Payer Mix Association with Primary Care Telehealth Service Trajectories

Context: Telehealth became an essential tool to assist care delivery in the outpatient primary care settings during the COVID-19 pandemic. Previous studies documented that the type of insurance coverage was associated with the likelihood of a patient receiving care through telehealth. How this finding translates to a clinic’s willingness and capacity to offer telehealth services is unknown.

Objective: To determine whether the payer mix (Medicaid versus private commercial insurance) and other clinic characteristics resulted in differential telehealth service initiation and trajectories among outpatient clinics in 2020.

Study Design and Analysis: In this retrospective cohort study, outpatient visits were identified in the Arkansas All-Payer Claims Database (APCD). Given the complex dynamics associated with being designated as a federally-qualified health center (FQHC), proportion of Medicaid patients, and proportion of telehealth services, an advanced statistical method of mixture modeling with known groups was used to separate these effects.

Dataset: Insurance claims submitted to APCD from April through December, 2020.

Population Studied: 5,373 healthcare providers in Arkansas.

Measures: The outcome measure was the number of monthly telehealth services submitted for reimbursement per provider clinic. The primary exposure was the percentage of Medicaid patients’ claims at clinic level. Other predictors included rural and urban classification area, number of claims submitted by mental or behavioral health specialists, patient characteristics, and FQHC status.

Results: A higher proportion of Medicaid paid clinic visits was associated with both lower telehealth utilization (p=0.011) and higher rate of decrease in telehealth utilization (p<0.001) over the study period. FQHCs started with a slightly higher rates of telehealth services in April, 2020 (p=0.005), but ended up with lower rates of telehealth services than non-FQHCs by December, 2020. Among non-FQHCs, the proportion of Medicaid visits were associated with a higher initial rate (p<0.001) but also a higher rate of decrease in telehealth usage over the study period (p<0.001). However, among FQHCs, a variation of the proportion of Medicaid visits was not associated with the rate of telehealth usage.

Conclusions: Our findings highlight the need to address the barriers that FQHCs and clinics with a high proportion of Medicaid patient visits experience in order to sustain the use of telehealth.