Telemedicine: a substitute or complement for home-based medical care? the experience of Medicare enrollees with dementia.

Introduction: As Alzheimer's disease and related dementias (ADRD) progress, many individuals become homebound and increasingly depend on home-based medical care (HBMC), such as clinician house calls. The COVID-19 pandemic spurred a rapid expansion of telemedicine under Medicare, but its impact on outpatient care by modality-HBMC, telemedicine, and office-based-among enrollees with ADRD remains unclear. Methods: Using national Medicare claims, we examined changes in primary care visits-categorized as office-based, HBMC, and telemedicine-between the pre-expansion period (March 2019-February 2020) and the late post-expansion period (March-November 2021), when telemedicine use had stabilized. Analyses were stratified by regions with low vs high HBMC provider availability. Results: Regions with high HBMC availability saw a 13.6% greater increase in HBMC visits and a 5.0% greater increase in all visits compared to low-availability regions. Both groups had similar increases in telemedicine and declines in office-based visits. HBMC growth reflected broader access, with more beneficiaries receiving HBMC post-expansion. However, gains were concentrated among non-Hispanic White enrollees, with no significant changes for non-Hispanic Black or Hispanic enrollees. Conclusion: These findings suggest that Medicare's telemedicine waivers expanded, rather than replaced, HBMC. Sustaining these policies may support aging in place for individuals with dementia, though disparities in access remain a critical concern.