44% of mental health patients had in-person visits before telehealth

April 11, 2024 - Between 2019 and 2022, less than half of patients had an in-person visit before a telehealth appointment for mental healthcare, new research reveals.

The US Congress has permanently allowed Medicare patients to receive telehealth services for behavioral and mental healthcare in their homes, provided they have an in-person visit with the clinician within six months before the telehealth appointment. During the COVID-19 pandemic, the in-person requirement was waived through the end of 2024.

Given the looming expiration of the waiver, researchers from Harvard Medical School, Beth Israel Deaconess Medical Center, McLean Hospital, RAND Corporation, and the Greater Los Angeles Veterans Affairs Medical Center investigated whether patients had in-person visits before telemental health visits while the requirement was lifted.

They used 2018-2022 national data for traditional Medicare beneficiaries to identify the first telemental health visit between a patient and clinician. They excluded visits for patients not enrolled in Medicare in the year prior and those with substance use disorders.

For telehealth visits included in the analysis, the researchers determined whether there was an in-person visit for any reason with the same clinician in the prior three, six, or 12 months.

The study included 4.16 million telemental health visits between 2019 and 2022. Visits peaked in April 2020 and then decreased, with 205,463 telemental health visits across 197,430 patients in 2022.

Researchers found that between 2019 and 2022, 44.2 percent of patients had a prior in-person visit before a telemental health visit with the same clinician. Most in-person visits occurred 86 days before the telehealth visit. Approximately 26.8 percent of patients had their in-person visit three months prior, 34.5 percent six months prior, and 39.4 percent 12 months before their telemental health visit with the same clinician.

The study shows that by 2022, only 18.4 percent of patients with a telemental health visit had an in-person visit with the same clinician, 28.2 percent had an in-person visit with any clinician in the same practice, and 22.3 percent had an in-person visit with a clinician from the same specialty in the same practice in the previous six months.

Further, racial gaps persisted. Black and Hispanic patients were less likely to have an in-person visit in the six months before a telehealth visit for mental health conditions.

“These findings suggest that Medicare’s in-person visit requirement will require substantial changes in current practice,” the researchers concluded. “Future work should assess quality benefits of requiring in-person care. Medicare could consider increasing flexibility for in-person visit requirements to minimize disruptions in care.”

Telehealth remains widely used in mental healthcare, even as utilization in other areas declines.

Data from Epic Research shows that telehealth use jumped to 31.2 percent of all healthcare visits in the second quarter (Q2) of 2020 before dropping to 5.8 percent of all visits in the third quarter (Q3) of 2023.

The proportion of telehealth visits peaked across all specialties in Q2 2020, with the highest telehealth use rates in mental health (65.5 percent) and endocrinology (55.5 percent). By Q3 2023, 37 percent of mental health visits occurred virtually, followed by infectious disease (11 percent).

Thus, stakeholders, including patients, providers, and policymakers, largely support efforts to preserve telemental healthcare access.

In January, US Senators Ben Cardin (D-MD), Bill Cassidy, MD (R-LA), Tina Smith (D-MN), and John Thune (R-SD) reintroduced the Telemental Health Care Access Act. The legislation aims to remove the requirement that Medicare beneficiaries be seen in person within six months before receiving telemental healthcare services.

“This bill removes barriers to allow Medicare patients to receive the telemental health services they deserve,” said Cassidy in the press release.