Telehealth is now a long-term part of Medicare mental health care

Telehealth has become a significant part of mental health care for Medicare patients, mostly replacing in-person visits instead of adding more care, while total spending remains higher than before the pandemic, according to a study published in JAMA Network Open.

During the COVID-19 pandemic, the government eased guidelines around telehealth, leading to a sharp rise in virtual mental health visits. While earlier studies looked at telehealth changes for people with employer-based insurance, less is known about Medicare fee-for-service patients.

These patients represent a large share of mental health care users who often face challenges with access and cost. To understand trends, researchers analyzed monthly data on telehealth and in-person outpatient mental health visits and related spending among Medicare fee-for-service beneficiaries. The study focused on five common mental health conditions that account for about three-quarters of all diagnoses in this population.

Researchers from RAND Healthcare and Brown University reviewed all Medicare fee-for-service beneficiaries who had outpatient mental health visits from January 2019 to December 2023. They included visits with outpatient or telehealth codes and diagnoses of anxiety, depression, bipolar disorder, schizophrenia or posttraumatic stress disorder. Visits were counted if the diagnosis was primary or secondary. The study also divided the timeline into pre-pandemic, acute pandemic and post-pandemic periods.

The study included 9.5 million Medicare fee-for-service patients; about two-thirds of those were women, with $8.1 billion in mental health spending. Before the pandemic, only 2.1% of outpatient mental health visits were telehealth. During the pandemic, telehealth visits rose to 54.4% and later dropped to 42.9%. This trend was similar across mental health conditions.

For example, depression visits went from 2.4% before the pandemic to 57.3% during and 44.2% after. Total monthly visits stayed mostly the same, averaging about 9,000 visits per 100,000 patients before the pandemic, rising to 10,642 during and 9,395 after.

Spending on outpatient mental health care increased from $71,109 to $91,003 per 10,000 patients per month during the pandemic and stayed higher at $87,792 afterward. Telehealth spending alone rose from $973 to $15,673 during the pandemic and settled at $12,415 after. These results show that telehealth mostly replaced in-person visits while overall spending remained higher.

According to telehealth.org, policy changes have also helped telehealth become a permanent option for Medicare patients. The Consolidated Appropriations Acts of 2021 and 2023 removed limits on where behavioral health visits can happen, allowing patients to receive care from home using video or audio-only visits when needed.

New rules let marriage and family therapists, mental health counselors and clinicians at community and rural health clinics bill Medicare for virtual mental health services. Most patients must have an in-person visit within six months of starting telehealth and then annually, which ensures oversight while keeping care convenient.

The study has significant strengths because it analyzed mental health care trends over five years, including a period of major health care disruptions. It shows telehealth became a lasting part of care while overall visits stayed stable.

Its limitations include its focus on Medicare fee-for-service patients only, lack of data on patient outcomes and no comparison of younger and older groups. Results also depended on how pandemic periods were defined and on recorded claims data.

The authors suggest future research on outcomes and other patient groups to better understand the long-term impact of telehealth.