Telemedicine Boomed for Mental Health, but Rural Patients Still Cannot Get In

The promise was straightforward: if psychiatrists, psychologists, and therapists could see patients by video, geography would stop being a barrier. Rural communities with few or no mental health providers would finally have access. The technology was ready. The pandemic forced adoption. Telemedicine use among mental health specialists surged.

It did not work the way anyone hoped.

The numbers from 17,742 specialists

Researchers from the Brown University School of Public Health, Harvard Medical School, and McLean Hospital analyzed Medicare billing records from 2018 to 2023 for 17,742 mental health specialists. They grouped the providers by how heavily they used telemedicine and compared the patient populations each group served.

The differences were marginal. Specialists who used telemedicine the most saw only 0.9 percentage points more rural patients than those who used it the least. They saw 0.1 percentage points more patients from areas designated as lacking reliable access to mental health care. And they treated 2.6 percentage points more patients located 20 or more miles away.

Those modest increases came with a catch: they primarily reflected existing patients who had moved to areas farther from their providers and continued care via telemedicine. The specialists were maintaining old relationships, not building new ones in underserved areas.

The results were published in JAMA Network Open.

An unintended trade-off

The study also revealed an unintended consequence. Specialists using telemedicine most heavily actually saw 3.6 percentage points fewer new patients overall. Virtual visits may help providers maintain long-term relationships with existing patients, but they appear to reduce capacity for taking on new ones -- the opposite of expanding access.

This makes sense from a scheduling perspective. If virtual visits make it easier for existing patients to keep appointments (no travel, no time off work), the clinician's calendar fills up with follow-ups, leaving fewer openings for new patients. Good for continuity of care; bad for access.

Why telemedicine alone is not enough

The fundamental barrier is not technology. It is licensing. Most mental health professionals are licensed by the state in which they practice. A psychiatrist in Boston cannot treat a patient in rural Montana without holding a Montana license, regardless of whether the visit is in-person or virtual. Getting licensed in multiple states is expensive and administratively burdensome.

Lead author Jacob Jorem of Harvard Medical School pointed to licensing reform as the critical first step. Making it easier for clinicians to practice across state lines would directly address the geographic mismatch between where providers are concentrated and where patients need care.

What the study cannot tell us

The analysis covers Medicare patients only, which skews toward older adults. Patterns among younger adults, children, and those with commercial insurance or no insurance may differ. The study also cannot explain why providers are not reaching into new geographic areas with telemedicine -- whether it is licensing barriers, patient outreach challenges, reimbursement differences, or provider preference.

And the time period -- 2018 to 2023 -- captures the pandemic surge but may be too early to see longer-term shifts as telemedicine becomes more established.

The gap between potential and reality

Study author Ateev Mehrotra, a professor at Brown, put it directly: telemedicine's potential cannot be ignored, but simply offering it will not address the barriers that rural patients face. The technology is necessary but not sufficient. Without policy changes -- particularly around cross-state licensing -- telemedicine may continue to primarily benefit patients who already had access to care, rather than extending it to those who do not.