Telehealth Expansion and Medicare Beneficiaries’ Care Quality and Access

Importance Understanding the association of telehealth use with health care outcomes is fundamental to determining whether telehealth waivers implemented during the COVID-19 public health emergency should be made permanent. The current literature has yielded inconclusive findings owing to its focus on select states, practices, or health care systems. Objective To estimate the association of telehealth use with outcomes for all Medicare fee-for-service (FFS) beneficiaries by comparing hospital service areas (HSAs) with different levels of telehealth use. Design, Setting, and Participants This US population-based, retrospective cohort study was conducted from July 2022 to April 2023. Participants included Medicare claims of beneficiaries attributed to HSAs with FFS enrollment in Parts A and B. Exposures Low, medium, or high tercile of telehealth use created by ranking HSAs according to the number of telehealth visits per 1000 beneficiaries. Main Outcomes and Measures The primary outcomes were quality (ambulatory care–sensitive ACS hospitalizations and emergency department ED visits per 1000 FFS beneficiaries), access to care (clinician encounters per FFS beneficiary), and cost (total cost of care for Part A and/or B services per FFS Medicare beneficiary) determined with a difference-in-difference analysis. Results In this cohort study of claims from approximately 30 million Medicare beneficiaries (mean SD age in 2019, 71. 04 1. 67 years; mean SD percentage female in 2019, 53. 83% 2. 14%) within 3436 HSAs, between the second half of 2019 and the second half of 2021, mean ACS hospitalizations and ED visits declined sharply, mean clinician encounters per beneficiary declined slightly, and mean total cost of care per beneficiary per semester increased slightly. Compared with the low group, the high group had more ACS hospitalizations (1. 63 additional hospitalizations per 1000 beneficiaries; 95% CI, 1. 03-2. 22 hospitalizations), more clinician encounters (0. 30 additional encounters per beneficiary per semester; 95% CI, 0. 23-0. 38 encounters), and higher total cost of care (164. 99 higher cost per beneficiary per semester; 95% CI, 101. 03-228. 96). There was no statistically significant difference in ACS ED visits between the low and high groups. Conclusions and Relevance In this cohort study of Medicare beneficiaries across all 3436 HSAs, high levels of telehealth use were associated with more clinician encounters, more ACS hospitalizations, and higher total health care costs. COVID-19 cases were still high during the period of study, which suggests that these findings partially reflect a higher capacity for providing health services in HSAs with higher telehealth intensity than other HSAs.