High Telehealth Use Linked to More Visits for Serious Mental Illness

Receiving care from medical practices with higher telehealth use is associated with an increase in mental health visits among Medicare patients with serious mental illness, according to a new study.

Published in JAMA Health Forum, the study assesses changes in mental health service use patterns and care quality during the first year of the COVID-19 pandemic among Medicare beneficiaries with serious mental illness.

The multi-cohort study included Medicare fee-for-service (FFS) beneficiaries with schizophrenia or bipolar I disorder receiving care at specialty mental health practices. Patients were divided into a pandemic and a pre-pandemic cohort. For the pandemic cohort, the researchers assessed changes in outcomes from March 2019-February 2020 (year one) to March 2020-February 2021(year two). For the pre-pandemic cohort, they examined changes in outcomes from March 2018-February 2019 (year one) to March 2019-February 2020 (year two).

The patients were also linked to the mental health practice where they received most of their care. The 11,170 practices included in the study were categorized into three groups based on the proportion of telemental health visits provided from March 2020 to February 2021: 3,180 in the lowest use category (0 percent to 49 percent), 3,793 in the middle use category (50 percent to 89 percent), and 4,197 in the highest use category (90 percent to 100 percent).

The study included 247,707 Medicare beneficiaries with serious mental illness, of which 120,050 patients were in the pandemic cohort and 127,657 patients in the pre-pandemic cohort.

Compared to the number of mental health visits observed among practices with the lowest telehealth use, patients who received care at middle telehealth use practices had 1.11 more mental health visits per year, and patients who received care at the highest telehealth use practices had 1.94 more visits per year. These increases represent a 7.5 percent and a 13 percent jump in mental health visits per year for the patients at the middle and highest telehealth use practices compared to patients receiving care at practices with the lowest telehealth use.

In addition, patients receiving care at the highest telehealth use practices more often had at least one mental health visit every six months compared with patients at the lowest telehealth use practices.

However, acute care encounters for mental illness, such as hospitalizations and emergency department (ED) visits, were differentially higher among patients of the middle and highest telehealth use practices compared to their counterparts at low telehealth use practices.

“This finding could be interpreted as a sign that greater telemedicine use was associated with a lower quality of care,” the researchers stated. “An alternative explanation may be that the underlying assumption that, at a population level, more ED visits and hospitalizations are a sign of poor quality of care is incorrect. In some circumstances, increased hospital use might be a sign of better care in that patients in acute crisis were correctly identified and stabilized.”

The researchers did not find differential changes across other outcomes, including months with medication fills, outpatient follow-up after mental health hospitalization, or all-cause mortality.

Thus, they concluded that “during a period when practices rapidly adopted telemedicine, patients in practices with a high use of telemedicine had more visits with their clinicians and did not appear to experience some of the adverse outcomes that might be expected if telemedicine visits were a poor substitute for in-person care.”

The results align with a study published in 2022 showing that increased telehealth use in rural communities boosted access to healthcare services for Medicare beneficiaries with severe mental illness.

The study included data from Medicare beneficiaries in 2,916 rural counties between Jan. 1, 2010, and Dec. 31, 2018. The beneficiaries had received a prior diagnosis of schizophrenia or bipolar I disorder.

Researchers found that patients residing in counties with high telemental health service use were 1.2 percentage points more likely to participate in a minimum number of specialty mental health service visits and had a 13.7 percentage point higher likelihood of outpatient follow-up within seven days of hospitalization, compared to those in counties with no telemental healthcare.