Older, Rural Medicare Beneficiaries Used Telehealth Less During Pandemic

Medicare beneficiaries in accountable care organizations (ACOs) were less likely to use telehealth during the COVID-19 pandemic if they were older or lived in rural areas, a study published in the Journal of Patient Experience revealed.

Prior to the public health emergency, the Centers for Medicare and Medicaid Services (CMS) did not reimburse for telehealth services for traditional fee-for-service Medicare beneficiaries. Unsurprisingly, when the agency amended this policy during the pandemic, telehealth visits increased significantly.

To understand the trends in telehealth and in-person outpatient primary care utilization among Medicare beneficiaries during the pandemic, researchers analyzed claims from an ACO in southern Wisconsin.

They looked at claims from beneficiaries who were in the ACO between April 1, 2020, and September 30, 2020, and compared them to claims from April 1, 2019, to September 30, 2019.

The study pool consisted of 32,417 Medicare beneficiaries. Just over 14,000 beneficiaries were considered high-risk because they had a hierarchical condition category (HCC) score of two or higher — 8,758 were in the pre-pandemic group and 9,554 were from the pandemic cohort. Around 18,000 of the beneficiaries were considered low-risk, with 6,903 in the control group and 7,202 in the pandemic group.

Primary care visits in general, including both in-person and virtual, decreased by nearly 22 percent during the pandemic. Telehealth accounted for 78 percent of all primary care visits from Medicare beneficiaries during April 2020 but dropped to 22 percent by September.

During the pandemic, 38 percent of all primary care visits for low-risk beneficiaries were conducted via telehealth, compared to 65 percent of all visits for the high-risk group. Over six months, there were an average of 574 telehealth encounters per 1,000 beneficiaries for the low-risk group and 1,340 encounters per 1,000 beneficiaries for the high-risk group, the researchers found.

Beneficiaries in the high-risk group were older and more likely to be dually eligible for Medicare and Medicaid. The group had more beneficiaries with three or more chronic conditions compared to the low-risk group, and high-risk beneficiaries also had higher enrollment in the ACO care management or integrated care programs.

Telehealth user characteristics varied by risk group, but within both the high- and low-risk groups, beneficiaries who used telehealth were more likely to live in urban rather than rural areas.

In the high-risk group, which was more likely to use virtual care services, telehealth users were younger and less likely to be dual eligible beneficiaries compared to those who did not use telehealth. However, in the low-risk group, where telehealth use was less common, telehealth users were older and were more likely to be dually eligible for Medicaid coverage.

Telehealth users in both groups had higher HCC scores and were more likely to have three or more chronic conditions. Overall, beneficiaries who were 86 years or older in both groups were less likely to have used telehealth during the pandemic.

Additionally, the high-risk group experienced a smaller decline in overall primary care utilization, including in-person and telehealth visits, compared to the low-risk group. According to the researchers, this may have been because high-risk beneficiaries had greater needs and limiting their healthcare use was not possible. These beneficiaries were also more likely to be in an ACO care management program, which could have helped them navigate their care options better.

Overall, the study results revealed that sociodemographic factors continue to widen care disparities when it comes to accessing telehealth. Older patients may have low digital literacy levels, making it harder for them to use virtual care services. Additionally, patients in rural areas may have limited access to stable internet connection.

“Our findings suggest that additional interventions, such as care coordination programs, as well as institutional regulations and payment models, could contribute to more equitable expansion of telehealth by engaging older and low-income Medicare beneficiaries to avoid increasing disparities in healthcare access,” the researchers concluded.