When North Carolina Medicaid analyzed what their patients’ experience was with telehealth early in the pandemic, they discovered that white, urban patients were more likely to access care digitally.
Patients who were Black, Native American, Hispanic or lived in rural areas were less likely to access their physician or other health professionals via telehealth, a review of the state’s Medicaid data showed.
That telehealth gap has gradually and slowly closed among North Carolina’s Medicaid patients since the early days of the pandemic, but concerns about equity linger, according to Shannon Dowler, MD, chief medical officer for North Carolina Medicaid. So do questions about how to best incorporate telehealth for everyone going forward and how it will be paid for, Dr. Dowler said in an interview taking part in a panel discussion on telehealth at the 2023 AMA State Advocacy Summit.
These are the questions that payers, policymakers and physicians need to figure out, Dr. Dowler said.
“It's the ultimate in patient-centered care to be able to provide the right care to the right person at the right time. Sometimes that's going to be telehealth, and if we close the door on it completely, it's really a disservice,” she said.
Supporting telehealth is an essential component of the AMA Recovery Plan for America’s Physicians.
Telehealth is critical to the future of health care, which is why the AMA continues to lead the charge to aggressively expand telehealth policy, research and resources to ensure physician practice sustainability and fair payment.
Closing equity gaps
One concern Dr. Dowler flagged after receiving results from a Consumer Assessment of Healthcare Providers and Systems survey was that Black and Native American Medicaid patients were much less likely to be offered telehealth as an option.
Dr. Dowler said it’s necessary to discover why that is and come up with ways to prevent a widening telehealth gap. Another thing she fears will contribute to widening the digital health divide is patients too often accessing their physicians by phone only.
“It's easier to pick up the phone, but that's—I think—ultimately the lowest-value care in the grand scheme of things. If we do too much of that with certain populations because they don't have access to digital literacy or devices or broadband, we're actually setting them up for worse outcomes down the road,” Dr. Dowler said. “You can't do a diabetic foot exam on the phone. You could do aspects of a diabetic foot exam on video and you can do a complete diabetic foot exam in person, but you can't do any of that on the telephone.”
Learn more with the AMA issue brief, “Equity in Telehealth: Taking Key Steps Forward” (PDF).
Ensuring access, payment
Beyond divides in who is receiving telehealth, there are also concerns over how to move forward in a way that patients are able to access telehealth as part of their medical care.
The North Carolina Medicaid CAHPS survey results showed only one in four Medicaid patients had even been offered telehealth in the prior year.
“It's being offered less and less,” Dr. Dowler said. “In talking to friends who are physicians, they prefer the traditional style of medicine and having somebody in the room and having their vital signs and getting to lay eyes on them, but they recognize that there's value in telehealth. But it's complicated. How do you fit that into a work schedule and how do you know—in the post-pandemic world—how long that payment is going to last?”
While the $1.7 trillion omnibus legislation signed by President Joe Biden extended telehealth payment and regulatory flexibilities for two years, there is variation at the state level. It’s true that all 50 states and Washington, D.C., cover video visits, according to a presentation by Jacqueline Marks of Manatt Health during the panel discussion that Dr. Dowler took part in.
But only 17 states cover all four modalities of telehealth: video visits, audio-only visits, remote patient monitoring, and store and forward. The latter is when a patient’s medical information is transmitted electronically, usually to a specialist, who uses the information to evaluate the case or render a service outside of a real-time or live interaction.
According to the Manatt data, there are:
- 34 states and Washington, D.C., covering audio-only visits.
- 34 states covering remote patient monitoring.
- 25 states covering store and forward.
Acknowledging the uncertainty regarding telehealth payment, North Carolina Medicaid put permanent policies in place last year so that practices would know what is covered and what isn’t. But, she said, a lot of payers haven’t done that yet and physicians are left wondering if telehealth payments will eventually go away.
“If we can provide a summary of which plans cover which things in permanent policy in a way that is really accessible” for physicians and others, “they'd be more likely to say: OK, this is how we're going to invest in this process or this platform,” Dr. Dowler said.
N.C. Medicaid plans to continue to work with the Payers Council, a group of all the public and commercial payers in North Carolina that meets to work through issues, and provide just that kind of clarity.