Methods: Using 2010-2017 data on a 20% random sample of Medicare beneficiaries, we examine trends in the rural-urban difference in rates of specialty care visits (in-person and TMH) across all urban and rural patients. Sub-analysis focused on rural patients in counties with highest TMH use. We focus on adult Medicare beneficiaries ages 18 and older diagnosed with (1) any mental illness and (2) schizophrenia or bipolar disorder specifically. Using a mixed-effects linear regression model for each outcome, we tested the significance of the rural-by-year interaction term using the initial and final years of data only (2010 and 2017).
Results: In 2010, rural and urban beneficiaries with any mental illness received 1.75 and 2.93 specialty visits per beneficiary respectively. From 2010 to 2017, among beneficiaries with any mental illness, there was no change in the overall rural-urban difference in specialty care (0.01 visits per beneficiary; p=0.40). While TMH differentially increased in rural areas compared to urban areas by 0.04 visits per beneficiary, the difference in overall specialty care use remained. In contrast, among beneficiaries with schizophrenia/bipolar disorder, the overall rural-urban difference in specialty care increased by 0.28 visits per beneficiary (p<0.05). However, the differential growth of 0.14 visits (p<0.05) in TMH in rural areas served to partially offset the differential decline in in-person visits in rural areas (0.42 visits per beneficiary; p<0.05). In counties with the highest uptake of TMH, TMH in 2017 accounted for roughly one-quarter of all specialty visits among patients with any mental illness (0.38 TMH visits per patient) and schizophrenia/bipolar disorder (1.07 TMH visits per patient). In these communities the differential increase in TMH visits fully offset the differential decline in in-person specialty care in rural areas relative to urban areas, resulting in no significant change in the overall rural-urban difference in all specialty care.
Conclusions and Implications: While rates of in-person specialty visits in rural areas continue to lag behind those in urban areas, TMH appears to have partially offset the growing difference in specialty care use in rural areas relative to urban areas for individuals with schizophrenia or bipolar disorder. Thus, TMH could be viewed as a success in that it has stemmed the decline in rural specialty care use (relative to urban) for individuals with severe and disabling mental health conditions, although the gap remains. Given the differential declines in in-person specialty care among rural beneficiaries with severe mental illness and the role that TMH has played in offsetting those declines, targeted policy approaches to accelerate TMH specialty care use among rural beneficiaries could help to improve access to specialty care in rural areas. Proposed Medicare policy changes include allowing TMH visits to be provided in the home and increasing reimbursement.