Key Findings from RAND Health Care Research on Telehealth Policy

by Lori Uscher-Pines, Shira H. Fischer

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Research Brief
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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 March 2020 over the previous year, by some measures (FAIR Health, 2020). Pre-pandemic policies regarding the specifics of 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 (Centers for Medicare & Medicaid Services, 2021; Public Law 116-136, 2020). More recently, telehealth use has leveled off as in-person care has begun to resume. Policymakers and payers must decide which policy waivers should remain in place.

Telehealth use increased by more than 4,000 percent in March 2020 over the previous year.

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RAND Health Care researchers have been using public and private data, such as data from health care claims, to understand telehealth's effect on health care delivery and how it affects care quality, access, equity, and costs. Researchers have also been working with an array of partners, including the National Institutes of Health, private payers, and telehealth services and app companies that work directly with patients to conduct studies to assess the impacts and effectiveness of particular services. Researchers have conducted randomized controlled trials and interviews and surveys of the general public, telehealth patients, and health care providers. This document synthesizes key findings from recent RAND research on telehealth.

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 this increase was due to patients seeing their own doctors through telehealth (Fischer et al., 2021). Being able to have virtual visits with their usual providers could affect patients' willingness to participate in telehealth (Fischer and Breslau, 2021).
  • Through rapid-response interviews conducted early in the pandemic, providers revealed that they pivoted to telehealth out of necessity, not only to protect themselves and their patients from spreading the virus, but also to quickly offset losses from reduced in-person visit volume. Post-pandemic policies, particularly on reimbursement, will play a large role in whether these providers will continue to offer telehealth services after the public health emergency ends (Uscher-Pines, 2020). In a different set of interviews regarding the sudden incorporation of telehealth into their practices, most psychiatrists were positive about the transition overall, although some had concerns about the amount of clinical data available, patient privacy, and home distractions (Uscher-Pines, Sousa, Raja, et al., 2020a).
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Enabling Treatment for Substance Use Disorders

  • In a qualitative study of providers who treat patients with opioid use disorder (OUD), RAND researchers found that many providers had made dramatic changes to care patterns in response to the COVID-19 pandemic, including using telemedicine with the majority of their patients, waiving urine toxicology screening, sending patients home with a larger supply of OUD medications, and requiring fewer visits (Hunter et al., 2021).
  • Most providers associated remote treatment with improved access and better patient interactions, although some reported challenges with having enough clinical data for decisionmaking and technological challenges (Uscher-Pines, Sousa, Raja, et al., 2020b). Another study examined substance use treatment facility offerings at the county level, along with changes in the amount that people traveled outside their homes before and after the start of the pandemic. Researchers found that facilities in counties with high social distancing (i.e., those counties where residents decreased travel the most) were least likely to offer telehealth services at the start of the pandemic (Cantor, Stein, and Saloner, 2020).
  • Before the pandemic, some companies began to offer virtual OUD treatment that allowed patients greater convenience and discretion than typical in-person care. Though this model might be especially beneficial to some, such as young parents or people with mobility challenges, it could be less appropriate for high-risk patients with unstable housing or those with additional mental health needs (Uscher-Pines, Huskamp, and Mehrotra, 2020).
  • Telehealth offerings for substance use disorder (SUD) services vary substantially across the United States. A nationwide survey of facility offerings between 2016 and 2019 found that less than 18 percent of SUD treatment facilities offered telehealth-based treatment, and adoption varied by state policy laws, among other local factors (Uscher-Pines, Cantor, et al., 2020).

Lowering Barriers to Care

  • Service members who live 40 miles or more from Military Health System facilities could have problems accessing high-quality care. Researchers identified strategies to pursue in closing their access gap—including telehealth options for psychotherapy—to improve remote service members' access to care and reduce their risk for worse outcomes for conditions such as posttraumatic stress disorder, depression, and substance use disorder (Hepner et al., 2021).
  • Infants need to be fed around the clock, and telehealth can help innovate service delivery by offering some services, such as telelactation, on a 24-hour basis, from any location. Almost 45 percent of mothers in rural Pennsylvania in a randomized controlled trial of remote lactation services used the app-based video services to help answer their breastfeeding questions and concerns (Uscher-Pines, Kapinos, et al., 2019). Analyses of survey data and call transcripts found that video call 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). Though the two arms of the trial did not show statistical differences in breastfeeding duration or exclusivity because of the small sample size, use of telehealth to deliver lactation services seems to be a promising prospect for expanding access to professional breastfeeding support. Researchers are currently conducting a large clinical trial that will provide definitive evidence on the impact of these services on breastfeeding rates (Uscher-Pines, Ghosh-Dastidar, et al., 2020).
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Addressing Health Care Inequities

  • Telephone-based visits were rarely conducted—or reimbursed—before the pandemic, but a study of visits to more than 40 federally qualified health centers serving 2 million patients in California found that audio-only calls made up about half of all visits in April 2020 (Uscher-Pines, Sousa, Jones, et al., 2021). This high proportion of audio-only visits might reflect barriers to video call access experienced by low-income patients. Thus, audio-only visits could be essential to preserve access to care for underserved populations, both during and after the pandemic (Uscher-Pines, Jones, et al., 2021).
  • Even with increased access through audio-only calls, telehealth might not be reaching as many children or low-income adults as it could. 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).
  • Though it is clear that telehealth alone cannot erase health care system inequities, there is still room to use telehealth to reach underserved populations. For instance, during the pandemic, people experiencing homelessness have been able to take advantage of telehealth, particularly through audio-only visits. Providers should not assume which patients in their panel will be digitally connected; they can help maintain patient engagement by checking for access to broadband internet, text, and phone services and adapting to patients' needs (Salhi, Abir, and Salhi, 2021).

Forging Ahead

During the pandemic, using telehealth to help patients and providers maintain access has rightly been a top priority. Concerns about telehealth's effect on health care spending and quality will arise again as policymakers begin to look beyond the pandemic. It is unclear how relevant pre-pandemic studies on cost and quality will be, given how much telehealth delivery models have shifted since March 2020. New studies will especially need to consider the forms of telehealth, such as audio-only visits and video using less-secure platforms, that have caught on in the past year. 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 work together in a hybrid format.

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

  • 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, Bradley D. Stein, and Brendan Saloner, "Telehealth Capability Among Substance Use Disorder Treatment Facilities in Counties with High Versus Low COVID-19 Social Distancing," Journal of Addiction Medicine, Vol. 14, No. 6, November/December, 2020, pp. e366–e368 (EP-68326, www.rand.org/t/EP68326).
  • Fischer, Shira H., and Josh Breslau, "Patients Log On to See Their Own Doctors During the Pandemic," RAND Blog Commentary, January 7, 2021 (www.rand.org/blog/2021/01/patients-log-on-to-see-their-own-doctors-during-the.html).
  • 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., Ryan Andrew Brown, Carol P. Roth, Teague Ruder, and Harold Alan Pincus, "Improving Behavioral Health Care for Remote Service Members: Three Key Priorities," Santa Monica, Calif.: RAND Corporation, RB-10093-OSD, 2021 (www.rand.org/t/RB10093).
  • 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).
  • Salhi, Rama A., Mahshid Abir, and Bisan A. Salhi, "No Patient Left Behind: Considering Equitable Distribution of Telehealth," RAND Blog Commentary, April 20, 2021 (www.rand.org/blog/2021/04/no-patient-left-behind-considering-equitable-distribution.html).
  • Uscher-Pines, Lori, "Moving on from Telehealth-by-Desperation: What Will Make Telehealth Stick," RAND Blog Commentary, August 18, 2020 (www.rand.org/blog/2020/08/moving-on-from-telehealth-by-desperation-what-will.html).
  • 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, Bonnie Ghosh-Dastidar, Debra L. Bogen, Kristin N. Ray, Jill R. Demirci, Ateev Mehrotra, and Kandice A. Kapinos, "Feasibility and Effectiveness of Telelactation Among Rural Breastfeeding Women," Academic Pediatrics, Vol. 20, No. 5, July 2020, pp. 652–659 (EP-68333, www.rand.org/t/EP68333).
  • Uscher-Pines, Lori, Haiden A. Huskamp, and Ateev Mehrotra, "Treating Patients with Opioid Use Disorder in Their Homes: An Emerging Treatment Model," JAMA Network Viewpoint, JAMA, Vol. 324, No. 1, May 27, 2020, pp. 39–40 (EP-68182, www.rand.org/t/EP68182).
  • 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 Commentary, March 12, 2021 (www.rand.org/blog/2021/03/the-doctor-will-call-me-maybe-the-uncertain-future.html).
  • 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, 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, "Suddenly Becoming a 'Virtual Doctor': Experiences of Psychiatrists Transitioning to Telemedicine During the COVID-19 Pandemic," Psychiatric Services, Vol. 71, No. 11, November 1, 2020a, pp. 1143–1150 (EP-68177, www.rand.org/t/EP68177).
  • 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 2020b, p. 108124 (EP-68422, www.rand.org/t/EP68422).
  • 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 (EP-68469, www.rand.org/t/EP68469).

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