Recognition of telehealth as an effective strategy for delivering treatment for substance use disorder (SUD) has raised hopes for improving access to this treatment in settings with limited transportation or when time constraints compromise regular use of consistent access to in-person substance use treatment.
But the findings from a team of researchers from the Virginia Center for Health Innovation, UCLA, RAND, and MedInsight, Milliman Inc., suggest that the promise of telehealth may vary by insurance and geography.
New research suggests that people who live in rural areas may be benefiting from telehealth as a modality for substance use disorder treatment to a greater extent than their urban counterparts. Meanwhile, despite accounting for the vast majority of substance use disorder services, people covered by Medicaid managed care are less likely to use telehealth compared with their counterparts who have Medicare Advantage or are commercially insured.
"We found diminishing rates of access to telehealth substance use disorder treatments among Medicaid managed care recipients, who are largely lower-income or socioeconomically disadvantaged," Dr. Lauryn Walker, Chief Strategy Officer at the Virginia Center for Health Innovation and the study's lead author. "In contrast, telehealth use appears to be closing previously reported gaps in substance use disorder treatment among rural individuals compared with those in urban settings."
The findings are described in a research letter to be published Feb. 12 in the peer-reviewed JAMA Network Open.
As telehealth became more popular as a treatment modality, with the hope of expanding access to care, Medicaid managed care beneficiaries received fewer SUD services overall while commercial and Medicare Advantage beneficiaries experienced an increase in service utilization during the same time period. Rural individuals experienced the greatest overall increase in substance use disorder treatment among all populations studied.
The researchers used the MedInsight Emerging Experience database to examine Medicaid managed care, Medicare Advantage, and commercial insurance claims for all 50 states for about 16 million adults age 18 years and older who were insured for 12 or more months between Jan. 1, 2019 and June 30, 2023.
Key findings include:
- Monthly telehealth substance use treatment increased substantially from 45to 10,974services, while in-person treatment increased much less notably from 186,000 to 292,300 services between 2019 and 2023
- Despite the addition of telehealth as a modality of care, average monthly substance use disorder treatment services per 100,000 adults (telehealth and in-person combined) decreased 17% for Medicaid covered individuals while they increased for Medicare Advantage and commercial insurance beneficiaries by 4% and 1%, respectively
- With Medicaid-covered individuals accounting for 93% of overall SUD treatment and in-person services, but only 75% of telehealth utilization, telehealth use is notably under-represented among those insured by Medicaid. Commercial and MA members, on the other hand, disproportionately use telehealth, accounting for only 5.8% and 0.4% of in-person SUD services respectively, yet 24.0% and 1.0% of telehealth services respectively.
- Rural individuals experienced an 90% increase in overall substance use treatment per 100,000 adults between 2019 and 2023, while rising 49% among urban individuals.
- Telehealth may be contributing to the overall increased utilization for rural individuals, with 8% of telehealth services provided to rural individuals compared to 6% of overall and in-person substance use disorder treatment services.
Federal policymakers continue to evolve telehealth and in-person requirements for SUDT. Research on how various populations use telehealth for their substance use disorder treatment can inform future effective policies to improve care for all populations.
"Telehealth is a relatively new modality of care, and policies and procedures are evolving quickly," said Dr. Katherine Kahn, Distinguished Professor of Medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA and the study's senior author "Understanding who is, and importantly, who is not using telehealth is essential for creating policies that promote access to care and minimize unintended consequences of reductions in care."
There are some limitations to the study. Organizations voluntarily contribute claims to the database, potentially limiting generalizability. However, the database reflects payer coverage consistent with U.S. demographics.. Also, the findings do not include uninsured individuals as well as providers that do not accept insurance.
Study co-authors are Manying Cui and Dr. John Mafi of UCLA, Jonathan Cantor and Cheryl Damberg of RAND, and Melody Craff of MedInsight, Milliman Inc. Kahn and Mafi are also affiliated with RAND.
