Use of Telemedicine and Quality of Care Among Medicare Enrollees With Serious Mental Illness

Abstract

ImportanceDuring the COVID-19 pandemic, a large fraction of mental health care was provided via telemedicine. The implications of this shift in care for use of mental health service and quality of care have not been characterized.ObjectiveTo compare changes in care patterns and quality during the first year of the pandemic among Medicare beneficiaries with serious mental illness (schizophrenia or bipolar I disorder) cared for at practices with higher vs lower telemedicine use.Design, Setting, and ParticipantsIn this cohort study, Medicare fee-for-service beneficiaries with schizophrenia or bipolar I disorder were attributed to specialty mental health practices that delivered the majority of their mental health care in 2019. Practices were categorized into 3 groups based on the proportion of telemental health visits provided during the first year of the pandemic (March 2020-February 2021): lowest use (0%-49%), middle use (50%-89%), or highest use (90%-100%). Across the 3 groups of practices, differential changes in patient outcomes were calculated from the year before the pandemic started to the year after. These changes were also compared with differential changes from a 2-year prepandemic period. Analyses were conducted in November 2022.ExposurePractice-level use of telemedicine during the first year of the COVID-19 pandemic.Main Outcomes and MeasuresThe primary outcome was the total number of mental health visits (telemedicine plus in-person) per person. Secondary outcomes included the number of acute hospital and emergency department encounters, all-cause mortality, and quality outcomes, including adherence to antipsychotic and mood-stabilizing medications (as measured by the number of months of medication fills) and 7- and 30-day outpatient follow-up rates after discharge for a mental health hospitalization.ResultsThe pandemic cohort included 120 050 Medicare beneficiaries (mean [SD] age, 56.5 [14.5] years; 66 638 females [55.5%]) with serious mental illness. Compared with prepandemic changes and relative to patients receiving care at practices with the lowest telemedicine use: patients receiving care at practices in the middle and highest telemedicine use groups had 1.11 (95% CI, 0.45-1.76) and 1.94 (95% CI, 1.28-2.59) more mental health visits per patient per year (or 7.5% [95% CI, 3.0%-11.9%] and 13.0% [95% CI, 8.6%-17.4%] more mental health visits per year, respectively). Among patients of practices with middle and highest telemedicine use, changes in adherence to antipsychotic and mood-stabilizing medications were −0.4% (95% CI, −1.3% to 0.5%) and −0.1% (95% CI, −1.0% to 0.8%), and hospital and emergency department use for any reason changed by 2.4% (95% CI, −1.5% to 6.2%) and 2.8% (95% CI, −1.2% to 6.8%), respectively. There were no significant differential changes in postdischarge follow-up or mortality rates according to the level of telemedicine use.Conclusions and RelevanceIn this cohort study of Medicare beneficiaries with serious mental illness, patients receiving care from practices that had a higher level of telemedicine use during the COVID-19 pandemic had more mental health visits per year compared with prepandemic levels, with no differential changes in other observed quality metrics over the same period.

Impacts of Telehealth Adoption on the Quality of Care for Individuals With Serious Mental Illness: Retrospective Observational Analysis of Veterans Affairs Administrative Data

“…Although telehealth helped preserve health care access during COVID-19, these findings suggest potential tradeoffs in quality metrics for individuals with SMI, particularly in PC engagement and continuity of care in psychotherapy or psychosocial rehabilitation settings and ICM programs. Though others report that practice-level telehealth use was associated with more visits per year for individuals with SMI [ 8 ], a subset of patients with SMI may require more robust supports (eg, from peers or case managers) to use telehealth without reducing access. Training and technical support may be necessary to overcome barriers such as hardware and software needs, broadband access, technological illiteracy, and condition-related aversions to technology mediated communication (eg, delusions) [ 10 11 ].…”

“…During the first 6 months of the pandemic, rapid telehealth growth was associated with lower MH use among individuals with SMI [ 7 ]. A recent study of specialty mental health practices with higher telehealth use found that Medicare patients with SMI had more visits per year, but no differences in medication refills, postpsychiatric hospitalization follow-up, or all-cause mortality [ 8 ].…”