糖心vlog

The COVID-19 pandemic鈥搑elated shift to telemedicine has been particularly prominent and sustained in mental health care. In 2021, more than one-third of mental health visits were conducted via telemedicine.¹ While most mental health specialists have in-person and telemedicine visits, some have transitioned to fully virtual practice, perhaps for greater work-life flexibility (including avoiding commuting) and eliminating expenses of maintaining a physical clinic. The decision by some clinicians to practice only via telemedicine has gained importance due to Medicare鈥檚 upcoming requirement, effective in 2025, that patients have an annual in-person visit to receive telemedicine visits for mental illness and new requirements from some state Medicaid programs that clinicians offer in-person visits.² We assessed the number and characteristics of mental health specialists who have shifted fully to telemedicine.

This cohort study used national, deidentified commercial health insurance claims from OptumLabs Data Warehouse for commercial insurance and Medicare Advantage enrollees from January 1 to December 31, 2019, and January 1 to December 31, 2022. Harvard Medical School exempted this study from review and informed consent because data were deidentified. We followed the guideline.

We identified mental health specialists (psychiatrists, psychologists, social workers, and psychiatric mental health nurse practitioners [PMHNPs])³ who had at least 30 visits and 5 patients in both 2019 and 2022 and conducted less than 25% of visits virtually in 2019 (eTable in Supplement 1). Clinicians defined as 鈥渢elemedicine only鈥� conducted more than 95% of visits virtually in 2022. We did not use 100% because of potential billing errors. For each clinician, we captured specialty, sex, US region, whether most patients were younger than 18 or older than 65 years, proportion of patients with severe mental illness (schizophrenia or bipolar disorder), and median house value and population per square mile in the county where most of their patients resided (eAppendix in Supplement 1). We ran a multivariable logit model in SAS, version 9.4, on the likelihood a clinician provided telemedicine-only care in 2022 by clinician variables and present marginal effect estimates. Two-sided P鈥�<鈥�.05 was significant.

Among 51鈥�309 mental health specialists meeting our inclusion criteria, 13.0% provided telemedicine-only care in 2022 (Figure). The adjusted rate was highest among PMHNPs (18.7%; 95% CI, 17.1%-20.3%) and lowest among psychiatrists (9.1%; 95% CI, 8.6%-9.7%). In multivariable models, characteristics associated with greater likelihood of switching to telemedicine only were being female (adjusted rate, 14.0% [95% CI, 13.6%-14.3%] vs 11.1% [95% CI, 10.6%-11.6%] for males; P鈥�<鈥�.001) and working in counties in the top (vs lowest) quartile of housing value (16.6% [95% CI, 15.9%-17.4%] vs 8.8% [95% CI, 8.2%-9.4%]; P鈥�<鈥�.001) and population density (16.0% [95% CI, 15.4%-16.7%] vs 8.8% [95% CI, 8.3%-9.4%]; P鈥�<鈥�.001) (Table). Clinicians with a pediatric focus were less likely than general clinicians to have a telemedicine-only practice (6.7% [95% CI, 6.0%-7.5%] vs 14.1% [95% CI, 13.8%-14.4%]; P鈥�&濒迟;鈥�.001).

In 2022, 13.0% of mental health specialists serving commercially insured or Medicare Advantage enrollees had shifted to telemedicine only. Rates were higher among female clinicians and those working in densely populated counties with higher real estate prices. A virtual-only practice allowing clinicians to work from home may be more attractive to female clinicians, who report spending more time on familial responsibilities,⁴ and those facing long commutes and higher office-space costs.

It is unclear how telemedicine-only clinicians will navigate new Medicare and Medicaid requirements for in-person care. While clinicians and patients may prefer in-person care,⁵ introducing in-person requirements for visits and prescribing could cause care interruptions, particularly for conditions such as opioid use disorder.⁶

Our analysis is limited to clinicians treating patients with commercial insurance or Medicare Advantage and therefore may lack generalizability. We were also unable to determine where clinicians physically practiced, particularly if they had transitioned to virtual-health companies. Given the shortage of mental health clinicians, future research should explore whether a virtual-only model affects clinician burnout or workforce retention.

Accepted for Publication: November 21, 2023.

Published: January 26, 2024. doi:10.1001/jamahealthforum.2023.4982

Open Access: This is an open access article distributed under the terms of the CC-BY License. 漏 2024 Hailu R et al. JAMA Health Forum.

Corresponding Author: Ateev Mehrotra, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (mehrotra@hcp.med.harvard.edu).

Author Contributions: Ms Hailu had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Hailu, Huskamp, Uscher-Pines, Raja, Mehrotra.

Drafting of the manuscript: Hailu, Raja, Mehrotra.

Critical review of the manuscript for important intellectual content: Hailu, Huskamp, Busch, Uscher-Pines, Raja.

Statistical analysis: Hailu.

Obtained funding: Huskamp.

Administrative, technical, or material support: Huskamp, Mehrotra.

Supervision: Uscher-Pines, Mehrotra.

Conflict of Interest Disclosures: Prof Huskamp reported receiving grants from the National Institute of Mental Health (NIMH) during the conduct of the study. Dr Raja reported being an independent contractor with RAND for the California Health Care Foundation鈥揻unded project Secret Shopper Study of Visit Modalities for Behavioral Health Services in California. Dr Mehrotra reported receiving grants from the NIMH during the conduct of the study and personal fees from the Commonwealth of Massachusetts, Black Opal Ventures, NORC, and Pew Charitable Trust outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported by grant # 1R01MH112829 from the NIMH.

Role of the Funder/Sponsor: The NIMH had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.