Primary care telehealth in a dynamic healthcare environment from digital divide to healthcare outcomes

Our findings demonstrate that telehealth in primary care is associated with reduced inpatient admissions, 30-day readmissions, and medical and medication spending, while highlighting persistent sociodemographic disparities in telehealth utilization. By accounting for time-invariant and time-varying factors, particularly primary care utilization patterns that reflect the dynamic healthcare environment during COVID-19 pandemic, we provide a nuanced yet thought-provoking perspective on its healthcare resource utilization, economic, and access implications.

Impact on healthcare access, resource utilization, and medication adherence

Telehealth was more commonly accessed by younger beneficiaries, females, White individuals, those entitled to Medicare due to disability, Medicaid enrollees, those residing in non-rural, non-HPSA regions, and individuals with a higher CCI. These findings align with existing literature^6,17, highlighting a significant digital divide and suggesting that certain sociodemographic groups, particularly older adults, racial minorities, and those in rural or underserved areas with poor health status may face greater barriers to accessing telehealth.

The observed increase in outpatient and ED visits post-weighting for the entire sample suggests that telehealth may facilitate triaging and expanded access to care, enabling earlier interventions, which could ultimately reduce hospitalizations. Driven by convenience and the patient-perceived need for immediate medical attention, patients may use ED visits as a substitute for outpatient care, sometimes after contacting the office of primary care physicians^18,19,20. However, these increases did not translate into higher inpatient or readmission rates. These were actually reduced, potentially indicating improved care coordination or more effective chronic condition management.

Subgroup analysis among beneficiaries with multiple chronic conditions further supported the robustness of most findings, while revealing nuances in outpatient utilization patterns for those with more complex healthcare needs. Unlike the entire sample, telehealth use in this subgroup was associated with a decrease in outpatient visits, likely reflecting both the more complex medical needs and telehealth-facilitated medication reconciliation or titration²¹, thus reducing the need for outpatient care.

The subgroup analysis also showed that telehealth was associated with improved adherence to antihypertensive medication but reduced adherence to antidiabetic and antilipidemic medications. This may reflect the relative ease of managing hypertension compared to diabetes, which often requires more frequent monitoring and treatment adjustments that are harder to achieve remotely^22,23. Additionally, the COVID-19 pandemic limited in-person outpatient services, potentially affecting medication adherence. Future work should further examine how telehealth can complement in-person care to enhance service quality and medication adherence. Hyperlipidemia, in contrast, is typically asymptomatic, yet antilipidemic medications can cause side effects requiring closer follow-up and in-person consultations, potentially impacting adherence²⁴. Moreover, antidiabetic and antilipidemic medications are generally more expensive than antihypertensive medications. As medication adherence often involves out-of-pocket costs, financial strains may further hinder adherence, particularly for patients managing multiple chronic conditions²⁵.

While telehealth enhances access to primary care services, it may not fully address sociodemographic barriers or alleviate the financial burdens that impact medication affordability, which are crucial for effective chronic disease management. Together with the observed sociodemographic disparities in accessing telehealth, these findings underscore the urgent need to optimize the future telehealth policy to better address the complex needs of underserved populations and ensure the access to care for all.

Reconsidering quality and cost narratives

Some studies have linked telehealth services to lower quality, citing increases in hospitalizations for ambulatory care-sensitive (ACS) conditions⁹, including chronic and acute conditions such as hypertension and diabetes, for which hospitalization can be potentially preventable. However, ACS metrics were originally designed to assess access to care for the uninsured rather than the quality of care provided. Their widespread misuse as proxies for quality of care in recent years has raised concerns among many researchers²⁶. Careful selection of outcomes and thoughtful interpretation are essential when translating statistical significance into practical policy recommendations^7,8.

Contrary to recent studies that link telehealth to lower quality and higher costs^8,9, our results indicate that telehealth use was associated with reductions across all medical and pharmacy spending categories. This difference may stem from our focus on telehealth within the primary care context, emphasizing accessibility, continuity, coordination, comprehensiveness, and whole-person care¹. Unlike prior studies^7,8,9, we adjusted for dynamic primary care utilization factors as confounders, serving as proxies for the key dimensions of primary care. As highlighted by a previous study¹³, telehealth was mostly utilized by patients whose medical needs required multiple primary care visits, further supporting the importance of these adjustments. By incorporating time-invariant and time-varying sociodemographic and primary care practice factors, our approach accounts for key aspects of the evolving healthcare environment during the COVID-19 pandemic, providing a more nuanced understanding of telehealth’s impact.

The persistent upstream of health disparities

Social determinants of health (SDoH) often drive patients’ healthcare needs, prompting them to use telehealth to fulfill primary care needs. Our findings, coupled with increased disparities, healthcare utilization and spending reported in other studies^11,17, may reflect a higher underlying healthcare need rather than a direct consequence of telehealth usage itself. By careful adjustments, our findings suggest the need for future research to disentangle whether increased healthcare utilization is driven by patients’ needs leading to telehealth use, rather than telehealth use driving increased utilization and costs.

Equity efforts should span every level from the upstream of SDoH to access equity, service equity, and ultimately health equity. By focusing on these interconnected dimensions, future telehealth policies and interventions can better support underserved populations while ensuring that telehealth fulfills its promise of equitable and effective care. As recommended by Nakamoto et al., given the dynamic nature of the healthcare landscape, it is imperative to continuously monitor the policy impacts on quality and spending⁸. Before COVID-19, telehealth was primarily designed to provide accessible care for underserved populations. With its expansion during the pandemic, future efforts should carefully consider how to broaden access while addressing pre-existing disparities across the spectrum, from upstream SDoH to downstream health outcomes.

Limitations

Several limitations of this study should be noted. First, our focus on Medicare beneficiaries in Mississippi may limit the generalizability of our findings to other states or populations, particularly those in more urbanized or resource-rich regions. Second, although we controlled for time-invariant and time-varying sociodemographic and primary care practice confounding factors, the findings rely on the no unobserved confounders assumption. Provider-level information within primary care practices that was not captured may have influenced our findings. The rapid expansion of telehealth during the pandemic may have introduced temporary shifts in healthcare practices that are not fully reflected in our data.