Michelle Savuto, Manager, Manatt Health | Jacqueline Marks-Smith, Senior Manager, Manatt Health | Jared Augenstein, Managing Director, Manatt Health | Dr. Shannon Dowler, Chief Medical Officer, North Carolina Department of Health and Human Services | Sam Thompson, Deputy Director - Program Evaluation, North Carolina Department of Health and Human Services
Editor’s Note: In a new issue brief published by the Milbank Memorial Fund and summarized below, Manatt Health and leadership from the North Carolina Department of Health and Human Services (NC DHHS) share insights into inequities in telehealth utilization rates among Black and Hispanic Medicaid and Children’s Health Insurance Program (CHIP) enrollees brought to light by the COVID-19 pandemic, as well as key strategies for improving equitable telehealth access and delivery. Click here to read the full issue brief.
Manatt Health and leadership from NC DHHS will be discussing North Carolina’s transformation in telehealth policy as well as lessons learned during the COVID-19 pandemic and beyond in a new webinar on November 13. The program will share the state’s innovative approach to telehealth policymaking, which can serve as a model for other states and stakeholders. Click here to register for the free webinar. For more information on telehealth policy lessons learned in North Carolina during and after the pandemic, read our previous article here.
Telehealth holds great potential as a tool to support improved access to and continuity of care.1 For a variety of reasons, this promise has been largely unfulfilled.2 The onset of the COVID-19 pandemic in early 2020 spurred a dramatic rise in telehealth adoption and use that was facilitated by the relaxation of federal and state rules and regulations.3, 4, 5 North Carolina rapidly evolved its telehealth coverage and reimbursement policies as a result of the pandemic and studied the impact on access to care. (For more information, please refer to NC DHHS’ policy evaluation brief “Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond” and companion chart pack.)
North Carolina’s Medicaid Telehealth Policy Transformation
NC DHHS’ prepandemic telehealth policy was restrictive relative to that of other states, allowing reimbursement for only a narrow set of telehealth encounters.6 Because of these barriers, telehealth use within the state’s Medicaid and CHIP program accounted for a negligible proportion of total claims.
At the onset of the COVID-19 pandemic, NC DHHS took early action to promote expanded delivery of Medicaid and CHIP services via telehealth by making foundational changes to its telehealth clinical coverage policy, including, but not limited to:
- Eliminating distance requirements and restrictions on originating sites, including allowing the originating site to be the patient’s home
- Enabling coverage of virtual patient communication services
- Expanding telehealth-eligible services and providers to include dentistry, perinatal and postpartum care, telebehavioral health and telepsychiatry, chronic disease self-management education, and counseling
- Allowing services to be delivered via any Health Insurance Portability and Accountability Act (HIPAA)-compliant, secure technology with audio and video capabilities
- Removing the requirement for members to obtain authorization or have an initial in-person examination prior to receiving telehealth services
- Clarifying that telehealth services would be reimbursed at parity with services delivered in person
In 2021, NC DHHS codified many temporary policy changes into permanent policy, incorporating health equity into criteria to guide temporary and permanent policymaking, and engaged key partners to promote equitable access to telehealth providers, required technologies and services.7 In parallel, North Carolina made significant investments in telehealth infrastructure and provider supports throughout the COVID-19 pandemic.
NC DHHS also invested in expanding analytic capacity to measure and understand the impact of the state’s pandemic-related telehealth flexibilities, which enabled the analysis of telehealth utilization by important demographic factors such as race and ethnicity. NC DHHS leveraged these data to closely monitor telehealth use trends and member experience to identify how availability of telehealth services impacted access to care.8, 9, 10
Impact of Telehealth Policy Change on Access to Care
NC DHHS’ analyses demonstrate that, though a higher volume of telehealth encounters were conducted in urban areas than rural areas, telehealth usage as a percentage of total claims did not differ markedly by geography. By contrast, telehealth use varied by race and ethnicity,11 with lower relative probability of telehealth use among Black and Hispanic members persisting through the end of 2022. Differences in telehealth offer rates may have contributed to disparities in telehealth use by race and ethnicity, as consumer survey data show lower telehealth offer rates for Black and Hispanic members.
Conclusion
North Carolina’s data illustrate that addressing health equity may require different strategies than those needed to improve access to telehealth services in rural areas (e.g., investment in broadband infrastructure). This could mean requiring providers to offer telehealth services to all patients and to complete implicit bias training.
NC DHHS is continuing to develop policies and initiatives to promote health equity in collaboration with the governor’s office, other state departments, providers and Medicaid members. Continued monitoring will support North Carolina’s effort to identify whether and to what extent different investments, programs and policies have a meaningful impact on digital equity.
1 Abernethy A, Adams L, Barrett M, et al. The promise of digital health: then, now, and the future. NAM Perspectives. Discussion paper. National Academy of Medicine. doi:10.31478/202206e. Published June 27, 2022. Accessed June 27, 2023.
2 Turner Lee N, Karsten J, Roberts J. Removing regulatory barriers to telehealth before and after COVID-19. Brookings Institution. Published May 6, 2022. Accessed June 27, 2023.
3 Lee EC, Grigorescu V, Enogieru I, et al. Updated national survey trends in telehealth utilization and modality: 2021-2022. Issue Brief No. HP-2023-09. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Published April 19, 2023. Accessed June 27, 2023.
4 Rudich J, Conmy AB, Chu RC, Peters C, De Lew N, Sommers BD. State Medicaid telehealth policies before and during the COVID-19 public health emergency: 2022 updates. Issue Brief No. HP2022-29. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Published November 2022. Accessed June 27, 2023.
5 Caraballo C, Massey D, Mahajan S, et al. Racial and ethnic disparities in access to health care among adults in the United States: a 20-year National Health Interview Survey analysis, 1999-2018. Preprint. medRxiv. 2020;2020.10.30.20223420. doi:10.1101/2020.10.30.20223420.
6 Center for Connected Health Policy. State telehealth Medicaid fee-for-service policy: a historical analysis of telehealth, 2013-2019. Published January 2020. Accessed June 27, 2023.
7 North Carolina Department of Health and Human Services. Special Bulletin COVID-19 #237: extension of NC state of emergency temporary flexibilities. Published March 21, 2022. Accessed June 27, 2023.
8 Shah SD, Alkureishi L, Lee WW. Seizing the moment for telehealth policy and equity. Health Affairs Blog. September 13, 2021. Accessed June 27, 2023.
9 Foundation for Health Leadership and Innovation. New report reveals significant challenges for North Carolina’s rural communities. Published June 28, 2022. Accessed June 27, 2023.
10 American Immigration Council. Examining gaps in digital inclusion in North Carolina. Published December 2022. Accessed June 27, 2023.
11 Dowler S, Crosbie K, Thompson S, Drucker E, Jackson C. Telemedicine utilization trends during the COVID-19 public health emergency. North Carolina Medical Journal 2021;82(4):255-258.