This study illuminates the TMH utilization among a pediatric population in Mississippi, revealing notable disparities across sociodemographic groups. Key determinants of TMH utilization include age, race, primary insurance type, rural residency, and household income. This study found that adolescents were more likely to utilize TMH services compared to younger children. Younger children, conversely, at risk for developing mental and behavioral disorders might require specific hands-on clinical assessment, including physical examinations, which cannot be fully met through TMH services.27,28

Notably, although UMMC is located in Jackson, where over 80% of the population identified as Black/African American,29 this group accounted for less than half of pediatric mental and behavioral health patients and were less likely to utilize TMH services compared to their White/Caucasian counterparts. This discrepancy may point not only to systemic inequalities in healthcare access but also to digital disparities that disproportionately affect underrepresented communities.30

Moreover, these digital disparities likely extend to include economic dimensions. Children who were either commercially insured or had other types of insurance, as well as those hailing from households with incomes above $50,000, were more likely to utilize TMH services compared to their less affluent counterparts, specifically those on Medicaid or with household incomes below $42,000. A possible explanation is that families with greater financial resources may have better access to requisite technology and reliable internet connectivity. The higher likelihood of using TMH among urban patients, compared to their rural counterparts, may reflect the unmet healthcare needs among rural residents.

Parents and guardians play an indispensable role in pediatric TMH utilization, given that youth typically rely on their parents to access care.28 As such, the sociodemographic characteristics and digital literacy of the family unit have become highly influential factors. Families restricted by limited access to reliable internet or suitable digital devices may find TMH services less accessible, thereby exacerbating existing health disparities. Hence, in alignment with previous studies that highlight the relationship between income and digital disparities,31 strategies aimed at increasing TMH adoption should consider patient-centered approaches to avoid exacerbating health inequities.11,30

This study further revealed the multifaceted effect of TMH on HCRU and medical expenditures among pediatric patients. Initially, the TMH cohort exhibited notably higher mental and behavioral health associated HCRU and medical expenditures. Conversely, the TMH cohort showed significantly lower overall healthcare services on all fronts. After adjusting for sociodemographic factors, the higher frequency of mental and behavioral health associated outpatient visits and medical expenditures remained statistically significant, as did the lower all-cause medical expenditures. These data indicate that TMH serves as a particularly effective channel for increasing access to outpatient mental and behavioral services, without exacerbating inpatient or ED utilization, underscoring its role in delivering efficient care.

The importance of mental and behavioral health in overall well-being is well-documented.32,33,34 The Centers for Disease Control and Prevention (CDC) has pointed out that youth with poor mental health are at increased risk of drug use, violence, and high-risk sexual behaviors, which can lead to human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), and unintended pregnancies.35 Previous research demonstrated the association between outpatient mental and behavioral health services and medical cost savings, predominantly in adult, commercially insured, and diagnosed with cancer cohorts.21,36,37 Building on these findings, this study extends this understanding to pediatric patients and suggests that enhanced access to mental and behavioral healthcare via TMH could offer broader benefits, including mitigating associated high-cost health risks and contributing to overall medical cost savings.

Lastly, this study suggests that underlying health disparities may be significant. While unadjusted figures indicated significant differences in inpatient admissions and ED visits between TMH and non-TMH cohorts, these differences diminished after adjusting for sociodemographic factors. This observation underlies the necessity for interventions to ensure equitable healthcare access across sociodemographic groups.

Several limitations should be considered. Firstly, the results are largely confined to the pediatric population receiving care at UMMC, an academic medical center. Consequently, these findings may not fully represent the broader pediatric landscape across Mississippi. Nonetheless, the study offers an important microcosm that sheds light on systemic health inequities. This study aimed to address the gap in literature regarding access to TMH among this population. Future work is warranted to address this gap in practice. Secondly, the potential for missing data on HCRU and medical expenditures is another limitation of selection bias, particularly when patients access mental and behavioral healthcare services from alternative institutions. An attempt was made to mitigate this by focusing on insured patients who consistently sought care from UMMC, but this approach could introduce a bias in the results. Future work should aim to address these limitations by expanding the scope of the study to include a more diverse range of healthcare settings and demographic groups, as well as the diversity in service use patterns.