Since its establishment in 2012, the Massachusetts Health Policy Commission (HPC) has advocated for, and invested in, innovative models for health care delivery that enhance access to care, meet the needs of complex patients, and safely and efficiently keep more patients in home and community-based settings. Telehealth is one such model of care delivery that leverages technology to connect patients to providers, and/or providers to other providers, when they are not in the same physical location. Modes of telehealth service delivery can include: store-and-forward (asynchronous), live videoconferencing (synchronous), and remote patient monitoring. This DataPoints issue focuses on live videoconferencing telehealth visits that occur between a patient and a provider, analyzing commercial claims data from the Massachusetts All-Payer Claims Database (APCD) for the first time.
Telehealth may improve convenience and access to care, especially when patients face barriers in travelling to a provider’s location or cannot secure a timely appointment for a potentially urgent, but not life-threatening, health care issue. Telehealth can also be useful when the geographic distribution or availability of providers does not meet the needs of patients, as is often the case for patients seeking behavioral health care. Recognizing this potential and the growing interest for telehealth options among providers, employers, and consumers, many commercial insurers have recently expanded their benefits to cover and reimburse for these visits. Telehealth can also be effective in fighting infectious disease outbreaks and may be part of a larger strategy to respond to the coronavirus disease 2019 (COVID-19), as it can be employed to triage the sick and care for others remotely.
Since little is known about the impact of telehealth efforts in Massachusetts, the HPC analyzed commercial claims for telehealth services from 2015 to 2017 (the most recent data available at time of publication) to characterize the extent and growth of telehealth usage among Massachusetts residents (note that telehealth visits that are paid for entirely out of pocket and outside of a member’s health insurance plan cannot be observed in this data). Recent state-led policy efforts and proposals to expand access to telehealth are briefly discussed at the conclusion of this issue.
The interactive graphics below will display best in full screen mode. Scroll to the bottom of each graphic and click on the far-right icon to view them in full screen mode. Use the same icon to return to the original view.
A Growing Trend
The rate of telehealth utilization among commercially-insured patients in Massachusetts almost doubled between 2015 and 2017, with sharp growth occurring between 2016 and 2017. During this time period, the rate of telehealth visits grew by 98 percent, from 2.0 visits per 1,000 members in 2015 to 4.0 visits per 1,000 members in 2017. This rate of growth mirrors trends observed in a similar national commercially-insured population, while the rate of use in Massachusetts in 2017 was 39% lower than the national rate observed in 2017 (6.57 visits per 1,000). Given the recent efforts of insurers and provider groups to expand access to these services to patients, continued growth in utilization of telehealth services in 2018 and 2019 is likely.
The following graphics use commercial claims data from 2017 (the most recent data available) to identify who is using telehealth, describe the services that were delivered and the conditions treated, and explore variation by commercial payer and provider organization.
Who is using telehealth and for what is it being used?
Commercially-insured patients who had at least one telehealth visit in 2017 were more likely to be female and younger than the overall commercial population. In 2017, 65% of all telehealth visits were for female patients, and the average age for a telehealth patient was 35 years old.
The ten most common services delivered during a telehealth visit are included in the left panel of the figure below and are sorted by volume for 2017. The highest volume visit was a 45 minute psychotherapy session (CPT 90834) with 2,420 visits. The next two most frequent visit types were for evaluation and management visits to address a medical issue (CPT 99212, 99201). The right panel of the figure below demonstrates the spending per visit (showing both what the patient and the plan/insurer would pay) for the ten most common telehealth services. The median cost of a telehealth visit was $77 while the median patient cost sharing amount was $20 per telehealth visit. Cost sharing for telehealth visits was generally quite low, with 23% of visits in 2017 delivered with zero cost sharing.
The next figure classifies telehealth visits in 2017 by diagnostic category to identify the types of conditions that were addressed using telehealth services.  In 2017 for the commercial population, more than half of all telehealth visits (63%) were for principal diagnoses related to mental health. The most commonly used diagnosis code among telehealth visits was for generalized anxiety disorder (F41.1) and accounted for 23% of all telehealth visits in 2017.
Variation by Payer and Provider Organization
Telehealth utilization can be driven by provider organization and payer efforts to expand access, availability, and ease-of-use. In addition, direct-to-consumer companies may engage patients outside of their insurer or provider network. The HPC observed variation by payer and provider organization as it relates to telehealth utilization. There was approximately five-fold variation in telehealth utilization across the five commercial payers included in this analysis. There is approximately four-fold variation of the rate of telehealth utilization across the 13 largest provider organizations in the state for their attributed commercial patients.
State Policy Landscape
In recent years, the Commonwealth has sought to expand access to telehealth services through numerous state-led efforts. The state Medicaid program, MassHealth, introduced a new benefit for behavioral health services (starting January 1, 2019) that could be rendered via telehealth. Of note, this policy established payment parity to ensure that behavioral health services provided via telehealth would be reimbursed at the same rate as in-person services. The HPC designed and implemented a one-year telehealth pilot program in 2017, which engaged provider organizations to identify how telehealth could improve access, convenience, quality, and coordination of behavioral health care for high-need target populations.
This year, the Massachusetts Legislature is actively considering significant reforms to further expand the availability and use of telehealth services across the Commonwealth. In October 2019, Governor Charlie Baker introduced legislation, An Act to Improve Health Care by Investing in VALUE, which seeks to establish coverage parity for telehealth services. The Mental Health ABC Act, passed by the state Senate in February 2020, would direct the Massachusetts Department of Public Health (DPH) to establish a pilot program implementing tele-behavioral health services in public high schools, and permits acute-care hospitals to use telehealth services to evaluate patients presenting with behavioral health issues in emergency departments. With several other bills still under review by the legislative committees on Financial Services, Ways and Means, and Health Care Financing, telehealth reform is likely to remain on the agenda throughout the 2019 to 2020 legislative session, which ends July 31, 2020.
While the threat to Massachusetts residents remains low as of the date of this publication, concerns about the COVID-19 outbreak and its potential impact on residents, caregivers, and health system capacity highlight the benefits of telehealth to triage and provide remote care and monitoring. The HPC recommends urgent action by policymakers, health plans, and providers to increase telehealth use and availability.
The HPC will continue to monitor and evaluate the impact of the provision of telehealth services on cost, quality, patient experience, and access to care in the Commonwealth.
 Barnett ML, Huskamp HA. Telemedicine for Mental Health in the United States: Making Progress, Still a Long Way to Go. Psychiatric Services (2019).
 The Massachusetts Employer Health Coalition, of which the HPC serves as a Strategic Partner, is promoting telehealth as one strategy to reduce potentially avoidable emergency department (ED) visits. https://www.maemployerhealthcoalition.com/
 Commercial claims data for this time period includes 5 of the largest commercial payers in Massachusetts: Blue Cross Blue Shield of Massachusetts, Tufts Health Plan, Harvard Pilgrim Health Care, Neighborhood Health Plan (AllWays Health Partners), and Unicare (Anthem). The data from these five payers include all medical claims for 1.8 million commercially-insured Massachusetts residents.
 Barnett ML, Ray KN, Souza J, Mehrotra A. Trends in Telemedicine Use in a Large Commercially Insured Population, 2005-2017. JAMA. 2018;320(20):2147–2149. doi:https://doi.org/10.1001/jama.2018.12354
 CPT procedure codes were used to identify the type of service rendered during a telehealth visit. Some CPT codes are identical in general description criteria (i.e. “Evaluation and management visit, established patient”) but are applicable to more than one code (CPT 99212 and 99213). The “level” (indicated by the final digit of the E&M CPT code) of an E&M visit can be defined based on time or the complexity of the visit and is determined by the billing provider.
 Telehealth visits were classified into diagnostic categories using the Clinical Classifications Software (CCS) for ICD-10-CM developed as part of the Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality (AHRQ)
 See Policy Recommendation #8, 2015 Annual Cost Trends Report; Policy Recommendation #8, 2017 Annual Cost Trends Report; Policy Recommendation #10, 2018 Annual Cost Trends Report; Policy Recommendation #1, 2019 Annual Cost Trends Report