Telemedicine Utilization and Impacts on Access Among Rural Medicare Beneficiaries

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PROJECT SUMMARY / ABSTRACT Candidate: Krisda H. Chaiyachati, MD, MPH, MSHP is a general internist and early-stage health services investigator passionate about improving access to health care and health outcomes for vulnerable, older, rural adults. He seeks content expertise in aging research and training in health economics to transition him towards independence and catalyze his career path towards improving health care access for older adults. Research Context: Rural, older Americans are facing an acute access crisis as fewer primary care providers and specialists work in rural areas to care for an increasingly older, poorer, sicker population. Telemedicine has been proposed as one solution to help overcome access barriers, but whether it is achieving this wanted outcome is unknown. Within fee-for-service Medicare plans—the most common insurance for rural, older Americans—telemedicine has been growing 128% per year since 2004. Understanding whether rural, older Americans with limited access have used telemedicine, how these visits have altered access, and whether telemedicine use reduces emergency department visits or hospitalizations remain fundamental questions for policymakers and providers if telemedicine is going to be promoted as a valuable way to deliver health care. Specific Aims: (1) Measure the association between telemedicine use and barriers to in-person care: residing in a county with fewer providers, having geriatric conditions, or living below the federal poverty level; (2) measure whether initial specialty telemedicine visits were follow-up visits or first-time visits and the association between barriers to in-person care and the frequency of follow-up or first-time telemedicine visits; and (3) measure the association between telemedicine use and subsequent acute care visits (emergency departments or hospitalizations), particularly among patients with geriatric conditions. Research Plan: To accomplish these aims, Dr. Chaiyachati will learn and develop quasi-experimental, econometric techniques to empirically analyze a large administrative datafile containing 2010-2018 fee-for- service Medicare Part B enrollees combined with provider supply measures, patient sociodemographics, and geographic indicators (e.g., rurality, broadband access, and transportation). Career Development Plan: Dr. Chaiyachati will (1) concentrate his passion and perspective on the needs of older adults; (2) develop expertise in analytic methods used by health economists to study large administrative datafiles; and (3) develop expertise in how telemedicine is being used and its impact in real-world settings. Dr. Chaiyachati's career development will be supported by close mentorship from international experts in geriatrics, health economics, telemedicine, and health policy. Environment: The University of Pennsylvania offers the ideal environment for him to pursue this training, with well-established mentors dedicated to his success and it is a well-resourced, interdisciplinary institution with a track record of producing successful, world-renowned, independent, health services researchers in aging.