After the start of the Covid-19 pandemic, sweeping policy changes by the Centers for Medicare and Medicaid Services led to a surge in virtual visits. A new study puts a number on that increase: telehealth visits increased 63 fold for fee-for-service Medicare patients between 2019 and 2020.

The report, put together by the Department of Health and Human Services, provides some important context as regulators consider how to more permanently extend telehealth provisions beyond the public health emergency. For example, HHS found that the biggest increase in telehealth use was for behavioral health visits, but also noted disparities in telehealth use between urban and rural patients.

In total, the number of telehealth visits by Medicare beneficiaries increased from roughly 840,000 in 2019 to 52.7 million in 2020. But even as the number of telehealth visits increased, total Medicare Part B visits decreased as many people delayed care during the early months of the pandemic.

One common thread across the past few years has been that telehealth is most widely used to access mental health services. Roughly a third of all behavioral health visits last year by Medicare patients were conducted through telehealth. By comparison, roughly 8% of primary care visits were virtual, and a smaller portion, about 3%, of other specialty visits were virtual.

The report, created by HHS’ Office of the Assistant Secretary for Planning and Evaluation Analysis, was based on all 34.9 million Medicare fee-for-service beneficiaries who had Part A or B in 2020.

Disparities in telehealth use
As telehealth use increased, disparities in who used virtual visits the most became apparent. Across the board, telehealth visits were used significantly more by people in urban settings (accounting for 5.7% of total part B visits) than people in rural settings (accounting for 4.7% of visits). There were also some differences as state policies and demographics shaped telehealth access. Most of the states where telehealth use was highest were in the northeast, including Massachusetts, Vermont and Rhode Island. Meanwhile, the states with the lowest telehealth rates were across the midwest and south, including Tennessee, Nebraska and Kansas.

Disparities also continued beyond state boundaries and metro areas. Generally, the report found that Black people used telehealth slightly less than white people, while Asian and Hispanic people used telehealth visits more often.

There were also slight differences for dual-eligible people, who are enrolled in both Medicare and Medicaid. While dual-eligible patients used telehealth more than people who were only enrolled in Medicare, it still wasn’t enough to offset a bigger decrease in in-person visits last year.

Informing future policy
CMS Administrator Chiquita Brooks-LaSure said in a press release that the agency would use the results to inform future policies around telehealth. CMS has already emphasized some of the findings in recent policy decisions. For instance, in Medicare’s recent physician fee schedule, the agency confirmed that Medicare will pay for mental health visits provided by rural health clinics and federally qualified health centers, including audio-only calls, which might help expand access to people who don’t have the needed internet services or equipment for video visits.

Medicare patients will also be able to continue to access behavioral health visits at home, per the Consolidated Appropriations Act. This is a departure from the past, when Medicare would only cover telehealth visits for patients in rural locations, and at certain sites, such as hospitals or clinics.

As for coverage of other telehealth services, that’s still to be determined. While the public health emergency continues through December of next year, Medicare will continue to cover a wide range of telehealth services. The agency is still evaluating which ones to cover on a more permanent basis, and it will take an act of Congress to actually expand the Medicare program to include in-home telehealth coverage.

“While Congress has made certain in-roads related to tele-mental healthcare though the Consolidated Appropriates Act of 2021, general clinical services, such as primary care, need an additional legislative fix for permanent adoption,” wrote Jacob Harper, an attorney at Morgan Lewis, in an email.

Some states have already ended public health emergency waivers, rolling back  pandemic telehealth flexibilities as a result. One of the biggest challenges is cross-state licensing, which can be costly and time-consuming for clinicians looking to practice in multiple states.

“While the federal waivers have been an important component for enabling expanding telehealth usage in the Medicare program, it was really state licensing waivers and flexibilities that enabled widespread adoption of telehealth,” Harper wrote. “Many states have allowed their flexibilities to sunset and have not enacted permanent legislation to enable easy telehealth cross-border licensing.  As a result, particularly in states with fewer specialty care options, patients’ only option becomes traditional in-person care, even if Medicare coverage for virtual care services is available.”

Photo: Maria Symchych-Navrotska, Getty Images