Medicare beneficiaries in poor neighborhoods helped most by waived telemedicine restrictions, study finds

Outpatient telemedicine visits increased substantially among Medicare beneficiaries after the start of the COVID-19 pandemic, with the largest increases coming among people living in poor neighborhoods and rural areas.

Those findings emerged from a new study comparing telemedicine use before and after the March 2020 public health emergency declaration. The declaration enabled the Centers for Medicare and Medicaid Services (CMS) to waive restrictions on telemedicine coverage to expand it to all Medicare beneficiaries and allowed clinicians to bill for virtual visits at the same rate as in-person visits.

The study’s authors analyzed roughly 30 million Medicare fee-for-service claims to quantify outpatient telemedicine use before and after telemedicine restrictions were lifted and associate its use with the Area Deprivation Index, a tool used to measure neighborhood socioeconomic disadvantage through metrics such as household income, education levels and employment status.

They found that before the waiver 0.42% of patients had at least one outpatient telemedicine visit, with no significant difference between those in the most and least disadvantaged areas. Following the waiver, however, nearly 10% of patients had at least one outpatient telemedicine visit, with residents of disadvantaged neighborhoods having the highest odds of use relative to those living in the least disadvantaged neighborhoods.

The latter finding, the authors note, runs counter to earlier studies showing an inverse association of socioeconomic status with telemedicine use during the pandemic. The difference, they say, is that the earlier studies were limited to single health systems, whereas theirs was based on national Medicare claims data. “The correlation shown by our data suggests that CMS was successful in reaching even people in the most disadvantaged neighborhoods with its telemedicine coverage waiver, at least among Medicare beneficiaries,” they write.

The study’s results may help to dispel concerns that increased telemedicine use would worsen race-based disparities in access to health care, the authors say. “After Medicare telemedicine expansion, we found that telemedicine access was improved for all minority populations compared with White patients,” they write.

Removing telehealth restrictions also reversed the pre-pandemic trend of higher telehealth use among people living in rural areas, since before the pandemic those patients were usually the only ones eligible to use it. But without the restrictions patients living in rural areas had 22% lower odds of using telemedicine compared to people living in metropolitan areas.

An important exception to greater telehealth use during the pandemic has been among the elderly, with those 85 and older being the least likely to use it compared to younger adults. The authors suggest this could be because older adults are less likely to own smartphones and other technology required for telehealth visits.

Overall, however, the researchers say their findings are “encouraging,” in that they show the Medicare telemedicine coverage waiver improved access to health care for people in the poorest neighborhoods without worsening disparities in care access, and demonstrate the need to continue the expanded use of telemedicine and reimbursement parity with in-person visits after the public health emergency has ended.

The study, “Medicare Beneficiaries in Disadvantaged Neighborhoods Increased Telemedicine Use During the COVID-19 Pandemic,” appears in the May, 2022 issue of Health Affairs.