Telemedicine’s place in the healthcare system continues to be under the microscope.
A recent study in JAMA Health Forum looks at how patients used the technology to access providers across state lines during the COVID-19 pandemic.
“There are ongoing debates about whether to permanently change licensure regulations to facilitate out-of-state telemedicine visits,” concluded the study published last Friday in JAMA Health Forum.
Those debates and lobbying efforts tied to them occur on both the federal and state levels, examples of which include:
- States passing legislation making permanent changes to licensure requirements.
- Patient groups lobbying state legislatures for more access to telemedicine.
- Actions taken by government and medical organizations and associations. The Federation of State Medical Boards creating exceptions for when a license isn’t needed. The Uniform Law Commission drafting legislation about expanding the use of telemedicine that states could adopt. And the American Medical Association investigating telemedicine use.
- The Biden administration’s calling on Congress to act on this issue.
The study found that data on this issue so far have been limited, and they pulled their information from “a period where licensure regulations were temporarily waived, out-of-state telemedicine visits were common and used most by patients who live near state borders or in rural communities, those receiving primary care services and mental health treatment, and those receiving cancer care.”
Researchers with Harvard Medical School and other institutions focused on the use of telemedicine visits for fee-for-service Medicare recipients between January to June 2021. “We chose this period because it was after the turmoil of the early pandemic when vaccines became widely available and the health care system had stabilized, but before many of the temporary licensing regulations began to lapse by mid-2021,” the study said.
Ateev Mehrotra, M.D., a professor of health care policy and medicine at Harvard Medical School, and the study’s corresponding author, told Fierce Healthcare that while the current telemedicine data aren’t limited to the Medicare population, the “Medicare program is particularly important because this is a population that gets a lot of care. Also, Congress has jurisdiction over the Medicare program.”
There were 8,392,092 telemedicine visits during this time of which 422,547 (5%) involved patients consulting with providers in another state. The study says that 33.1% of the visits involved patients who lived within 15 miles of a state border, accounting for 57.2% of all out-of-state telemedicine visits. Most of the telemedicine visits (64.3%) were with a primary care physician or a mental health provider, and in 62.6% of the out-of-state visits, the patient and clinician had had an in-person visit between March 2019 and the telemedicine visit.
This utilization pattern surprised Mehrotra because “I had assumed that out-of-state telemedicine was largely focused on more specialized care.”
Counties with a higher number of physicians per capita saw fewer out-of-state telemedicine visits, compared with counties with a lower number of physicians. The three highest telemedicine visits were in Washington, D.C. (38.5%), Wyoming (25.6%), and North Dakota (21.1%). Meanwhile, states that saw the fewest number of telemedicine visits were California (1%), Texas (2%), and Massachusetts (2.1%), all with high numbers of physicians per capita.
“The initial spike and then gradual decline in out-of-state telemedicine visits we observed in the pandemic largely follow the trends observed in the pandemic across all telemedicine visits in Medicare commercial health plans, and other data sources,” the researchers said. “In these analyses, we find that a large fraction of out-of-state telemedicine visits were for mental illness. Prior work has found that, in general, telemedicine use has been higher for the treatment of mental illness and that mental health specialists have embraced telemedicine at higher rates than other clinical specialties.”
Reinstating pre-pandemic restrictions on telemedicine would hurt patients living near a border, who the study said are subject to “an accident of geography.” The researchers note that “a patient with a primary care physician who lives in the middle of a state can access care via telemedicine. However, a similar patient living near a state border with a primary care physician in the neighboring state now will have to physically travel to that appointment.”
The authors suggest that lawmakers should perhaps allow telemedicine visits for states within a region, although there may be some question about what actually constitutes a region. For instance, the U.S. Census Bureau says that there are four regions: the Northeast, the Midwest, the South, and the West. The Bureau of Economic analysis splits the nation into eight different regions.
“To the degree that the patterns of out-of-state telemedicine we observed in 2021 are a prologue to the future, they imply that regional compacts would have a similar effect as more sweeping reforms such as a national license,” the study states. “They also might be politically more feasible.”
But telemedicine might be able to reach beyond a region. Researchers accounted for the “snowbird” effect; beneficiaries with two residences who spent the winter months in states with warmer climates such as Florida or Arizona.
“We looked at visits early in the pandemic,” said Mehrotra. “During that period, most of the out-of-state telemedicine was with providers in bordering states. However, in the future, if out-of-state telemedicine became easier to provide, then one could see a circumstance where more people start ‘seeing’ a provider far, far away. But that is just conjecture. I don’t know.”