Rural Telehealth Growth Dramatic but Uneven

John Commins, May 2, 2017

Behavioral health visits account for 87% of Medicare's telemedicine billings. But there is a pronounced uneven distribution of services across states.

Depending upon which baseline you start at, and which state you're looking at, telemedicine use expanded significantly between 2004 and 2014, or not much at all.

While the overall use of telemedicine for mental health diagnosis and treatment in rural America remains very low (1.5%), a new study from Harvard Medical School and the RAND Corp. in the May issue of Health Affairs shows an average 45% jump per year in telemedicine visits among rural patients over the decade, with striking variation across states.

Four states had no such visits in 2014. In nine states, however, there were more than 25 telemedicine visits per 100 patients with serious mental illness. 

"In some states it's pretty high. In Nevada, Wyoming, and Iowa we are seeing in the rates of 30-40 visits per 100 people with serious mental illness. Those are really big numbers," says study lead author Ateev Mehrotra, MD.

Mehrotra is associate professor in the Department of Health Care Policy at Harvard Medical School.

ateev-mehrotra
Ateev Mehrotra, MD

The study found that the number of telemedicine behavioral health visits increased from 2,365 in 2004 to 87,120 in 2014. An average of five out of 100 rural beneficiaries with a mental health condition had a telemedicine visit, and the number was even higher—12 out of 100—for patients with serious mental illnesses, such as bipolar disorder or schizophrenia.

The latter group makes up only 3% of rural Medicare beneficiaries, yet it accounted for more than a third of these telemedicine visits. Behavioral health visits account for 87% of Medicare's telemedicine billings.

Mehrotra says the study's findings show that while telemedicine use remains remarkably low, it is also catching on.


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"In one sense it interesting that 1.5% usage is starting to have a population-level impact, because 1.5% of the Medicare population, and 3.7% of people with serious mental health issues were getting telemedicine. Those are real numbers now, when most people thought of telemedicine being in the theoretical future," he says.

"In that sense that is the glass-half-full thing, which is people have been talking about telemedicine for a long time. The numbers are small still and yet now we are starting to see in certain communities among certain populations real use. But you could flip it around and say only 1.5%!"

Mehrotra says there is no clear explanation for the state-to-state discrepancy, but he has a few theories.

"There are a lot of conversations about telemedicine parity laws as being critical and we found there was a higher rate of tele-mental health use in states with those parity laws, but the difference was quite small and the growth rate was identical," he says.

"Maybe that is playing a role, but it's a marginal role."


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"We did look at regulatory environment," he says. "There are all kinds of rules, in particular, for mental health. For example, you must read a disclaimer every time you have a tele-mental health visit, etc. We found in states with less-strict regulatory environments that are more open to tele-mental health a larger increase in tele-mental health. That probably plays some role."

Mehrotra says he's hearing anecdotally that a big factor may be the idiosyncratic operations of community health centers where the telemedicine remote visits occur. The use of telemedicine may vary depending upon the enthusiasm of clinicians and administrators at a particular site.

"Many of these community health centers are chains, and the person who is the CMO at one of these chains may think tele-mental health is the way to go so she is pushing it at her practices. At another chain, they may think it's a bad way to provide care and they're not pursuing it," he says.

"This is evidence that in certain communities tele-mental health can happen and be a routine part of care, and it spurs the people in other communities to say this is possible and we need to rethink this idea because it is taking off." 

John Commins

John Commins is a senior editor at HealthLeaders Media.

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