How are Medicare patients using interstate telehealth visits?

Most are established patients getting treatment for routine diagnoses

Opponents of the loosened interstate telehealth restrictions that were instituted at the start of the COVID-19 pandemic argued that it would result in out-of-state doctors luring patients away from their current physicians. But a new study finds that most out-of-state telehealth is used for continuity of care, not acquiring new patients.

The study compares interstate telehealth use among Medicare beneficiaries after March 2020, when all 50 states and the District of Columbia instituted temporary measures allowing clinicians to treat patients in other states via telehealth, with telehealth’s interstate use during the years 2017-19.

Using data from a national, random 20% sample of Medicare fee-for-service beneficiaries, the authors analyzed how rates of out-of-state telehealth changed from 2017 through 2020, the content of out-of-state telehealth visits, the characteristics of those who used out-of-state telehealth, and state-level variation in out-of-state telehealth use. They applied their analysis to four types of visits: interstate telehealth visits, interstate in-person visits, in-state telehealth visits, and in-state, in-person visits.

Among their findings was a high degree of similarity between the billing and primary diagnosis codes for in-state and out-of-state telehealth visits, and that most out-of-state care went to established patients for treatment of routine diagnoses.

The top three Healthcare Common Procedure Coding System codes for both in-state and out-of-state health care visits were for established patient office visits levels 3 and 4, and audio-only E/M visits. In addition, they found little increase in the volume of new patient visits from 2017 to 2020, even though telehealth use increased.

“These findings should mitigate possible concerns that extending licensure flexibilities will result in out-of-state clinicians luring away patients from their existing clinicians,” they write.

In addition, the study showed that about two-thirds of out-of-state telehealth visits were with a physician in a bordering state, and that a higher percentage of rural patients used both out-of-state in-person and telehealth services compared to patients in non-rural areas. Consequently, the authors suggest that states with rural counties along their borders way want to enact policies such as licensure reciprocity to enable continued telehealth access in rural communities.

The authors note that while the number of out-of-state telehealth visits increased significantly in 2020 compared to prior years, they remained a relatively small percentage of all outpatient visits during the study period. That percentage varied by state, however ranging from 9.3% for the District of Columbia to 0.4% for Louisiana and Utah. Knowing how much care their residents obtain in other states, they say, can help states decide how high a priority to place on allowing out-of-state telehealth after the pandemic ends.

The study, “Interstate Telehealth Use By Medicare Beneficiaries Before And After COFID-19 Licensure Waivers 2017-2020” appears in the June, 2022 issue of Health Affairs.