Examining telehealth use in a single state reveals key trends and policies

In just three years, millions of people across Michigan’s two great peninsulas have taken advantage of their new ability to connect with their doctors, nurses and therapists via computer or phone, a new report shows.

Between 11% and 17% of all appointments to evaluate symptoms or discuss treatment are now taking place virtually, depending on the type of insurance, according to the analysis.

That’s up from less than 1% of such visits before the COVID-19 pandemic suddenly prompted temporary flexibility in health insurance rules for telehealth, according to a report by a team from the University of Michigan Institute for Healthcare Policy and Innovation.

The team used insurance data to prepare reports for the Michigan Health Endowment Fund and the Ethel and James Flinn Foundation.

Their analysis shows how telehealth specifically helps the 1 in 5 Michiganders who have a mental health care need — especially those who live in 38 counties that have few or no behavioral health care providers.

It also reveals lags in telehealth use by those living in rural areas, especially areas with a lower percentage of homes with broadband Internet access. The team also examined telehealth across the state, including by a “snowbird” that splits its time between Michigan and Florida.

Policy implications

The temporary telehealth rule will expire next year. So the report’s authors make recommendations that they hope policymakers and private health insurers will take note of as they plan for telehealth coverage for the long term.

“From the Upper Peninsula to Detroit, and everywhere in between, it’s clear that Michiganders have embraced telehealth for the access and convenience it provides, as well as the original goal of reducing exposure to the coronavirus,” said Chad Elllimoottil, MD, MS, UM researcher and telehealth expert who led the team. “But the future of telehealth in our state and beyond will depend on the decisions policymakers and insurance leaders make in the coming months, not only for coverage but for the expansion of Internet access and the supply of mental health providers.”

Ellimoottil leads the IHPI Telehealth Research Incubator and serves as medical director of Virtual Care for the University of Michigan Medical Group, part of the UM academic medical center called Michigan Medicine.

She worked on the report with researchers Ziwei Zhu, Xinwei Hi, Monica Van Til, who jointly analyzed Medicare data on the cost of traditional services and some data from patients covered by private managed care plans from Blue Cross Blue Shield of Michigan, and with IHPI member Sarah Clark, MPH, who analyzed Medicaid data.

On August 10, Ellimoottil will talk about the findings and more at a webinar hosted by the Michigan Health Endowment Fund; Registration information and links are here.

“This report highlights how telehealth has changed the way we think about access to care in Michigan, including dramatic changes in the delivery of behavioral health care,” said Becky Cienki, director of Behavioral Health and Special Projects at the Michigan Health Endowment Fund. “We are excited about the valuable insights uncovered in the data and the way they equip providers and policy makers to make informed and effective decisions that maximize the benefits of telehealth for expanding access to care.”

Main Findings:

Telehealth visit by insurance source:

Overall, 11% of Medicare participant visits will be via telehealth by 2022, compared to 13% of visits covered by Medicaid and 17% of visits billed to private insurance. In addition, 10% of people with Medicare coverage who seek care in ‘safe net’ clinics are seen via telehealth.

The overall volume of outpatient visits by people covered by traditional Medicare and private insurance remained stable from mid-2020 to late 2022, so Ellimoottil notes that this shows telehealth is replacing appointments that should be in-person, rather than increasing the number of visits.

Rural vs non-rural:

Before the pandemic, Medicare and other insurance companies had narrow requirements for telehealth, which focused on people living in rural areas. But they can only get covered for such visits if they leave their homes and go to their local clinic to register.

The new study found that in 2019, rural counties in central and northern Michigan had the highest rates of telehealth visits per 1,000 residents. But in 2020 and 2021, the counties with the highest rates of telehealth use will also be the most populous, especially the five counties in southeastern Michigan where nearly half of the state’s population lives.

Overall, about 31% of people living in rural areas had telehealth visits, compared to 46% of people in non-rural areas. The authors note that continued telehealth coverage from home, rather than a return to access only from rural clinics, will be important.

Mental health and behavior:

Telehealth has long been seen as a potential option for providing treatment for mental health conditions and substance use disorders including drug and alcohol addiction, as it often does not require a “hands-on” approach. Plus, patients often feel stigmatized against seeking treatment in person, and there is a shortage and unequal distribution of trained providers to care for patients with this condition.

Telehealth use: The new report includes analysis that confirms previous estimates that 1 in 5 people in Michigan have a mental health or behavioral health condition at any given time. Previous studies have shown that 40% of all adults with mental health conditions, and 80% of those with addiction problems, do not receive treatment.

The report shows that nearly half of all visits for mental/behavioral health care are now made by telehealth among Michiganders covered by traditional Medicare, based on two different analyses.

They also determined which counties had the most number of patients receiving mental and behavioral health care. For people with Medicaid coverage who live in these high-demand areas, the percentage of mental and behavioral health care visits by telehealth is much lower than Medicare, at around 17% of those visits.

Disadvantages of the provider: The report also shows that half of all Michigan counties have fewer than 10 mental health specialists, defined as practicing specialists in psychiatry, geriatric psychiatry, neuropsychiatry, psychology, clinical psychology, licensed clinical social work, or addiction treatment. One in 5 Michigan counties has one or no such provider.

The team focused on the 38 districts with the most severe shortages. In these countries, 57% of all visits with these providers are via telehealth, for patients on traditional Medicare.

Getting help outside the shortage area: The researchers dug further to see where patients live compared to where their mental/behavioral health provider practices, to see if the availability of telehealth makes it easier to get care from providers based in areas with a higher supply of providers.

Overall, 82% of mental health visits by people living in areas with a shortage of mental health providers involved providers outside the patient’s home area. Of these, the vast majority is through telehealth – in fact, overseas telehealth accounts for 47% of all mental health visits for people living in these deprived counties.

In 13 districts, all mental/behavioral health visits by district residents were conducted with providers in different districts.

These data show that telehealth means greater access to mental health care for people living in areas where there is a shortage of such care providers.

Broadband Internet access:

The higher the percentage of households with broadband Internet access in an area, the higher the use of telehealth by Medicare participants there.

The authors note that efforts to increase broadband availability statewide, but particularly in the 29 counties that are below the average level of broadband availability (82% of households), could increase telehealth use.

Demographics:

The researchers saw minimal differences in telehealth use by age, sex, race/ethnicity, although women and people under the age of 65 were slightly more likely to use telehealth. Interestingly, they did see higher rates of telehealth use among people who qualified for Medicaid because of low income and Medicare because of age or disability status; this “dual entitlement” population accounts for 23% of all telehealth users covered by traditional Medicare in 2020.

While the new report doesn’t look at the percentage of telehealth visits that are made via voice only telephone connections, previous research by the UM team suggests that discontinuing insurance coverage for telephone visits could reduce telehealth access for patients who are older, African-American, need an interpreter, are dependent on Medicaid, and/or live in areas with limited broadband access.

Snowbirds and other out-of-state telehealth:

Temporary pandemic rules allowing patients to see providers located in different states led to more appointments of this kind in Michigan. But the percentage of all telehealth visits by Michiganders with Medicare involving out-of-state providers remains the same at around 3%.

More than a quarter (28%) of all Michiganders visits that saw providers in other states nearly involved providers in Florida. These are likely Michigan “snowbirds” who spend part of their year in Florida and may have appointments with their provider there even when they return to Michigan.

Most other visits with out-of-state providers involve providers in neighboring states of Michigan. Ellimoottil said this shows policymakers should prioritize reciprocal medical licensing agreements with neighboring states and Florida, to give patients ongoing access to this kind of care.

Learn more about telehealth research and policy work at IHPI: https://ihpi.umich.edu/telehealth-research-and-policy

Learn more about the Michigan Health Endowment Fund’s telehealth work: https://mihealthfund.org/issues/telehealth

In addition to the report team, the analysis involved members of the Susan B. Meister Child Health Evaluation and Research (CHEAR) Center who worked on the Medicaid analysis, and data from the Michigan Value Collaborative which provides access to data from BCBSM’s Preferred Provider Organization Commercial insurance claims data from 103 acute care hospitals and 40 physician organizations across Michigan.

Telehealth in Michigan: Insights and Data for Effective Policy Making
https://mihealthfund.org/news/publications/telehealth-in-michigan