Telehealth: Providing Access to Care in a Time of Social Distancing

Key Points:

• • Telehealth is the use of electronic information and telecommunication technologies to support long-distance clinical health care, patient and professional healthrelated education, public health and health administration.
  • Telehealth may provide cost saving opportunities, if savings are not outweighed by an increase in spending from new service use.
  • While telehealth has been used for a variety of purposes, most utilization has been for behavioral health services, which includes mental health services and substance use
    disorder (SUD) services.
  • Telehealth may be one way to increase access to care in rural areas. If the technology infrastructure exists and providers are willing, rural residents have demonstrated high rates of use.

This issue brief is the first of a two-part series. It defines telehealth, which includes telemedicine and other services, and describes its growing use and potential impact on the cost of care and health outcomes. The second brief, Telehealth: Policy Options to Improve Access to Care in Kansas, explores factors that influence the utilization of telehealth and how those factors relate to the Kansas policy landscape.

Introduction

While health care providers have offered telehealth services for years, the COVID-19 pandemic has driven the use of those services to levels never seen before. Beginning in March, as COVID-19 quickly spread around the world, increased use of telehealth provided vital access to health care services while allowing many people to remain socially distanced in their homes.

Telehealth can be used to provide routine medical care, specialty care (e.g., behavioral health services, dermatology), home and community-based services (HCBS), and long-term services and supports (LTSS). Traditionally seen as a tool for increasing access to health care, particularly in remote and rural areas, telehealth also has been used in urban areas and by a variety of health care systems in countries throughout the world.

Telehealth can be provided in multiple ways or modalities, including via real-time communication, mobile health (mHealth), remote patient monitoring (RPM) and store-and-forward. Figure 1 defines these modalities in more detail. A patient receives telehealth services at the “originating” site (e.g., at home) and the provider administers services from the “distant” site.

Direct to consumer telemedicine, which is a common form of telehealth, involves real-time communication between a patient and a provider via telephone or videoconference. Direct to consumer telemedicine has been used for a variety of conditions and services and is often provided by companies such as Teledoc, American Well and Doctor on Demand.

Utilization

Use of telehealth prior to the pandemic was low — but increasing — as seen in both the number of individuals receiving telehealth as well as the volume of services provided via telehealth.

Among 22 states with telemedicine reimbursement for Medicaid in 2008-2009, only 0.1 percent of enrollees received services via telemedicine. Similarly, a study that included patients with public or private insurance found that only 0.7 percent of patients received telemedicine services between 2010 and 2015, although the rate of telehealth users per 10,000 enrollees increased during the study period.

In the Texas Medicaid program, the number of clients using telehealth, telemedicine and home telemonitoring increased by 30 percent from fiscal year (FY) 2016 to FY 2017, and the percentage of veterans using clinical video telemedicine (CVT) in the Veterans Health Administration (VHA) increased from 1.2 percent to 4.6 percent from FY 2009 to FY 2015.

The volume of services provided via telehealth was also growing prior to the pandemic. In Minnesota, telemedicine visits grew by 600 percent from 2010 to 2015, and CVT encounters grew 421 percent in the VHA from FY 2009 to FY 2015.

Rural Populations

Telehealth has been touted by many as one option to increase access to services for individuals living in rural areas.

Prior to COVID-19, telehealth services provided to rural residents were more likely to be covered by public health insurance. Among Minnesota telemedicine users in nonmetropolitan areas in 2015, more than 60 percent were covered by public insurance such as Medicaid, Medicare or both. Among telemedicine users in metropolitan areas, only 20 percent were covered by public health insurance.

Among Medicaid telemedicine patients in 22 states where those services were reimbursed, those living in rural areas were 17 times more likely to receive telemedicine care than their metropolitan counterparts. In another study, VHA patients living in rural areas or at a greater distance to a VHA facility were more likely to use CVT and the rate of utilization grew more quickly among rural patients.

Behavioral Health Care

While telehealth has been used to deliver a variety of health services, behavioral health services, including mental health and substance use disorder (SUD) services, are among the most common. Among VHA patients, at least half of all CVT encounters in FY 2009 and FY 2015 were for mental health care, although use of telemedicine for other specialties grew during the study period. Among Medicaid patients in 22 states with telemedicine reimbursement in 2008-2009, nearly 93 percent of telemedicine claims were associated with a behavioral health diagnosis. In Minnesota, while only about one-third of telemedicine services in 2015 were provided by physicians, the majority (51.5 percent) of those physicians were psychiatrists.

Higher utilization of telehealth for behavioral health services compared to other specialties could be due to many factors, including earlier adoption of telehealth by behavioral health providers, ease of delivering behavioral health care virtually compared to other disciplines (e.g., it does not require a physical exam) and regulatory differences across states.

Cost

In addition to increasing access to health care, telehealth also has the potential to reduce health care costs. Telehealth use has shown some evidence of reducing costs for patients by replacing visits to physician offices and emergency rooms with less expensive telehealth visits and reducing travel costs for primary care. In a systematic review, 23 percent of studies concluded that telehealth interventions, including RPM and mHealth, were effective at producing cost savings or positive health outcomes, while another 42 percent of studies concluded that the evidence was promising that telehealth interventions produce cost savings or positive health outcomes.

One factor influencing the overall cost saving potential of telehealth utilization is the degree to which telehealth services replace or add to existing health care utilization. Among California Public Employees’ Retirement System (CalPERS) beneficiaries seeking care for acute respiratory infections between 2011-2013, an estimated 88.2 percent of telehealth visits represented new utilization. While the average per episode spending for a telehealth visit was less than a physician office visit or emergency room visit, telehealth use resulted in a net increase in spending. Ultimately, telehealth may provide cost saving opportunities only when savings from service substitution are not outweighed by an increase in spending from new utilization.

Health Outcomes

While the available data on health outcomes are less robust than that on utilization and cost, there is optimism about the potential effectiveness of telehealth services. In general, findings across a variety of domains support its continued use, although outcomes are not universal across all systems and types of care.

In telepalliative care, for example, positive outcomes have been identified for reducing hospital and emergency room visits, along with some evidence of improved communication and more time for direct care because documentation efforts are simplified or reduced. In a study of a multidisciplinary team-based diabetes self-management program in rural Montana, telehealth showed similar effectiveness to in-person care after two years. Other studies have likewise indicated that telehealth, including telehealth for behavioral health services, may produce similar outcomes as services provided in person.

Conclusion

The use of telehealth has increased over the last decade. While telehealth utilization represents a small piece of total health care utilization, it holds promise for increasing access to health care services and supporting positive health outcomes, particularly among rural populations. As Kansas legislators, stakeholders and patients continue to search for mechanisms to increase health care access across the state, consideration of policies and regulatory actions that support and expand the use of telehealth will likely be among those considered.

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