Cover: Key Findings from RAND Health Care Research on Telehealth Policy

Key Findings from RAND Health Care Research on Telehealth Policy

Published May 11, 2023

by Lori Uscher-Pines, Shira H. Fischer

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Research Brief
Close up of a mother and daughter consulting with their doctor over a video call on their digital tablet, photo by Geber86/Getty Images

Photo by Geber86/Getty Images

Although virtual health care has been on the horizon for years, telehealth use exploded in the early days of the coronavirus disease 2019 (COVID-19) pandemic: It increased by more than 4,000 percent in the first months of the pandemic, relative to the same period in 2019 (FAIR Health, 2020). Yet increased use of telehealth offset only about half of the decline in in-person visits, suggesting that a significant amount of services were deferred (Cantor et al., 2022).

Increased use of telehealth offset only about half of the decline in in-person visits, suggesting that a significant amount of services were deferred.

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RAND Health Care researchers have been studying telehealth's effects on care quality, access, and equity to gain insights on the uses of and preferences regarding telehealth before and during the pandemic. Prepandemic policies regarding telehealth service reimbursement, which had been in place to limit overspending and potential fraud, were temporarily waived to ease access to care during the public health emergency (PHE) (Centers for Medicare & Medicaid Services, 2021; Public Law 116-136, 2020). The Consolidated Appropriations Act of 2023 (Public Law 117-328) preserves the effects of those waivers until December 31, 2024, but policymakers and payers will eventually need to make long-term decisions regarding telehealth.

The key findings from recent RAND research on telehealth synthesized in this brief will help policymakers and payers make informed decisions about telehealth policies as the PHE ends.

Adapting to Emergencies

  • About 30 percent of patients used video telehealth services in the first months of the pandemic, a RAND American Life Panel survey found. This was a marked increase from the 4 percent of patients surveyed in 2019 who used video telehealth services. Much of the increase was due to patients seeing their own doctors through telehealth (Fischer et al., 2021).
  • Survey data collected later in the pandemic showed that willingness to try telehealth among respondents — particularly Black respondents — significantly increased, relative to February 2019 (Fischer, Predmore, et al., 2022). Willingness to use telehealth may also depend on whether virtual visits can occur with their usual providers (Fischer and Breslau, 2021). However, if virtual visits cost more, most respondents preferred in-person visits for nonemergency care (Predmore et al., 2021).
  • Rapid-response interviews conducted early in the pandemic revealed that providers pivoted to telehealth out of necessity, not only to protect themselves and their patients from viral spread, but also to offset losses from reduced in-person visit volume (Uscher-Pines, 2020).
  • Use of telehealth may be driven more by the features of the health system in which care is delivered and its payment models than by patients themselves (Whaley et al., 2022).
  • Psychiatrists interviewed in the summer of 2021 felt that almost all their patients would be good candidates for receiving care through televisits as part of hybrid care, given some essentials, such as access to private space (Uscher-Pines, Parks, et al., 2022).
Photo of a young woman having a counselling session with a psychologist using a video conferencing tool. Photo by PeopleImages/Getty Images

Photo by PeopleImages/Getty Images

Enabling Treatment for Substance Use Disorders

  • Many providers who treat patients with opioid use disorder (OUD) made dramatic changes to care patterns by including telemedicine with the majority of their patients and adjusting pre-pandemic standards of care, such as toxicology screenings and OUD medication supplies (Hunter et al., 2021).
  • Early in the pandemic, most providers associated remote treatment with improved access and better patient interactions, though some reported challenges with having enough clinical data for decisionmaking and technological issues (Uscher-Pines, Sousa, Raja, et al., 2020). By 2022, many providers associated video visits with higher quality care than audio visits and had adopted digital equity practices to facilitate remote access (Uscher-Pines, Riedel, et al., 2023).
  • Before the pandemic, less than 18 percent of substance use disorder treatment facilities nationwide offered telehealth-based treatment, and adoption varied by state policy laws, among other local factors (Uscher-Pines, Cantor, et al., 2020).
  • Although various states instituted some policies expanding access to and initiation of remote OUD treatment, no state implemented policies to comprehensively expand access to OUD treatment (Pessar et al., 2021).

Lowering Barriers to Care

  • Though behavioral health visits in the Military Health System decreased overall at the start of the pandemic, telehealth accounted for about two-thirds of visits in 2020. The quality of those visits was comparable to the quality of care delivered in 2019 — and even improved on some measures (Hepner et al., 2023).
  • Telehealth can be used to deliver professional breastfeeding support. Almost 45 percent of mothers in rural Pennsylvania in a randomized controlled trial of remote lactation services used app-based video services to help answer their breastfeeding questions and concerns (Uscher-Pines, Kapinos, et al., 2019). Users were more likely to be new to breastfeeding and working at 12 weeks postpartum, and calls typically occurred outside normal business hours (Kapinos et al., 2019).
  • Telehealth's ability to relieve issues of workforce distribution or shortage is limited by underlying issues regarding reimbursement. A study of mental health availability and accessibility in New York City found neighborhoods in which no providers accepted Medicaid or other insurance payment. PHE-related reimbursement waivers helped increase the number of patients seen, but this increase was mainly among providers accepting insurance payments and serving English-speaking patients (Breslau et al., 2022).
A mid adult female doctor, sitting in her office, uses the landline to make phone calls. Photo by SDI Productions/Getty Images

Photo by SDI Productions/Getty Images

Addressing Health Care Inequities

  • In 2020, about half of visits to a sample of health centers in California were through audio-only telehealth (Uscher-Pines, Sousa, Jones, et al., 2021). In-person visits increased substantially by August 2022, though audio-only visits constituted up to 40 percent of visits (especially for behavioral health), likely due to barriers to video telehealth (Uscher-Pines, McCullough, et al., 2023).
  • Initially, some thought that audio-only visits could be essential to overcoming access barriers (Uscher-Pines, Jones, et al., 2021). However, the continued high prevalence in 2021 of audio-only visits raised questions about whether patients were receiving enough preventive care (Uscher-Pines, Arora, et al., 2022). Future policies regarding telehealth should try to address the underlying reasons for lower access to in-person visits among some populations (Uscher-Pines and Schulson, 2021).
  • A study of about 6.5 million commercial insurance claims found that the 20-fold increase in the use of telehealth early in the pandemic occurred mostly among adults in higher-income counties (Cantor et al., 2021). Patients in lower-income zip codes were less likely to defer office visits — but also less likely to access telehealth services (Whaley et al., 2020).
  • An estimated 6 million children and adolescents live in low-income and rural counties with access to neither child psychiatric services nor sufficient broadband to support telepsychiatry (McBain et al., 2021).

Forging Ahead

Using telehealth to help patients and providers maintain access to care has rightly been a top priority during the pandemic. But some newer uses of telehealth, such as audio-only visits, have raised concerns about care quality. Telehealth access appears to be uneven, with individuals in low-income or rural areas having low access to broadband internet that enables video calls. These issues will need continued research, and studies will need to continue investigating telehealth's effects on costs, health outcomes, and health equity (Mehrotra and Uscher-Pines, 2022). Policymakers might also want to begin thinking of telehealth less as an either-or proposition (i.e., either telehealth or office visits) and more in terms of how the two modalities can be used in a hybrid format.

This research highlight summarizes RAND Health Care research reported in the following publications:

  • Breslau, Joshua, Dionne Barnes-Proby, Mallika Bhandarkar, Jonathan H. Cantor, Russell Hanson, Aaron Kofner, Rosemary Li, Nipher Malika, Alexandra Mendoza-Graf, and Harold Alan Pincus, Availability and Accessibility of Mental Health Services in New York City, Santa Monica, Calif.: RAND Corporation, RR-A1597-1, 2022 (www.rand.org/t/RRA1597-1).
  • Cantor, Jonathan H., Ryan K. McBain, Megan F. Pera, Dena M. Bravata, and Christopher M. Whaley, "Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic," American Journal of Preventive Medicine, published online March 6, 2021 (EP-68574, www.rand.org/t/EP68574).
  • Cantor, Jonathan, Neeraj Sood, Dena M. Bravata, Megan Pera, and Christopher Whaley, "The Impact of the COVID-19 Pandemic and Policy Response on Health Care Utilization: Evidence from County-Level Medical Claims and Cellphone Data," Journal of Health Economics, Vol. 82, March 2022, p. 102581 (EP-68902, www.rand.org/t/EP68902).
  • Fischer, Shira H., and Josh Breslau, "Patients Log on to See Their Own Doctors During the Pandemic," RAND Blog, January 7, 2021 (www.rand.org/blog/2021/01/patients-log-on-to-see-their-own-doctors-during-the).
  • Fischer, S. H., Z. Predmore, E. Roth, L. Uscher-Pines, M. Baird, and J. Breslau, "Use of and Willingness to Use Video Telehealth over the Course of the COVID-19 Pandemic," Health Affairs, November 2022.
  • Fischer, Shira H., Lori Uscher-Pines, Elizabeth Roth, and Joshua Breslau, "The Transition to Telehealth During the First Months of the COVID-19 Pandemic: Evidence from a National Sample of Patients," Journal of General Internal Medicine, Vol. 36, January 6, 2021, pp. 849–851 (EP-68428, www.rand.org/t/EP68428).
  • Hepner, Kimberly A., Carol P. Roth, Jessica L. Sousa, Teague Ruder, Ryan Andrew Brown, Layla Parast, and Harold Alan Pincus, Behavioral Health Care Following the Onset of the Pandemic, Santa Monica, Calif.: RAND Corporation, RR-A421-3, 2023 (www.rand.org/t/RRA421-3).
  • Hunter, Sarah B., Alex R. Dopp, Allison J. Ober, and Lori Uscher-Pines, "Clinician Perspectives on Methadone Service Delivery and the Use of Telemedicine During the COVID-19 Pandemic: A Qualitative Study," Journal of Substance Abuse Treatment, Vol. 124, May 2021, p. 108288 (EP-68626, www.rand.org/t/EP68626).
  • Kapinos, Kandice A., Virginia Kotzias, Debra L. Bogen, Kristin Ray, Jill R. Demirci, Mary Ann Rigas, and Lori Uscher-Pines, "The Use of and Experiences with Telelactation Among Rural Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled Trial," Journal of Medical Internet Research, Vol. 21, No. 9, September 2019, p. e13967 (EP-68337, www.rand.org/t/EP68337).
  • McBain, Ryan K., Jonathan H. Cantor, Aaron Kofner, Bradley D. Stein, and Hao Yu, "Ongoing Disparities in Digital and In-Person Access to Child Psychiatric Services in the United States," Journal of the American Academy of Child & Adolescent Psychiatry, December 20, 2021 (EP-68892, www.rand.org/t/EP68892).
  • Mehrotra, Ateev, and Lori Uscher-Pines, "Informing the Ongoing Debate About the Future of Telemedicine Reimbursement: What Do We Need to Know?" New England Journal of Medicine, November 12, 2022.
  • Pessar, Seema Choksy, Anne Boustead, Yimin Ge, Rosanna Smart, and Rosalie Liccardo Pacula, "Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond," JAMA Health Forum, Vol. 2, No. 11, November 19, 2021 (EP-68773, www.rand.org/t/EP68773).
  • Predmore, Zachary, Elisabeth Roth, Joshua Breslau, Shira H. Fischer, and Lori Uscher-Pines, "Assessment of Patient Preferences for Telehealth in Post-COVID-19 Pandemic Health Care," JAMA Network Open, Vol. 4, No. 12, December 1, 2021 (EP-68854, www.rand.org/t/EP68854).
  • Uscher-Pines, Lori, "Moving on from Telehealth-by-Desperation: What Will Make Telehealth Stick," RAND Blog, August 18, 2020 (www.rand.org/blog/2020/08/moving-on-from-telehealth-by-desperation-what-will).
  • Uscher-Pines, Lori, Natasha Arora, Maggie Jones, Abbie Lee, Jessica L. Sousa, Colleen M. McCullough, Sarita D. Lee, Monique Martineau, Zachary Predmore, Christopher M. Whaley, and Allison J. Ober, Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative, Santa Monica, Calif.: RAND Corporation, RR-A1840-1, 2022 (www.rand.org/t/RRA1840-1).
  • Uscher-Pines, Lori, Jonathan Cantor, Haiden A. Huskamp, Ateev Mehrotra, Alisa Busch, and Michael Barnett, "Adoption of Telemedicine Services by Substance Abuse Treatment Facilities in the U.S.," Journal of Substance Abuse Treatment, Vol. 117, October 2020, p. 108060 (EP-68228, www.rand.org/t/EP68228).
  • Uscher-Pines, Lori, Maggie Jones, Jessica L. Sousa, Zach Predmore, and Allison J. Ober, "The Doctor Will Call Me Maybe: The Uncertain Future of Audio-Only Visits and Why We Need Them to Address Disparities," RAND Blog, March 12, 2021 (www.rand.org/blog/2021/03/the-doctor-will-call-me-maybe-the-uncertain-future).
  • Uscher-Pines, Lori, Kandice A. Kapinos, Jill R. Demirci, Bonnie Ghosh-Dastidar, Kristin Ray, Virginia Kotzias, and Debra L. Bogen, "Use of Virtual Breastfeeding Support Among Underserved, Rural Mothers," Pediatrics, Vol. 144, No. 2, Meeting Abstract 275, August 2019 (EP-68335, www.rand.org/t/EP68335).
  • Uscher-Pines, Lori, Colleen M. McCullough, Jessica L. Sousa, Sarita D. Lee, Allison J. Ober, Diana Camacho, and Kandice A. Kapinos, "Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019–2022," JAMA, Vol. 329, No. 14, April 11, 2023, pp. 1219–1221 (EP-70041, www.rand.org/t/EP70041).
  • Uscher-Pines, Lori, Amanda M. Parks, Jessica Sousa, Pushpa Raja, Ateev Mehrotra, Haiden Huskamp, and Alisa B. Busch, "Appropriateness of Telemedicine Versus In-Person Care: A Qualitative Exploration of Psychiatrists' Decision Making," Psychiatric Services, January 26, 2022 (EP-68918, www.rand.org/t/EP68918).
  • Uscher-Pines, Lori, Lauren E. Riedel, Ateev Mehrotra, Sherri Rose, Alisa B. Busch, and Haiden A. Huskamp, "Many Clinicians Implement Digital Equity Strategies to Treat Opioid Use Disorder," Health Affairs, Vol. 42, No. 2, February 2023, pp. 182–186 (EP-70004, www.rand.org/t/EP70004). (EP-70004, www.rand.org/t/EP70004).
  • Uscher-Pines, Lori, and Lucy B. Schulson, "Rethinking the Impact of Audio-Only Visits on Health Equity," RAND Blog, December 17, 2021 (www.rand.org/blog/2021/12/rethinking-the-impact-of-audio-only-visits-on-health).
  • Uscher-Pines, Lori, Jessica L. Sousa, Maggie Jones, Christopher M. Whaley, Christopher Perrone, Colleen M. McCullough, and Allison J. Ober, "Telehealth Use Among Safety-Net Organizations in California During the COVID-19 Pandemic," Research Letter, JAMA, Vol. 325, No. 11, February 2, 2021, pp. 1106–1107 (EP-68493, www.rand.org/t/EP68493).
  • Uscher-Pines, Lori, Jessica L. Sousa, Pushpa Raja, Ateev Mehrotra, Michael L. Barnett, and Haiden A. Huskamp, "Treatment of Opioid Use Disorder During COVID-19: Experiences of Clinicians Transitioning to Telemedicine," Journal of Substance Abuse Treatment, Vol. 118, November 2020, p. 108124 (EP-68422, www.rand.org/t/EP68422).
  • Whaley, Christopher M., Yuki Ito, Jonathan T. Kolstad, David W. Cowling, and Benjamin Handel, "The Health Plan Environment in California Contributed to Differential Use of Telehealth During the COVID-19 Pandemic," Health Affairs, Vol. 41, No. 12, December 2022, pp. 1812–1820 (EP-70055, www.rand.org/t/EP70055).
  • Whaley, Christopher M., Megan F. Pera, Jonathan Cantor, Jennie Chang, Julia Velasco, Heather K. Hagg, Neeraj Sood, and Dena M. Bravata, "Changes in Health Services Use Among Commercially Insured U.S. Populations During the COVID-19 Pandemic," JAMA Network Open, Vol. 3, No. 11, November 5, 2020, p. e2024984 www.rand.org/t/EP68469).

References

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