Older Medicaid Beneficiaries Had Higher Rates of Telemedicine Visits During COVID-19 Pandemic

Older Medicaid beneficiaries had significantly higher telemedicine use during the COVID-19 pandemic compared with younger beneficiaries, according to a new report. Results of the claims-based analysis, using data from January 2018 to December 2020, were published in Journal of Medical Internet Research.

Prior to the pandemic, telemedicine use was uncommon in Louisiana, accounting for less than 1% of total office visits. However, COVID-19 hit the state hard and fast: The first case in Louisiana was confirmed on March 9, 2020, and within days, Louisiana had the highest infection rate in the United States, study authors wrote.

Although telemedicine has the potential to reach patients of all ages, “there remain concerns about the rapid transition to telemedicine during COVID-19 owing to long-standing inequities in telemedicine access, including unequal levels of digital literacy and broadband connectivity along the age distribution,” the researchers wrote.

The investigators said Louisiana was well suited for their review: Residents generally experienced more health challenges than those in other states. Furthermore, as the only Medicaid expansion state in the Deep South, 40% of its population was covered by Medicaid and the Children’s Health Insurance Program.

In the study, which included 850,821 Medicaid beneficiaries, patients dually eligible for Medicare and Medicaid were excluded because study investigators lacked access to Medicare claims.

Using data from the Louisiana Medicaid Claims Data Warehouse, analysis was limited to claims submitted with evaluation and management (E&M) codes, which have a high level of substitutability between in-person and telemedicine delivery. The older beneficiaries used E&M services at a higher rate than younger beneficiaries both before and during the pandemic.

The researchers differentiated in-person and telehealth visits by claim modifiers or with a place of service code. However, they could not distinguish between video and telephonic telemedicine visits using the available data.

To evaluate age-based trends, they divided Medicaid beneficiaries into 4 age categories: 0 to 17, 18 to 34, 35 to 49, and 50 to 64 years. Time series models were applied to analyze changes in care pattern trends and levels during peak infection periods (April 2020 and July 2020) and for end-of-year infection (December 2020).

Results showed that telemedicine E&M claim volume spiked in April 2020, coinciding with the first wave of peak COVID-19 infections in Louisiana and the state’s Department of Health’s guidance to providers to substitute telemedicine services for in-person services “when appropriate to do so.”

Telemedicine use increased across all age groups beginning in April 2020. However, increases were most pronounced in patients aged 50 to 64 years, who saw the largest absolute increase and the largest relative increase, a 70-fold gain over baseline levels. Baseline rates were calculated per 1000 beneficiates from January 2018 through February 2020.

In this age category, telemedicine claim volume saw increases above baseline of 184.09 (95% CI, 172.19-195.99) claims. In comparison, beneficiaries aged 18 to 34 years saw an increase of 84.47 (95% CI, 78.64-90.31) claims and those aged 35 to 49 years saw an increase of 154.66 (95% CI, 143.26-166.05) claims.

Sharp increases in telemedicine claim volume also appeared during a second infection peak in July 2020, followed by flat trends thereafter until December 2020. Still, the trend of higher telemedicine use among older age beneficiaries continued through year-end.

The authors said their study had important limitations. It did not distinguish between video and telephonic visits, so results could not address the effect of digital literacy across age groups. They also cautioned that findings from a Medicaid population might not generalize to other populations. Furthermore, past studies on the association between age and telemedicine had mixed findings, they noted. However, research has typically focused on patients at a single medical center or those seeking care from narrow subsets of providers, such as otolaryngologists. In contrast, their study examined a broad patient population receiving all manner of evaluation and management services.

Despite limitations, the authors believe their findings can help guide policy makers as they continue to debate the merits of extending COVID-19-era flexibilities.

“Our findings can inform this policy debate by highlighting the link between the transition to telemedicine services during the pandemic and access to care for older Medicaid beneficiaries,” they concluded. 

Reference

Park S, Walker B, Anderson A, Shao Y, Callison K. Telemedicine use by age in Louisiana Medicaid during COVID-19: claims-based longitudinal analysis. J Med Internet Res. Published online April 26, 2023. doi:10.2196/46123