Visit Volumes Decline When Out-of-State Telehealth Waivers Expire

Following the expiration of waivers enabling out-of-state telehealth visits, patients tended to stop seeing the physician rather than switch to in-person care, according to a study published in JAMA Network Open.

Amid the COVID-19 pandemic that restricted in-person care, nearly all states implemented licensure waivers, lifting some requirements for out-of-state care. Several states also entered into licensure compacts allowing healthcare providers to practice in states they were not licensed in, provided they held a license in good standing in their home state. These waivers and compacts supported interstate telehealth care as well.

However, many licensure waivers have since expired. Thus, researchers aimed to assess out-of-state telehealth use in states where licensure waivers expired compared to states where waivers remained in place.

The researchers used Elevance Health claims data from January 2019 to June 2022. They gathered data on patients in Colorado, Maine, and Wisconsin, where licensure waivers expired in mid-2021, and those in California, Georgia, Indiana, New Hampshire, and New York, where waivers continued through June 2022.

They defined out-of-state telehealth relationships as “unique patient-clinician pairings,” with at least two visits from March 2020 to April 2021, when all states had active waivers. Called the ‘pre-period,’ one of the two visits during this time frame was conducted via telehealth. The pre-period included 45,087 unique patients and 55,845 out-of-state telehealth relationships.

During the ‘post-period’ from July 2021 to June 2022, when some waivers had expired, researchers collected data on visit volumes and whether the visits were in-person or via telehealth.

More patients were from rural areas, and patient-clinician distances were greater than 804.7 km for more patients in states with expired waivers versus those with continued ones.

The study shows that in states with expired waivers, patients with out-of-state telehealth relationships were less likely to participate in any post-period visits. Patients with out-of-state relationships were less likely to have telehealth or in-person visits after waiver expiration. This finding was most prominent when the patient and clinician were over 321.9 km apart.

“The results support the need to reform state licensure,” researchers wrote. “Among the small number of telemedicine relationships in which out-of-state physicians held a license in states where patients resided, there was no decrease in continuity.”

The study adds to research on how licensure waivers impacted telehealth use.

A study published in June 2022 showed that the patient and healthcare provider were in neighboring states in 64 percent of interstate telehealth visits.

Conducted by researchers from the University of Michigan's Institute for Healthcare Policy and Innovation, the study analyzed trends in interstate telehealth use by Medicare beneficiaries from 2017 to 2020.

Out-of-state telehealth comprised 0.8 percent of all outpatient visits and 5 percent of all telehealth visits. In some states, less than 1 percent of telehealth visits in 2020 were out-of-state. But in others, like Vermont, New Hampshire, and Washington, D.C., 4 percent to 9 percent of evaluation and management visits occurred through telehealth.

Another study published in 2022 revealed that 422,547 Medicare beneficiaries (5 percent) participating in a telehealth visit between January and June 2021 had one or more out-of-state telehealth visits.

Overall, 8.3 million Medicare beneficiaries participated in a telehealth visit between January and June 2021. Of the out-of-state telehealth visits, 64.3 percent included a primary care or mental health clinician, and an in-person visit preceded 62.6 percent.

Further, rural residents were more likely to receive telehealth from an out-of-state location, with 33.8 percent of out-of-state visits involving a rural resident versus 21 percent of within-state telehealth visits.