Telehealth facilitates medical care, allows for the sharing of health information, and offers patient health education through remote communication. In 2020, the onset of the public health emergency prompted many localities to restrict in-person gatherings to prevent transmission of the virus. Health care providers responded by expanding telehealth services in an effort to continue serving their patients. At the same time, federal and state governments, as well as commercial insurers, introduced policy and coverage changes to make telehealth more accessible.
To understand changes in telehealth utilization over the first year of the pandemic, we explored trends in monthly telehealth utilization for two types of telehealth services: primary care and behavioral health. These services are important to patients who need to manage ongoing physical, social, and mental health needs, many of which were exacerbated by the pandemic. We used HCCI's employer-sponsored insurance (ESI) claims dataset as well as Medicare and Medicaid claims data for this analysis.
Use of Telehealth Services Peaked in April of 2020
Figure 1 shows the rate of telehealth visits per 100,000 enrollees by month for 2020. Across individuals with ESI, Medicare, and Medicaid, overall telehealth use in 2020 increased from 141 visits per 100,000 enrollees in January to 7,116 visits per 100,000 enrollees in April, more than a 50-fold increase. Following this dramatic increase, telehealth utilization decreased almost immediately (6,074 visits per 100,000 in May and 5,123 visits per 100,000 in June) but remained substantially higher than pre-COVID rates for the remainder of the year.
Telehealth use for primary care visits increased from 220 visits per 100,000 enrollees in January to 10,478 visits per 100,000 in April across all payers, a 48-fold increase. Medicare enrollees, on average, used primary care telehealth services at higher rates than Medicaid enrollees or than people with ESI. In fact, Medicare enrollees used over 20,000 telehealth primary care visits per 100,000 enrollees in April 2020 compared to 7,677 visits per 100,000 enrollees among those with Medicaid and 7,512 visits per 100,000 ESI enrollees.
Across all payers, behavioral health visits in 2020 increased from 61 per 100,000 enrollees in January to 3,753 per 100,000 enrollees in April, a 62-fold increase. Figure 1 shows that telehealth utilization rates were lower for behavioral health visits compared to primary care visits. Behavioral telehealth services were highest among Medicaid enrollees, with a utilization rate of 4,871 visits per 100,000 in April 2020, compared to 3,369 visits per 100,000 in ESI and 2,016 visits per 100,000 in Medicare.
States with More Expansive Telehealth Policies Experienced Higher Telehealth Use
There was significant variation in the use of telehealth services in 2020 across states. Figure 2 shows the percent difference in average monthly utilization of telehealth services by state compared to the national average; averages are taken within each of the three payer types. Figure 2 can be filtered by payer and visit type.
To better understand what might be causing the differences in telehealth use by state, we looked at policy actions the individual states took following the onset of the pandemic. States have broad authority to regulate the use and licensure of telehealth services. At the start of the pandemic, states generally relaxed regulations surrounding telehealth. However, individual states took different approaches, from simply relaxing some or most regulations to actively encouraging telehealth use.
Unsurprisingly, states with higher-than-average utilization rates of telehealth services had more expansive policies (though other factors and state characteristics may also influence higher-than-average telehealth use). For example, Rhode Island, Massachusetts, New Hampshire, New York, New Jersey, and Connecticut all had significantly higher telehealth utilization compared to the national average. These states implemented policies such as requirements to match telehealth reimbursement to in-person reimbursement, prohibitions on cost-sharing for telehealth, prohibitions on payment reduction for telehealth, and funding for education and awareness of telehealth services.
This pattern generally held across payers for both primary care and behavioral health visits. For example, Massachusetts, which required matched reimbursement for telehealth, even among those with private insurance, had among the highest rates of telehealth use for those enrolled in ESI, Medicare, and Medicaid.  In Massachusetts, the utilization rate for primary care telehealth visits was 7,497 per 100,000 among those with ESI (nearly twice the national average), 18,657 per 100,000 among those with Medicare (over twice the national average), and 6,171 per 100,000 among those with Medicaid (1.5 times the national average). For behavioral telehealth, Massachusetts had an average utilization rate that was over three times the national average, with of 9,289 visits per 100,000 among those with ESI, 4,932 visits per 100,000 among those with Medicare, and 14,647 visits per 100,000 among those with Medicaid.
In contrast, states with lower telehealth utilization rates appear to have taken a more limited approach to relaxing regulations governing telehealth (though other factors and state characteristics may also influence lower-than-average telehealth use). These states implemented policies such as allowing telemedicine services only for already established patients, requiring providers to be licensed by the state or providing only temporary licensure to out-of-state providers, and allowing only specific types of practitioners to be included in the expansion of telehealth.
For example, North Dakota, which had the lowest telehealth utilization rate for primary care amongst those enrolled in ESI and Medicare, allowed credentialing reciprocity for out-of-state providers (i.e., the state would recognize providers credentials from other states assuming they were in good standing). However, it did not implement any telehealth expansion policies beyond this. The rate of primary care telehealth in North Dakota was 956 visits per 100,000 in ESI (less than 30 percent of the national average), 2,508 visits per 100,000 in Medicaid (less than 70 percent of the national average), and 3,201 visits per 100,000 in Medicare (less than 40 percent of the national average).
Other states with more restrictive policies included Wyoming, South Dakota, and Arkansas. These states had telehealth utilization rates lower than the national average.
Telehealth Expansion was Prompted by the COVID-19 Pandemic, and Enabled by Changes to Payment and Service Delivery Regulation Changes
Telehealth became an important and widely used service at the onset of the COVID-19 pandemic. Although this paper did not examine the displacement of in-person care, our data show that the expansion of telehealth services allowed patients to continue receiving care when in-person services were limited. Even after restrictions were lifted, use of telehealth for both primary care visits and behavioral health services remained high throughout 2020.
The COVID-19 pandemic created a shock to the health care system which increased the need for telehealth, but use of these services seems to have been affected, in part, by regulatory and reimbursement policies. Payment policies, licensing requirements, and funding for telehealth education may have impacted the variation we see in telehealth utilization from state to state, though more research is needed to examine the effects of individual policies.
While some state and payer policies may have increased access to telehealth, inequities remain. Access to telehealth can be burdensome for patients who do not have reliable internet service through their electronic devices. Technological and other barriers such as communication difficulties, financial restraints, and limited service availability need to be addressed to provide adequate and appropriate access to telehealth.
Telehealth use remained higher throughout 2020 than prior to the start of the pandemic among enrollees in all major sources of coverage – Medicare, Medicaid, and ESI. Going forward, it will be important to understand more about the optimal role of telehealth within the health care system and how state and federal policy can facilitate equitable, appropriate access to these services.
- The telehealth utilization rates were calculated as the total number of services (identified by unique patient and service date combinations) amongst the total population divided by the total population per 100,000 enrollees. All enrollees who had a known age and sex were included in the denominator. Additional restrictions were made based on age by payer. The Medicare FFS population was limited to enrollees over age 18, while the ESI population was limited to those under age 65.
- Note, some state's Medicaid data may be underreported, and we were unable to benchmark our findings to other available data sources.
- The following CPT codes and modifiers were used to identify telehealth services: [downloadable file (there are ~500)]
- CPT codes with an accompanying BETOS code that began with 'EV' were categorized as a Primary Care Visit while BETOS codes that began with 'EB' were categorized as a Behavioral Health Service.