Telemedicine use by Texas Medicaid patients grew statewide even pre-COVID, especially in rural areas

Telemedicine has been presented as a cost-effective alternative to in-person care and a way to provide services for those facing barriers to conventional care. For example, people living in rural areas often face provider shortages and transportation challenges. Additionally, telemedicine services could help people with disabilities (many of whom are covered by Texas Medicaid) and people with mental health issues.

Until now, however, information on how mental health telemedicine services in Texas are used and have grown in different regions of the state has been scarce. A new study that is part of a larger, funded study conducted by faculty at the Texas A&M University Population Informatics Lab helps fill this gap.

“We focused on people who have long-term needs for mental health care and who are most likely to face barriers to in-person care,” said Hye-Chung Kum, PhD, who led the team.

Kum and Benjamin Ukert, PhD, both in the Department of Health Policy and Management at the Texas A&M University School of Public Health, and Mark Lawley, PhD, from Texas A&M’s College of Engineering, analyzed Texas Medicaid claims and telemedicine care growth overall and for those with a mental health condition along rural, urban and suburban residence in the state from September 2012 through August 2018.

The team assessed Medicaid claims data for nearly 520,000 patients diagnosed with schizophrenia, bipolar disorder or depression, and around 9 percent of those had received some type of telemedicine care. These data include inpatient and outpatient care, plan enrollment and information on patient demographics and eligibility.

The analysis also considered patient location, categorizing counties with a population of less than 2,500 as rural, those with between 2,500 and 250,000 residents as suburban, and counties having 250,000 or more as urban. The researchers examined changes in the number of Medicaid patients receiving care from providers who deliver telemedicine services, those receiving telemedicine care, those receiving mental health care and those using telemedicine mental health services during the study period. They also analyzed growth rate changes based on geography.

“We found that growth in telemedicine care was strong in urban and rural areas between 2013 and 2018—even before the COVID-19 pandemic—with notable regional variations,” Ukert said.

The number of disabled Medicaid patients with a telemedicine visit grew by 81 percent overall during the study period, though there was notable geographic variation. Suburban patients had the slowest increase in telemedicine use, but rural patients showed a 181 percent increase in telemedicine use despite the number of rural patients only increasing 32 percent.

The researchers also found a 77 percent increase in the number of mental health telemedicine patients, with rural mental health telemedicine patients increasing by 160 percent. This increase and the increase in total mental health patients in rural counties points to a promising possible increase in mental health care being provided in rural areas.

The researchers also found that mental health patients using telemedicine had two to three more mental health visits per year than mental health patients not using telemedicine. This could indicate that telemedicine care leads to more care; however, whether this is truly beneficial for Medicaid patients with disabilities remains to be seen.

The analysis also found a geographical shift in disabled Medicaid patients using telemedicine. In 2013, 25 percent of these patients lived in urban counties. In 2018, this had shifted to 38 percent. Rural counties saw an opposite shift, going from 15 percent to 8 percent. The researchers also noted a decrease in the share of disabled patients with mental health diagnoses, driven mostly by decreases in suburban and rural counties. Urban disabled Medicaid patients showed a slight increase in mental health diagnoses, however, suggesting greater access to mental health providers in those counties.

The researchers note a few limitations to their study that must be considered. It is possible that their analysis included some phone visits, as codes for audio-only visits were not available prior to 2020. The findings may also not be generalizable to non-disabled Medicaid patients in Texas or disabled Medicaid patients in other states. Limited broadband internet access in rural parts of Texas could have also limited telemedicine growth relative to other states. Lastly, Texas Medicaid has covered telemedicine services since 1997, so there may be more providers able to provide remote care than other states.

“While telemedicine does not appear to be a substitute for in-person care among patients with mental health diagnoses, it could provide benefits like better medication adherence and continuity of care,” Kum said. “Telemedicine could serve as a cost-effective way to complement conventional health care services.”