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A cohort study published in JAMA Network Open finds that increased telemedicine adoption among mental health specialists was associated with only marginal gains in care delivery to rural, low-income, or underserved communities, raising pointed questions for policymakers who have long counted on virtual care to solve the geographic maldistribution of mental health services.
The study, led by researchers at Brown University School of Public Health and Harvard Medical School, examined Medicare fee-for-service claims for 17,742 mental health specialists between 2018 and 2023. Specialists were grouped by telemedicine uptake in 2021, ranging from those conducting fewer than 40% of visits virtually to those conducting nearly 100% virtually. Using a difference-in-differences framework, the researchers measured changes in the share of each specialist's patients living in rural areas, in mental health shortage counties, in other states, or more than 20 miles from the practice.
The findings were sobering. Compared with low-adopters, the highest telemedicine users showed a differential increase of just 0.88 percentage points in rural patient visits by 2023. A meaningful portion of even that modest gain was attributable not to specialists reaching new patients in underserved areas, but to established patients who had simply moved farther away and continued care remotely. High-telemedicine specialists also saw a 3.55 percentage-point reduction in new patients overall, suggesting that extended retention of existing patients may be crowding out access for those seeking care for the first time.
The authors argue that reimbursement reform, dedicated referral pathways, and interstate licensure flexibility may be necessary for telehealth to fulfill its equity promise in mental healthcare.
