Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits.

BACKGROUND: Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care. METHODS: A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends. RESULTS: Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%). CONCLUSIONS: Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

Disparities in the Use of In-Person and Telehealth Primary Care Among High- and Low-Risk Medicare Beneficiaries During COVID-19.

We conducted a retrospective cohort study using a difference-in-differences design to estimate differences in primary care outpatient clinic visit utilization among high- and low-risk Medicare aging beneficiaries from an Accountable Care Organization during the COVID-19 pandemic compared to a control cohort from the previous year. High-risk was defined as having a Hierarchical Condition Category score of 2 or higher. A total of 582 101 patient-month records were analyzed. After adjusting for patient characteristics, those in the high-risk group had 339 (95% CI [333, 345]) monthly outpatient encounters (in-person and telehealth) per 1000 patients compared to 186 (95% CI [182, 190]) in the low-risk group. This represented a 22.8% and 26.5% decline from the previous year in each group, respectively. Within each group, there was lower utilization among those who were older, male, or dually eligible for Medicaid in the high-risk group and among those who were younger, male, or non-white in the low-risk group. Telehealth use was less common among patients who were older, dually eligible for Medicaid or living in rural/suburban areas compared to urban areas. All results were significant at the 95% level. We found significant disparities based on age, gender, insurance status, and non-white race in primary care utilization during the pandemic among Medicare beneficiaries. With the exception of gender, these disparities differed between high- and low-risk groups. Interventions targeting these vulnerable groups may improve health equity in the setting of public health emergencies.

AcademyHealth Annual Research Meeting (ARM): A Selection of Abstracts Accepted for Oral Presentation, 2021.

RESEARCH OBJECTIVE: To investigate the extent to which telehealth visits mitigated COVID-19 pandemic-related impacts on in-person outpatient visits among Medicare beneficiaries, including those who are high-cost high-need. High-cost high-need patients were defined as those 65 years or older and with 2 or higher Hierarchical Condition Categories (HCC) scores. STUDY DESIGN: A difference-in-difference design was used to estimate the change in outpatient in-person and telehealth utilization for the COVID-19 pandemic cohort compared to the control cohort in the prior year. POPULATION STUDIED: Medicare patients from an Accountable Care Organization (ACO) were used as the study sample. The pandemic cohort was defined as those enrolled in the ACO in 2019-2020 (N = 21,361). The control cohort was defined as those enrolled in the ACO in 2018-2019 (N = 20,028). The study period was defined as April-September 2020 for the pandemic cohort and the same months in 2019 for the control cohort, with the preceding 12 months used as the baseline periods, respectively. Over 740,000 patient-month records were analyzed using logistic and negative binomial regressions. The models were adjusted for patient-level characteristics, including HCC scores, which reflect the complexity of patient health conditions and risk for future healthcare costs. PRINCIPAL FINDINGS: The total number of outpatient encounters (in-person and telehealth) in both primary and specialty care decreased by 41.5% in April 2020 compared to the pre-pandemic period. Telehealth comprised 78% of all outpatient encounters in April 2020 but declined to 22% by the end of September 2020. Only about 40% of all patients had at least one telehealth encounter between April-September 2020. Compared to the control cohort, the pandemic cohort experienced a monthly average of 113 fewer primary care encounters per 1000 patients (OR: 0.75, 95% CI: [0.73, 0.77]) and 49 fewer specialty care encounters (OR: 0.82, 95% CI: [0.80, 0.85]) over the six-month study period. This represented a decline of 25.6% and 17.3% in primary care and specialty encounters, respectively, among high-cost high-need patients. High-cost high-need patients or those with disabilities were more likely to use telehealth and experienced a lesser reduction in outpatient care utilization than other Medicare beneficiaries (OR: 1.20 and 1.06). Medicare beneficiaries with dual Medicaid coverage, those of non-white race/ethnic groups, and those living in rural/suburban areas were less likely to use telehealth and experienced a greater reduction in total outpatient care (OR: 0.86, 0.96 and 0.90). CONCLUSIONS: While there was a substantial significant increase in telehealth use in April 2020, utilization declined significantly during the six-month study period, and did not fully mitigate the decline in in-person outpatient visits resulting from the COVID-19 pandemic. While high-cost high-need Medicare patients and those with disabilities were more likely to use telehealth, disparities in telehealth usage and reductions in outpatient care remain among low-income, non-white, and rural Medicare beneficiaries. IMPLICATIONS FOR POLICY OR PRACTICE: Older patients insured by Medicare, including those with high-cost high-need or disabilities were able to make use of telehealth services for outpatient visits during the COVID-19 pandemic. Health policies and interventions should target improving telehealth access and delivery for advancing sustainability and equity among Medicare beneficiaries. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.