In a study published in JAMA Network Open on Tuesday, Included Health and Harvard Medical School found that patients in high deductible health plans are less likely to seek virtual behavioral healthcare when costs are re-introduced.
Included Health services telehealth care to approximately 50 million Americans. Together with Harvard Medical School, Included Health studied telemental healthcare utilization of 15,000 patients in high deductible health plans (HDHPs) when the services were completely covered versus requiring out-of-pocket costs.
During the COVID-19 public health emergency, Congress allowed health plans to waive cost-sharing for telehealth services for patients in HDHPs before they met their deductible without jeopardizing health savings account (HSA) eligibility. Though the cost-sharing waiver has been allowed since 2020, some health plans that use Included Health's telehealth services chose to reinstate cost-sharing for telehealth in 2021.
The study shows the possible impact of Congress letting the pandemic-era waiver lapse at the end of the year.
“When patients were required to pay out-of-pocket for telehealth, we observe they had substantially fewer telemental health visits and a larger fraction stopped seeing their mental health specialists,” the study says.
First-dollar telehealth coverage for high-deductible health plans is not currently included in either of the two Medicare telehealth extension bills moving through Congress.
The study included patients from all 50 states and D.C. and compared telemental healthcare utilization during two, six-month periods. From January 2021 to June 2021, both groups received telehealth without cost-sharing. From July 2021 to December 2021, one group had cost-sharing for telehealth re-introduced (intervention group) while the other remained cost-free (control group).
Included Health and Harvard found that patients in the intervention group, for which costs were reintroduced, paid an average of $29.50 per telemental health visit. The charge per visit was enough to cause patients to attend 1.5 fewer telemental health visits per month and for 11.7% of patients to stop visits altogether.
Ami Parekh, chief health officer at Included Health, speculated if the HDHP telehealth cost-sharing waiver lapses, fewer patients in high-deductible health plans will use virtual behavioral health services, leading to worse outcomes.
“What the study shows is that financial friction is real friction,” Parekh said. “And when you introduce that to patients, they will not access services that absolutely could improve their overall health outcomes.”
The majority of members in the study were 30-year-old white females. Patients represented in the study ranged in severity of depression according to results of the PHQ9 questionnaire. The intervention group contained more patients with mild depression, while, in the control group, almost half of patients had moderate to severe depression.
Patients who were in the group where cost-sharing was reintroduced were more likely to be located in urban areas (95%) compared to the control group (79%).
Though this study did not analyze the impact of cost-sharing on minority populations, Parekh said internal data from Included Health shows that “people who live in zip codes where there are less white populations are more likely to use virtual care as an access point."
“The more marginalized your population is, the more having virtual access is critical for you to be able to access services,” she explained.
While the telehealth industry has faced closures of some prominent businesses this year, Parekh said telehealth is still in its infancy.
“We haven't actually figured out how to best use [telehealth] and pay for it and incentivize it,” Parekh said. “So part of what's happening right now is business models are figuring themselves out. And also I do think what we call telehealth 1.0 is insufficient to really transform healthcare.”
She said Included Health is looking towards “telehealth 2.0” which will be more longitudinally integrated into healthcare and less transactional.