That changed with stay-at-home orders. In March 2020, the federal government granted providers expanded—but temporary—flexibility to provide two-way video and telephone health care services. Many doctor’s offices have quickly replaced in-person appointments with virtual ones.
The possibility of continuing virtual visits is linked to the federal government’s public health emergency for the pandemic. While there are bipartisan efforts to maintain telehealth flexibilities once the emergency is over, policy analysts have expressed concern that reimbursing providers the same amount for virtual visits as for in-person visits nobody could make health spending more difficult to control.
These are reasonable concerns, but we know that the sudden and unprecedented expansion of telemedicine during covid has addressed an unmet need, especially for underserved communities. This is the main takeaway from a recent report by the Bipartisan Policy Center. (I am a board member of the BPC, but I was not involved in the research.)
The report’s authors analyzed federal Medicare data and found dramatic adoption of telemedicine. In 2019, less than 1% of people who had Medicare for their insurance participated in a telehealth visit. In 2020, no less than 44% did so. There has been some stabilization in 2021, with 28% requesting a telehealth visit in the first three quarters of this year.
The dominant specialty using telehealth was primary care. Almost all of these patients – 95% – sought virtual care from providers with whom they already had a relationship.
This finding is not surprising. My colleagues in primary care have told me how some patients appreciate the convenience of a quick phone check-in to manage chronic conditions such as high blood pressure and diabetes. A virtual visit doesn’t involve the hassle of taking half a day off and asking loved ones to come to the clinic.
The second most sought-after specialty for telehealth was behavioral health. It also makes sense because mental health counseling lends itself more naturally to virtual interactions than conditions that require a physical exam.
The BPC study found that nearly half of all behavioral health visits in 2021 were conducted via telehealth. Unlike primary care visits, 65% were new treatment relationships, in which the patient saw this mental health specialist for the first time.
Clearly, the use of telehealth has increased dramatically. And there’s an indication that care delivered from virtual appointments isn’t just additional care: Total visit volume — the combination of in-person and virtual appointments — was lower in 2020 and 2021 compared to to 2019, suggesting that virtual care replaced rather than added to in-person care.
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The one notable exception is mental health, where many of those who sought behavioral telehealth were new patients. This could probably be explained by the lack of access; About 150 million Americans live in areas where there is a shortage of mental health professionals, and telehealth has likely opened up mental health support to people who otherwise would not have received it.
Perhaps most surprising is who benefited from these gains. Before the pandemic, those most likely to use digital health technologies were generally younger, whiter, and wealthier. The BPC report found the opposite. Those most likely to use telehealth services in 2020 and 2021 were people with disabilities, minorities and older people with multiple underlying health conditions.
Overall, the research indicates that the expansion of telemedicine during covid either replaces care that could be delivered more easily in the form of a virtual visit, or enables services that otherwise would not be accessible.
Of course, telemedicine cannot and should not replace in-person care, as many diagnoses require physical exams, tests, and procedures. Additionally, many patients prefer in-person visits now that the covid risk is manageable. It is also unclear whether virtual-only providers can provide the level of high-quality care offered by traditional practices that offer both in-person and telehealth services. And it remains to be seen under what conditions telehealth is a cost-effective measure to reduce more costly care such as emergency room visits and hospitalizations.
As researchers search for these answers, policy makers must keep in mind the large number of patients who have sought telehealth in the wake of covid. It would be a shame if the gains made to increase access were reversed as suddenly as they were implemented, especially considering the vulnerable populations who have benefited from virtual care.
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