Telehealth Monitoring, Research and Evaluation: Issues for State Medicaid Agencies to Consider

Background

The use of telehealth increased exponentially in 2020 and 2021 as health care providers and patients responded to the COVID-19 pandemic. The Government Accountability Office (GAO) estimated that the use of telehealth services by Medicaid enrollees increased 15-fold from March 2020 to February 2022.¹ This increasing utilization was spurred in part by Medicaid agencies adjusting policies and reimbursement to expand the array of services that could be delivered via telehealth.

As Medicaid agencies look to the future, many are analyzing telehealth utilization, quality and expenditures to evaluate whether and how to expand telehealth policies permanently.² In addition to state activity, the federal government continues to evolve telehealth policy. For a comprehensive list of federal and state developments in telehealth policy since the beginning of the pandemic, please see Manatt on Health’s Telehealth Tracker.

State Medicaid agencies are also working to understand the ongoing impact of telehealth on service use, access to care, quality and equity. Despite the increase in telehealth use, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) found that state Medicaid programs had limited data with which to provide oversight for telehealth services and understand its impact.³ The OIG found that states would benefit from expanding telehealth data collection and monitoring, developing additional billing controls, and evaluating the impact of telehealth on the quality of care. These and other measures would allow state programs to optimize the use of telehealth while mitigating risks to care quality and program integrity.

Issues for Consideration

Assess domains for telehealth monitoring and evaluation

State Medicaid agencies should consider the following domains of measures for telehealth research, monitoring and evaluation:

• Access and utilization
• Most frequently used services (e.g., outpatient medical, behavioral health)
• Disparities and equity
• Quality and outcomes of care
• Enrollee and provider experience

Comprehensive data in these areas can be leveraged to inform current and future state telehealth policymaking. For example, understanding telehealth use by service type (e.g., outpatient medical or mental health) could serve as a data-driven management tool to revisit and update benefit and policy decisions regarding reimbursement, enrollee consent, appropriateness of telehealth modality and other issues. Additionally, as with the implementation of any new service, states are working to understand how to best monitor and evaluate utilization and identify issues with clinical quality or program integrity.⁴

Understand what telehealth data are available for monitoring and evaluation

To understand what questions can be answered and what policy and program issues can be addressed, state Medicaid agencies need a comprehensive understanding of available telehealth data. Data will largely be from claims, but some programs may also collect beneficiary and provider experience data through surveys. Some data questions for consideration include:

• Do submitted claims include telehealth modifiers? Synchronous and asynchronous modalities?
• Is there a claims submission lag? If so, how long before claims with telehealth modifiers are available for analysis and reporting?
• Do the claims data allow for a differentiation of service modality (e.g., video visit, audio-only visit, in-person visit)?
• Does the state collect data on beneficiary and/or provider satisfaction with telehealth use?
• Do the data collected allow the state to answer its priority questions (e.g., how does telehealth contribute to access to services for different demographic groups)?

Provider billing, claims submission and reimbursement are inherently complex, and telehealth has added other requirements. Claims data may not yet include thorough data to use for telehealth monitoring and evaluation. Some questions for consideration include:

• Are updates needed to provider manuals and/or claims adjudication systems to accurately capture telehealth modifiers?
• Does encounter data from managed care plans have the requisite information?

Key telehealth program and policy questions to address in the short term

Medicaid programs should consider the different internal and external purposes and audiences when building an approach to using telehealth data. These purposes include policy development and refinement, program integrity, and understanding access to services. States would have to prioritize questions to address. Some questions include, but are not limited to:

• How does post-pandemic telehealth utilization by modality type compare to pre-pandemic utilization?
• What are the most commonly delivered services via telehealth modalities?
• How does telehealth, and the different modalities therein, contribute to access to services and changing use patterns?
• For different population groups (e.g., race/ethnicity, eligibility categories) and regions (e.g., urban, rural), how does telehealth contribute to access to services?
• What are the characteristics of providers who do and do not leverage telehealth services?

Report on telehealth utilization

Telehealth utilization is an area of broad stakeholder interest. Monitoring telehealth utilization would allow states to report to their internal and external stakeholders, including the legislature, providers and consumer advocates. Analysis and reporting can occur on a short-term timetable (e.g., annual reporting), while others, as noted below, may require longer time periods. Programs may have numerous options for making data and reports available. States can consider these issues:

• Who are the key audiences (e.g., program directors, legislature), and what questions do they have about telehealth?
• How does telehealth reporting fit with the state’s other reporting regimens (e.g., format, periodicity)?
• Does the state have dashboards for reporting and monitoring service use? Are they internally or externally facing?
• What kinds of resources are available to dedicate to telehealth data collection, analysis and reporting?
• Does the state currently make claims data available to external parties (e.g., researchers, advocates)?

Addressing some telehealth impact questions will require longer-term evaluations

The questions and considerations above focus on data analysis and monitoring with a short-term time frame, such as annual reporting on utilization. Some states may be interested in answering questions about the impact of telehealth utilization that are longer term and more evaluative in nature. These evaluation questions are likely to be more methodologically challenging and may require multiple data sets and external research partners or contractors. Answering the research questions below may help address how best to deploy telehealth policy and resources. States can consider addressing:

• How do patients and providers perceive the use of services delivered via different telehealth modalities? How do perceptions vary by race/ethnicity, language and other demographic factors?
• How do beneficiaries and providers perceive telehealth services compare to those delivered in person?
• What impact does telehealth have on Medicaid expenditures (e.g., total costs of care, provider type, types of visits)?
• How do telehealth services contribute to quality of care—for example, to specific HEDIS measures about prevention (e.g., the relationship of telehealth visits to annual screenings) and continuity of care (e.g., outpatient follow-up care after emergency department visits or hospitalization)?
• Have telehealth services reduced racial/ethnic or geographic disparities in access to care or health outcomes?
• What barriers prevent providers from billing telehealth services or prevent patients from utilizing them?
• To what extent are providers including correct procedure codes/modifiers to appropriately indicate use of telehealth, and how can fidelity be improved?

State Spotlight: California Medicaid and Telehealth Research and Evaluation

In July 2021, the California Legislature passed AB 133, requiring the California Department of Health Care Services (DHCS) to convene a Telehealth Advisory Workgroup to provide payment and policy guidance to inform development of the state budget. The state had already been analyzing and reporting some basic measures of telehealth use. In legislation the following year, the state also required DHCS to develop the DHCS Telehealth Research and Evaluation Plan, which was released in December 2022. The plan proposes near- and long-term research questions to evaluate the impact of telehealth on Medi-Cal beneficiaries and opportunities for telehealth data collection, reporting and analysis.

_{¹ Government Accountability Office. Telehealth in the Pandemic—How Has It Changed Health Care Delivery in Medicaid and Medicare? September 29, 2022. https://www.gao.gov/blog/telehealth-pandemic-how-has-it-changed-health-care-delivery-medicaid-and-medicare}  

_{² Kaiser Family Foundation. How the Pandemic Continues to Shape Medicaid Priorities: Results from an Annual Medicaid Budget Survey for State Fiscal Years 2022 and 2023. October 25, 2022. https://www.kff.org/report-section/medicaid-budget-survey-for-state-fiscal-years-2022-and-2023-executive-summary/}

_{³ U.S. Department of Health and Human Services. Office of the Inspector General. Insights on Telehealth Use and Program Integrity Risks Across Selected Health Care Programs During the Pandemic. November 30, 2022. https://oig.hhs.gov/oei/reports/OEI-02-22-00150.asp}

_{⁴ U.S. Department of Health and Human Services. Office of the Inspector General.}