eAppendix 1. FQHCs in Study Sample Compared to FQHCs Excluded From the Study Sample
eAppendix 2. Defining Telehealth
eAppendix 3. Defining High Versus Low Telehealth FQHCs
eAppendix 4. Identifying Video vs Audio-Only Telehealth Visits
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Cole MB, Lee EK, Davoust M, Carey K, Kim J. Comparison of Visit Rates Before vs After Telehealth Expansion Among Patients With Mental Health Diagnoses Treated at Federally Qualified Health Centers. JAMA Netw Open. 2022;5(11):e2242059. doi:10.1001/jamanetworkopen.2022.42059
Telehealth could improve care for patients with low income and mental health needs.1 However, despite rapid expansion nationwide,2 limited evidence exists on the association between telehealth expansion and access to care for this population. In 2019, only 6% of Massachusetts federally qualified health centers (FQHCs) used telehealth to deliver live, remote mental health services.3 By 2020, all Massachusetts FQHCs delivered some mental health services via telehealth, with vast heterogeneity in the extent of adoption.3,4 The aim of the study was to assess whether FQHC-level telehealth availability was associated with visit rates for patients with mental health diagnoses enrolled in Medicaid and served by FQHCs.
Our cohort study included patients aged 18 to 64 years enrolled in Medicaid with any baseline mental health diagnosis (eg, depression, anxiety, bipolar disorders), who were attributed to Community Care Cooperative (the largest US FQHC-based Medicaid accountable care organization, located in Massachusetts) and had 1 or more FQHC visits within the past 18 months as of each month, including 1 or more visits before telehealth expansion. The Boston University Institutional Review Board deemed the study exempt and waived informed consent because only deidentified data were used. We followed the STROBE reporting guideline.
The primary data source was the 2019 to 2021 Electronic Data Warehouse, which stores electronic health record data from Community Care Cooperative; 11 FQHCs were included and 5 with invalid telehealth data were excluded. The secondary data source was the 2019 American Community Survey. Study outcomes included (1) visit rates among patients with any mental health diagnosis and 1 of the 4 most prevalent mental health diagnoses and (2) having a follow-up visit within 30 days of a mental health–related emergency department visit, which was a contractual accountable care organization quality measure. The treatment group included FQHCs with high availability of telehealth during the COVID-19 pandemic (≥50% of all visits from April 2020 to March 2021; mean [SD], 68.0% [13.9%]), and the comparison group included FQHCs with lower availability of telehealth during COVID-19 (<50% of visits; mean [SD], 25.7% [8.6%]).
The unit of analysis was the patient-month. We used a difference-in-differences approach with negative binomial and linear probability models to examine changes in outcomes for patients at high-telehealth vs low-telehealth FQHCs before (March 2019-February 2020) vs after (April 2020-March 2021) telehealth expansion. Models were adjusted for patient age, sex, clinical risk score, zip code–level digital access, applied study month and FQHC fixed effects, with errors clustered at the FQHC level. Additional details are in eAppendixes 1 to 4 in the Supplement.
A 2-tailed P = .05 was considered to be statistically significant. Analyses were performed using Stata, version 17.0 (StataCorp LLC).
The study included 143 205 person-months among 11 267 patients (55 173 male person-months [38.5%] and 88 032 female person-months [61.5%]) with a mental health diagnosis (Table 1). Visit rates declined across all FQHCs during the COVID-19 pandemic (Table 2). However, high telehealth availability was associated with a larger relative increase in visit rates among patients with mental health diagnoses (incidence rate ratio, 2.07; 95% CI, 1.97-2.17; P <.001) compared with lower telehealth availability. Results were similar for patients with specific diagnoses of depression, anxiety, stressor-related, or mood disorders. High telehealth availability was associated with a relative increase of 7.67 percentage points (95% CI, 2.11-13.23; P = .007) in the likelihood of having a follow-up visit within 30 days of a mental health–related emergency department visit.
High telehealth availability at FQHCs was associated with better care engagement during the COVID-19 pandemic for patients enrolled in Medicaid who had mental health diagnoses despite declines in overall visit rates across all FQHCs. Study limitations included having only 1 year of posttelehealth expansion data, potential data reporting error, unmeasured confounding due to simultaneous implementation of telehealth and other pandemic-related programs, and potential limited generalizability outside Massachusetts. As supported by other research,5,6 this study suggests that care delivery models that support telehealth as part of mental health care may be associated with improved engagement for patients enrolled in Medicaid.
Accepted for Publication: October 2, 2022.
Published: November 15, 2022. doi:10.1001/jamanetworkopen.2022.42059
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Cole MB et al. JAMA Network Open.
Corresponding Author: Megan B. Cole, PhD, MPH, Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Talbot Building 240W, Boston, MA 02118 (firstname.lastname@example.org).
Author Contributions: Dr Cole had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Cole, Kim.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Cole, Davoust.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Cole, Carey.
Obtained funding: Cole, Kim.
Administrative, technical, or material support: Cole, Lee, Davoust, Kim.
Conflict of Interest Disclosures: Dr Cole reported receiving grants from the National Institute on Minority Health and Health Disparities and the National Center for Advancing Translational Sciences. No other disclosures were reported.
Funding/Support: This work was funded by the Robert Wood Johnson Foundation (grant 78235, Dr Cole) and The Donaghue Foundation Greater Value Portfolio (Dr Cole).
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: The authors acknowledge continuous input and support from Community Care Cooperative and contributions from Arcadia, which derived the study data set.