Key Findings from RAND Health Care Research on Telehealth Policy

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Although virtual health care has been on the horizon for years, telehealth use exploded during the coronavirus disease 2019 (COVID-19) pandemic: It increased by more than 4,000 percent in the first months of the pandemic, relative to the same period in 2019 (FAIR Health, 2020). Yet increased use of telehealth offset only about half of the decline in in-person visits, suggesting that a significant amount of health care was deferred (Cantor, Sood, et al., 2022). Since the end of the public health emergency (PHE), use of telehealth has plateaued (McBain et al., 2024), but use of telehealth for mental health care remains higher than it was before the COVID-19 pandemic (Cantor et al., 2023).

RAND Health Care researchers have studied telehealth's effects on care quality, access, and equity to gain insights on the uses of and preferences regarding telehealth before, during, and after the pandemic. Prepandemic policies regarding telehealth service reimbursement, which had been in place to limit overspending and potential fraud, were temporarily waived to ease access to care during the PHE (Centers for Medicare & Medicaid Services, 2021; Public Law 116-136, 2020). The Consolidated Appropriations Act of 2023 (Public Law 117-328) preserved the effects of those waivers until December 31, 2024, but policymakers and payers will soon need to make long-term decisions regarding telehealth.

The key findings from recent RAND research on telehealth synthesized in this brief will help policymakers and payers make informed decisions about telehealth policies as the impact of the pandemic comes into clearer focus.

Adapting to Emergencies

• About 30 percent of patients used video telehealth services in the first months of the pandemic, a RAND American Life Panel survey found. This was a marked increase from the 4 percent of patients surveyed in 2019 who used video telehealth services. Much of the increase was due to patients seeing their own doctors through telehealth (Fischer, Uscher-Pines, et al., 2021).
• Survey data collected later in the pandemic showed that willingness to try telehealth among respondents — particularly Black respondents — significantly increased, relative to February 2019 (Fischer et al., 2022). Willingness to use telehealth may also depend on whether virtual visits can occur with patients' usual providers (Fischer and Breslau, 2021). However, if virtual visits cost more, most respondents preferred in-person visits for nonemergency care (Predmore et al., 2021).
• Rapid-response interviews conducted early in the pandemic revealed that providers pivoted to telehealth out of necessity, not only to protect themselves and their patients from viral spread, but also to offset losses from reduced in-person visit volume (Uscher-Pines, 2020).

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Enabling Treatment for Behavioral Health

• Among a sample of nearly 16,000 outpatient behavioral health facilities, availability of telehealth increased by 77 percent for mental health treatment facilities and 143 percent for substance use disorder treatment facilities from 2020 to 2021. In 2021, facilities that did not accept Medicaid payment were less likely to offer telehealth than those that did (Cantor, McBain, et al., 2022).
• In contrast, a study of more than 1,000 mental health treatment facilities conducted between December 2022 and November 2023 found a small decline in offerings of telehealth and larger declines in availability of audio-only telehealth services and care for comorbid alcohol use disorder (McBain et al., 2024).
• Telehealth availability for mental health care varies significantly across states, from less than half of treatment facilities contacted in Mississippi and South Carolina, to every facility contacted in Maine and Oregon. There were differences in services offered depending on whether a mental health treatment facility was located in a rural or metropolitan area (Cantor et al., 2024).
• Despite the rapid growth of telehealth for behavioral health services, many patients do not have a choice of whether they receive in-person or remote care. In a nationally representative survey, about one-third of the patients receiving therapy or medication visits reported that their clinicians did not offer both telehealth and in-person care. In addition, 32 percent reported that they typically did not receive their preferred mode of care, and 45 percent said that they did not believe their clinician considered their preference when deciding the visit type. The study highlighted policy trade-offs in honoring patient choice and ways clinicians could identify and accommodate preferences of their patients (Sousa et al., 2023).

Supporting Maternal Care

• Telehealth can be used to deliver professional breastfeeding support. Almost 45 percent of mothers in rural Pennsylvania in a prepandemic randomized controlled trial of remote lactation services used app-based video services to help answer their breastfeeding questions and concerns (Uscher-Pines, Kapinos, et al., 2019). Users were more likely to be new to breastfeeding and working at 12 weeks postpartum, and calls typically occurred outside normal business hours (Kapinos et al., 2019).
• One-third of 1,617 new parents had at least one telelactation visit between October 2021 and January 2022 on Ovia's parenting mobile phone application, suggesting that telelactation is becoming increasingly common and acceptable to parents (Uscher-Pines, Kapinos, Mehrotra, et al., 2023).
• Telelactation may help reduce disparities by increasing access to lactation consultants. One study showed that Black patients found telelactation services to be acceptable and feasible and valued opportunities to engage with culturally competent providers (Howell et al., 2023). Another study found high demand for telelactation services among rural, underserved mothers. Better understanding of target populations' demand for and satisfaction with these services, as well as predictors of their use, can inform their design, marketing, and implementation (Uscher-Pines, Kapinos, Demirci, et al., 2019).
• The use of virtual doula care has become more common. One study examined the landscape for doula care and doula care's advantages and limitations and concluded that increased use of virtual doula encounters has the potential to improve equity in maternal care (Waymouth et al., 2024).

Assessing Impacts of State Policies

• Four state policies introduced during the COVID-19 pandemic were associated with marked expansion of telehealth availability for mental health care at nearly 13,000 mental health treatment facilities nationwide. The policies were (1) payment parity for telehealth services among private insurers, (2) authorization of audio-only telehealth services for the Medicaid and Children's Health Insurance Program (CHIP) beneficiaries, and participation in the (3) Interstate Medical Licensure Compact (IMLC) or the (4) Psychology Interjurisdictional Compact (PSYPACT). Despite these policies, telehealth services were less likely to be offered in counties with a greater proportion of Black residents and in facilities that accepted Medicaid and CHIP (McBain et al., 2023).
• Although various states instituted policies expanding access to and initiation of remote opioid use disorder treatment, no state implemented policies to comprehensively expand access to opioid use disorder treatment (Pessar et al., 2021).

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Addressing Health Care Access

• Early in the pandemic, most providers associated remote treatment with improved access and better patient interactions (Uscher-Pines, Sousa, Raja, et al., 2020), and some thought that audio-only visits could be essential to overcoming access barriers (Uscher-Pines, Jones, et al., 2021). However, the continued high prevalence in 2021 of audio-only visits raised questions about whether patients were receiving enough preventive care (Uscher-Pines, Arora, et al., 2022). By 2022, many providers associated video visits with higher-quality care than audio visits and had adopted digital equity practices to facilitate remote access (Uscher-Pines, Riedel, et al., 2023). Future policies regarding telehealth should try to address the underlying reasons for lower access to in-person visits among some populations (Uscher-Pines and Schulson, 2021).
• A study of about 6.5 million commercial insurance claims found that the 20-fold increase in the use of telehealth early in the pandemic occurred mostly among adults in higher-income counties (Cantor et al., 2021). Patients in lower-income zip codes were less likely to defer office visits — but also less likely to access telehealth services (Whaley et al., 2020).
• An estimated 6 million children and adolescents live in low-income and rural counties with access to neither child psychiatric services nor sufficient broadband to support telepsychiatry (McBain et al., 2021). Insufficient internet access also creates barriers to medication for opioid use disorder through telemedicine providers located outside rural areas (Ober et al., 2024). Chief financial officers of rural hospitals also viewed insufficient internet access, limited reimbursement, low patient volume, and preferences for in-person care as potential barriers to the financial viability of telehealth (Uscher-Pines, Sousa, Zachrison, et al., 2022).
• Proficiency with the English language could affect access to telehealth. In a "secret shopper" study, simulated patients who spoke Spanish were less likely to reach a scheduler who could give them appointment information and engage with them in their preferred language in real time; 22 percent were unable to engage (e.g., they were hung up on) (Uscher-Pines, Kapinos, Rodriguez-Solorio, et al., 2023).

Forging Ahead

Using telehealth to help patients and providers maintain access to care was a top priority during the pandemic. However, some critical policy decisions, such as whether to treat audio-only visits the same way as video visits, have raised concerns about care quality. Telehealth access appears to be uneven, with individuals in low-income or rural areas having less access to broadband internet that enables video calls. These issues will need continued research, and studies will need to continue investigating telehealth's effects on costs, health outcomes, and health equity (Uscher-Pines and Mehrotra, 2024). Policymakers might also want to begin thinking of telehealth less as an either-or proposition (i.e., either telehealth or office visits) and more in terms of how the two modalities can be used in a hybrid format.

This research highlight summarizes RAND Health Care research reported in the following publications:

• Cantor, Jonathan H., Ryan K. McBain, Aaron Kofner, Russell Hanson, Bradley D. Stein, and Hao Yu, "Telehealth Adoption by Mental Health and Substance Use Disorder Treatment Facilities in the COVID-19 Pandemic," Psychiatric Services, Vol. 73, No. 4, April 2022 (EP-70306, www.rand.org/t/EP70306).
• Cantor, Jonathan H., Ryan K. McBain, Pen-Che Ho, Dena M. Bravata, and Christopher Whaley, "Telehealth and In-Person Mental Health Service Utilization and Spending, 2019 to 2022," JAMA Health Forum, Vol. 4, No. 8, August 25, 2023 (EP-70222, www.rand.org/t/EP70222).
• Cantor, Jonathan H., Ryan K. McBain, Megan F. Pera, Dena M. Bravata, and Christopher M. Whaley, "Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic," American Journal of Preventive Medicine, published online March 6, 2021 (EP-68574, www.rand.org/t/EP68574).
• Cantor, Jonathan H., Megan S. Schuler, Samantha Matthews, Aaron Kofner, Joshua Breslau, and Ryan K. McBain, "Availability of Mental Telehealth Services in the US," JAMA Health Forum, Vol. 5, No. 2, February 2024 (EP-70373, www.rand.org/t/EP70373).
• Cantor, Jonathan, Neeraj Sood, Dena M. Bravata, Megan Pera, and Christopher Whaley, "The Impact of the COVID-19 Pandemic and Policy Response on Health Care Utilization: Evidence from County-Level Medical Claims and Cellphone Data," Journal of Health Economics, Vol. 82, March 2022 (EP-68902, www.rand.org/t/EP68902).
• Fischer, Shira H., and Josh Breslau, "Patients Log on to See Their Own Doctors During the Pandemic," RAND Blog, January 7, 2021 (www.rand.org/pubs/commentary/2021/01/patients-log-on-to-see-their-own-doctors-during-the).
• Fischer, Shira H., Zachary Predmore, Elizabeth Roth, Lori Uscher-Pines, Matthew D. Baird, and Joshua Breslau, "Use of and Willingness to Use Video Telehealth Through the COVID-19 Pandemic," Health Affairs, Vol. 41, No. 11, November 2022 (EP-69088, www.rand.org/t/EP69088).
• Fischer, Shira H., Lori Uscher-Pines, Elizabeth Roth, and Joshua Breslau, "The Transition to Telehealth During the First Months of the COVID-19 Pandemic: Evidence from a National Sample of Patients," Journal of General Internal Medicine, Vol. 36, January 6, 2021 (EP-68428, www.rand.org/t/EP68428).
• Howell, Khadesia, Gabriela Alvarado, Molly Waymouth, Jill R. Demirci, Rhianna C. Rogers, Kristin Ray, and Lori Uscher-Pines, "Acceptability of Telelactation Services for Breastfeeding Support Among Black Parents: Semistructured Interview Study," Journal of Medical Internet Research, Vol. 25, No. 1, 2023 (EP-70338, www.rand.org/t/EP70338).
• Kapinos, Kandice A., Virginia Kotzias, Debra L. Bogen, Kristin Ray, Jill R. Demirci, Mary Ann Rigas, and Lori Uscher-Pines, "The Use of and Experiences with Telelactation Among Rural Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled Trial," Journal of Medical Internet Research, Vol. 21, No. 9, September 2019 (EP-68337, www.rand.org/t/EP68337).
• McBain, Ryan K., Jonathan H. Cantor, Aaron Kofner, Bradley D. Stein, and Hao Yu, "Ongoing Disparities in Digital and In-Person Access to Child Psychiatric Services in the United States," Journal of the American Academy of Child & Adolescent Psychiatry, December 20, 2021 (EP-68892, www.rand.org/t/EP68892).
• McBain, Ryan K., Megan S. Schuler, Joshua Breslau, Aaron Kofner, Lulu Wang, and Jonathan H. Cantor, "Telehealth Availability for Mental Health Care During and After the COVID-19 Public Health Emergency" JAMA Network Open, Vol. 7, No. 7, 2024 (EP-70538, www.rand.org/t/EP70538).
• McBain, Ryan K., Megan S. Schuler, Nabeel Qureshi, Samantha Matthews, Aaron Kofner, Joshua Breslau, and Jonathan H. Cantor, "Expansion of Telehealth Availability for Mental Health Care After State-Level Changes from 2019 to 2022," JAMA Network Open, Vol. 6, No. 6, June 2023 (EP-70202, www.rand.org/t/EP70202).
• Ober, Allison J., Alex R. Dopp, Sarah E. Clingan, Megan E. Curtis, Chunquin Lin, Stacy Calhoun, Sherry Larkins, Megan Black, Maria Hanano, Katie P. Osterhage, Laura-Mae Baldwin, et al., "Stakeholder Perspectives on a Telemedicine Referral and Coordination Model to Expand Medication Treatment for Opioid Use Disorder in Rural Primary Care Clinics," Journal of Substance Use and Addiction Treatment, Vol. 156, January 2024 (EP-70459, www.rand.org/t/EP70459).
• Pessar, Seema Choksy, Anne Boustead, Yimin Ge, Rosanna Smart, and Rosalie Liccardo Pacula, "Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond," JAMA Health Forum, Vol. 2, No. 11, November 19, 2021 (EP-68773, www.rand.org/t/EP68773).
• Predmore, Zachary, Elisabeth Roth, Joshua Breslau, Shira H. Fischer, and Lori Uscher-Pines, "Assessment of Patient Preferences for Telehealth in Post-COVID-19 Pandemic Health Care," JAMA Network Open, Vol. 4, No. 12, December 1, 2021 (EP-68854, www.rand.org/t/EP68854).
• Sousa, Jessica L., Andrew Smith, Jessica Richard, Maya Rabinowitz, Pushpa Raja, Ateev Mehrotra, Alisa B. Busch, Haiden A. Huskamp, and Lori Uscher-Pines, "Choosing or Losing in Behavioral Health: A Study of Patients' Experiences Selecting Telehealth Versus In-Person Care," Health Affairs, Vol. 42, No. 9, September 2023 (EP-70228, www.rand.org/t/EP70228).
• Uscher-Pines, Lori, "Moving on from Telehealth-by-Desperation: What Will Make Telehealth Stick," RAND Blog, August 18, 2020 (www.rand.org/pubs/commentary/2020/08/moving-on-from-telehealth-by-desperation-what-will).
• Uscher-Pines, Lori, Natasha Arora, Maggie Jones, Abbie Lee, Jessica L. Sousa, Colleen M. McCullough, Sarita D. Lee, Monique Martineau, Zachary Predmore, Christopher M. Whaley, and Allison J. Ober, Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative, RAND Corporation, RR-A1840-1, 2022 (www.rand.org/t/RRA1840-1).
• Uscher-Pines, Lori, Maggie Jones, Jessica L. Sousa, Zach Predmore, and Allison J. Ober, "The Doctor Will Call Me Maybe: The Uncertain Future of Audio-Only Visits and Why We Need Them to Address Disparities," RAND Blog, March 12, 2021 (www.rand.org/pubs/commentary/2021/03/the-doctor-will-call-me-maybe-the-uncertain-future).
• Uscher-Pines, Lori, Kandice A. Kapinos, Jill R. Demirci, Bonnie Ghosh-Dastidar, Kristin Ray, Virginia Kotzias, and Debra L. Bogen, "Use of Virtual Breastfeeding Support Among Underserved, Rural Mothers," Pediatrics, Vol. 144, No. 2, Meeting Abstract 275, August 2019 (EP-68335, www.rand.org/t/EP68335).
• Uscher-Pines Lori, Kandice A. Kapinos, Ateev Mehrotra, Jill R. Demirci, Kristin Ray, Gabriela Alvarado, and Maria DeYoreo, "Use of and Attitudes About Telelactation Services Among New Parents," Telemedicine and e-Health, Vol. 29, No. 4, April 2023 (EP-70499, www.rand.org/t/EP70499).
• Uscher-Pines, Lori, Kandice A. Kapinos, Claudia Rodriguez, Samantha Perez-Davila, Pushpa Raja, Jorge A. Rodriguez, Maya Rabinowitz, Mara Youdelman, and Jessica L. Sousa, "Access Challenges for Patients with Limited English Proficiency: A Secret-Shopper Study of In-Person and Telehealth Behavioral Health Services in California Safety-Net Clinics." Health Affairs Scholar, Vol. 1, No. 3, September 2023 (EP-70229, www.rand.org/t/EP70229).
• Uscher-Pines, Lori, and Ateev Mehrotra, "The Effect of Telehealth on Spending — Reframing the Debate," JAMA, August 21, 2024 (EP70705, www.rand.org/t/EP70705).
• Uscher-Pines, Lori, Lauren E. Riedel, Ateev Mehrotra, Sherri Rose, Alisa B. Busch, and Haiden A. Huskamp, "Many Clinicians Implement Digital Equity Strategies to Treat Opioid Use Disorder," Health Affairs, Vol. 42, No. 2, February 2023 (EP-70004, www.rand.org/t/EP70004).
• Uscher-Pines, Lori, and Lucy B. Schulson, "Rethinking the Impact of Audio-Only Visits on Health Equity," RAND Blog, December 17, 2021 (www.rand.org/pubs/commentary/2021/12/rethinking-the-impact-of-audio-only-visits-on-health).
• Uscher-Pines, Lori, Jessica L. Sousa, Pushpa Raja, Ateev Mehrotra, Michael L. Barnett, and Haiden A. Huskamp, "Treatment of Opioid Use Disorder During COVID-19: Experiences of Clinicians Transitioning to Telemedicine," Journal of Substance Abuse Treatment, Vol. 118, November 2020 (EP-68422, www.rand.org/t/EP68422).
• Uscher-Pines L., Jessica L. Sousa, Kori Zachrison, Lee H. Schwamm, and Ateev Mehrotra, "Financial Impact of Telehealth: Rural Chief Financial Officer Perspectives." American Journal of Managed Care, Vol. 28, No. 12, December 2022 (EP-70052, www.rand.org/t/EP70052).
• Waymouth, Molly, Kourtney Floyd James, and Lori Uscher-Pines, "Advancing Equity in Maternal Health with Virtual Doula Care," JAMA Health Forum, Vol. 5, No. 1, January 2024 (EP-70389, www.rand.org/t/EP70389).
• Whaley, Christopher M., Megan F. Pera, Jonathan Cantor, Jennie Chang, Julia Velasco, Heather K. Hagg, Neeraj Sood, and Dena M. Bravata, "Changes in Health Services Use Among Commercially Insured U.S. Populations During the COVID-19 Pandemic," JAMA Network Open, Vol. 3, No. 11, November 5, 2020 (EP-68469, www.rand.org/t/EP68469).

References

• Centers for Medicare & Medicaid Services, COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, April 8, 2021 (www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf).
• FAIR Health, "Monthly Telehealth Regional Tracker, March 2020," 2020 (s3.amazonaws.com/media2.fairhealth.org/infographic/telehealth/mar-2020-national-telehealth.pdf).
• Public Law 116-136, Coronavirus Aid, Relief, and Economic Security (CARES) Act, March 27, 2020.
• Public Law 117-328, Consolidated Appropriations Act, December 29, 2022.

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Topics

• Coronavirus Disease 2019 (COVID-19)
• Health Care Access
• Health Care Quality
• Health Equity
• Telemedicine