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    Views 3,155
    Original Investigation
    October 15, 2021

    Trends in Outpatient Telemedicine Utilization Among Rural Medicare Beneficiaries, 2010 to 2019

    Author Affiliations
    • 1Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
    • 2Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
    • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
    • 4McLean Hospital, Belmont, Massachusetts
    • 5RAND Corporation, Arlington, Virginia
    • 6Department of Medicine, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia
    • 7Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
    JAMA Health Forum. 2021;2(10):e213282. doi:10.1001/jamahealthforum.2021.3282
    Key Points

    Question  How was telemedicine used by rural Medicare beneficiaries in the decade prior to the COVID-19 pandemic?

    Findings  This cross-sectional study of 10.4 million rural Medicare beneficiaries found sustained annual compound growth in telemedicine use among rural beneficiaries covered by Medicare in 2010 to 2019, especially for care provided by nurse practitioners and other nonphysician clinicians. Medicare beneficiaries with serious mental illness (eg, bipolar disorder) used a disproportionate share of all telemedicine visits, with more than 1 in 10 beneficiaries using telemedicine annually in 891 counties in the US.

    Meaning  The findings of this cross-sectional study indicate that telemedicine use grew rapidly before the COVID-19 pandemic among Medicare beneficiaries with mental health conditions; the model of telemedicine provided in the local health care setting before 2020 may be a viable modality for continued use in rural communities.


    Importance  Little is known about how telemedicine use was evolving before the broad changes that occurred during the COVID-19 pandemic in 2020. Understanding prepandemic patterns of telemedicine use can inform ongoing debates on the future of telemedicine policy.

    Objective  To describe trends in telemedicine utilization among Medicare fee-for-service beneficiaries before the COVID-19 pandemic and the specialties of clinicians providing telemedicine.

    Design, Setting, and Participants  This was a cross-sectional study and descriptive analysis of telemedicine utilization by 10.4 million fee-for-service Medicare beneficiaries from 2010 to 2019. Data analysis was performed from June 6, 2019, to July 30, 2020.

    Main Outcomes and Measures  Rates of telemedicine utilization, characteristics of beneficiaries who received telemedicine in 2010 to 2019, and specialties of clinicians delivering telemedicine.

    Results  Of 10.4 million rural Medicare beneficiaries, telemedicine was used by 91 483 individuals (age ≥65 years, 47 135 [51.5%]; women, 51 476 [56.3%]; and White, 76 467 [83.6%] individuals) in 2019. In 2010 to 2019, telemedicine visits grew by 23.1% annually. A total of 0.9% of all fee-for-service rural beneficiaries had a telemedicine visit in 2019 compared with 0.2% in 2010. In 2019, there were 257 979 telemedicine visits or 34.8 visits per 1000 rural beneficiaries and most (75.9%) of these visits were for mental health conditions. Patients with bipolar disorder or schizophrenia (3.0% of rural beneficiaries) received 40% of all telemedicine visits in 2019. Some traditionally disadvantaged and underserved groups comprised a larger share of telemedicine users than nonusers in 2019, such as those dually insured with Medicaid (56.9% of users vs 18.6% of nonusers; adjusted odd ratio, 3.83; 95% CI, 3.77-3.89). In 2010 to 2019, telemedicine for mental health conditions shifted away from psychiatrists (71.2% to 35.8% of all telemedicine visits) to nonphysician clinicians, eg, nurse practitioners, psychologists, and social workers (21.4% to 57.2%). There was wide variation in telemedicine utilization in 2019 across counties: median (IQR), 16.0 (2.5-51.4) telemedicine users per 1000 beneficiaries). In 891 counties (29% of all US counties), at least 10% of beneficiaries with bipolar disorder or schizophrenia used a telemedicine service in 2019.

    Conclusions and Relevance  In this cross-sectional study of telemedicine utilization before the COVID-19 pandemic, there was sustained growth in telemedicine visits among rural beneficiaries covered by the Medicare program, especially care delivered by nurse practitioners and other nonphysician clinicians. The prepandemic model of telemedicine provided in local health care settings may be a viable modality to maintain in rural communities.