedicine, and how they used it, did not play out as many had expected. Moving forward it will be essential to closely track the evolving use of telemedicine — and which Americans can access their care this way — to ensure that telemedicine does not widen disparities of care.
Josh Gray is a vice president at Health Data Analytics Institute, a predictive analytics company based in Dedham, Mass., where Douceur Tengu is a data analyst. Ateev Mehrotra is a physician and an associate professor of health care policy at Harvard Medical School. The research described here was supported in part by a grant from the Robert Wood Johnson Foundation.
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