Disparities in the Use of in‐Person and Telehealth Outpatient Visits Among Medicare Beneficiaries in an Accountable Care Organization during COVID‐19
Authors: Cao Ying/ Jessica , Chen Dandi , Liu Yao , Smith Maureen 
Published: September 2021

Research Objective

To investigate the extent to which telehealth visits mitigated COVID‐19 pandemic‐related impacts on in‐person outpatient visits among Medicare beneficiaries, including those who are high‐cost high‐need. High‐cost high‐need patients were defined as those 65 years or older and with 2 or higher Hierarchical Condition Categories (HCC) scores.

Study Design

A difference‐in‐difference design was used to estimate the change in outpatient in‐person and telehealth utilization for the COVID‐19 pandemic cohort compared to the control cohort in the prior year.

Population Studied

Medicare patients from an Accountable Care Organization (ACO) were used as the study sample. The pandemic cohort was defined as those enrolled in the ACO in 2019–2020 (N = 21,361). The control cohort was defined as those enrolled in the ACO in 2018–2019 (N = 20,028). The study period was defined as April–September 2020 for the pandemic cohort and the same months in 2019 for the control cohort, with the preceding 12 months used as the baseline periods, respectively. Over 740,000 patient‐month records were analyzed using logistic and negative binomial regressions. The models were adjusted for patient‐level characteristics, including HCC scores, which reflect the complexity of patient health conditions and risk for future healthcare costs.

Principal Findings

The total number of outpatient encounters (in‐person and telehealth) in both primary and specialty care decreased by 41.5% in April 2020 compared to the pre‐pandemic period. Telehealth comprised 78% of all outpatient encounters in April 2020 but declined to 22% by the end of September 2020. Only about 40% of all patients had at least one telehealth encounter between April–September 2020. Compared to the control cohort, the pandemic cohort experienced a monthly average of 113 fewer primary care encounters per 1000 patients (OR: 0.75, 95% CI: [0.73, 0.77]) and 49 fewer specialty care encounters (OR: 0.82, 95% CI: [0.80, 0.85]) over the six‐month study period. This represented a decline of 25.6% and 17.3% in primary care and specialty encounters, respectively, among high‐cost high‐need patients. High‐cost high‐need patients or those with disabilities were more likely to use telehealth and experienced a lesser reduction in outpatient care utilization than other Medicare beneficiaries (OR: 1.20 and 1.06). Medicare beneficiaries with dual Medicaid coverage, those of non‐white race/ethnic groups, and those living in rural/suburban areas were less likely to use telehealth and experienced a greater reduction in total outpatient care (OR: 0.86, 0.96 and 0.90).

Conclusions

While there was a substantial significant increase in telehealth use in April 2020, utilization declined significantly during the six‐month study period, and did not fully mitigate the decline in in‐person outpatient visits resulting from the COVID‐19 pandemic. While high‐cost high‐need Medicare patients and those with disabilities were more likely to use telehealth, disparities in telehealth usage and reductions in outpatient care remain among low‐income, non‐white, and rural Medicare beneficiaries.

Implications for Policy or Practice

Older patients insured by Medicare, including those with high‐cost high‐need or disabilities were able to make use of telehealth services for outpatient visits during the COVID‐19 pandemic. Health policies and interventions should target improving telehealth access and delivery for advancing sustainability and equity among Medicare beneficiaries.

Primary Funding Source

Patient‐Centered Outcomes Research Institute.