State Medicaid agencies hurried to develop telehealth policies at the outset of the pandemic. During a recent webinar put on by Manatt Health, Shannon Dowler, M.D., chief medical officer for North Carolina Medicaid, explained how telehealth was rolled out in her states and discussed ongoing challenges in making some of those changes permanent.
Before the pandemic, North Carolina Medicaid had only one telehealth policy use case —you had to be in a primary care office seeing a psychiatrist remotely. Three months before the pandemic, the Medicaid organization began developing a telehealth modernization plan. “We said that we think with three years and lots of dollars and legislation, we can modernize our telehealth program,” recalled Dowler. “Little did we know that we were going to do all of that and more in a six-week period only months later.”
Like North Carolina, many states had very limited experience with telehealth in their public payer space. “We rapidly launched a telehealth response team, and we included lots of stakeholders from within Medicaid but also externally, to make sure that what we were doing made the most sense,” Dowler said. “We went through a fairly structured process to make decisions on what we would put into temporary policy and what we would put into permanent policy. Then we worked really closely with the field to get their feedback as we went through this process.”
Usually changing clinical policy in a Medicaid program is like moving a ship in a really narrow channel, Dowler said. It’s slow and difficult. “But we were able to turn on dozens, if not hundreds, of flexibilities within weeks of the department making those decisions. Each one came with a lot of thoughts and in discussion about whether we were going to improve care or create risk for our members.”
“It felt like a lot of responsibility to rapidly change things without doing that due diligence we would normally do,” she said, but “we needed to keep people at home as we learned how to respond to the pandemic. We got way outside the box and thought really creatively about what we could do to take care of people if there was a stay-at-home order so that their healthcare wasn't negatively impacted.”
One of the first guiding questions that they put to themselves was around equity from the lens of racial, ethnic, gender, age, and geography. “We scrutinized a lot of our decisions. And in some ways we really struggled with whether something might actually exacerbate inequities versus make them better, which was, I would say, a fairly unpopular thought at the time,” Dowler said. “So another thing we looked at a lot was confidentiality and privacy. Of course, at the federal level, a lot of things were waived temporarily, but it was really important to us that we made sure that folks were safe and being able to have their privacy guarded, knowing that people were taking calls from home and doing group visits from home.”
Dowler said they had to plan for which use cases would be shorter term and how they would be unwound. “We knew we needed to give the field plenty of time so that they could prepare for things going away,” she said. “We created a very concrete process early on and as we finished turning things on, we were planning how we were going to turn things off. It did take quite a while to go through the rigor of all the steps that we put into this before we made decisions around permanent policy coverage.”
As they got all those things in place, they still struggled with determining whether it was equivalent or lower-quality care. “We wanted to make sure that outside of the public health emergency when we had all these flexibilities, would Medicare rules or Medicaid rules come into place that meant we couldn't cover things,” Dowler said. “We had a strong legal, regulatory and compliance arm that looked at every one of our temporary provisions and helped us decide whether they could be put into permanent policy.”
They also looked at utilization data. The Medicaid agency can get reports at any time: how many people have had a speech therapy code provided remotely in this age range by race or ethnicity or by geography. “One of the big promises we heard from the get-go was telehealth as a solution to overcoming health inequities,” Dowler said, “and that we’re going to be able to get more care to more people in the rural population.” From the data, she said, that wasn't necessarily the case. As they considered turning off services, the first counter-argument was that it's an equity issue. “In fact, oftentimes it was really the white urban members that access the services. So having it available remotely didn't actually drive the equity that we had hoped to see,” she said.
Sam Thompson, associate director for program evaluation at North Carolina Medicaid, provided details about their tracking of telehealth utilization. He said they did see lower rates of telehealth use for older Black, Hispanic and rural beneficiaries. “They're certainly not as dramatic as some disparities we see in other areas of Medicaid utilization, but they are worth noting,” he said. “They do tend to persist over time; they haven't lessened.”
Telehealth has been hugely useful, especially in the behavioral health space related to prescriptions as well as day-to-day care, while some of the more physical-oriented services have dropped off, especially as COVID vaccines picked up and social distancing decreased. “We see a still a great deal of popularity for behavioral health-related services.”
In terms of disparities identified, Black beneficiaries were 1 percent to 1.5 percent less likely to use telehealth, Hispanic beneficiaries were about 3.5 percent less likely. In rural areas, there was a slightly larger disparity, with the rural population about 4 percent less likely to use telehealth, Thompson said. Conversely, with the population of people with chronic conditions, NC Medicaid saw a 25 percent higher probability that those people would use telehealth initially, later decreasing over time down to 14.1 percent.
Another concerning data point involves asking patients if they were offered telehealth appointments. For instance, only 14.6 percent of the Hispanic population was offered telehealth as compared to 22.5 percent of the non-Hispanic population. “This is concerning,” Thompson said. “Our program-side folks are considering avenues for having providers offer it more broadly to remove any bias in this space.”
Dowler mentioned several ongoing challenges. “The equity issues that Sam referenced are real,” she said. “The fact that our Black members are offered telehealth at a lower rate consistently than our white members suggests that there's some implicit bias happening in healthcare. So there's work to do on the equity front, which is not a surprise to anybody out there.”
Another challenge is integrating telehealth into the permanent delivery system. “We turned on our permanent decisions really early on because we wanted people to know that if they were making this investment, it was going to stay around,” Dowler said. “But a lot of payers still haven't said what's going to go into their permanent policy. So that's really hard for practices. What we're seeing is utilization is just going down, down down. People are going back to business as usual. How do we stop that from happening? How do we make sure that we're getting the highest quality of care for our members?”
There's a balance between innovation and making sure that you're doing really high-quality care, she said. “How do we make sure that we continue to study it and learn from it? How do we go further? How do we augment audio-visual telehealth with remote patient monitoring? What are the things we haven't tried yet? How do we challenge ourselves, with all the competing priorities that are going on right now, to make sure that we're continuing to be creative and thinking about these things.”