Telehealth– using telecommunications to improve patient care – has the potential to improve health care access and quality, especially in rural and medically-underserved areas. But inconsistent public and private insurance coverage and other challenges have hindered implementation of this promising health care tool.
The National Academy for State Health Policy’s (NASHP) Patient-Centered Outcomes Research Workgroup met recently to explore how these telehealth services can be effectively deployed, and discuss what new state policies and funding are needed to implement this health care resource.
The Patient Centered Outcome Research Institute’s (PCORI) portfolio of research into telehealth includes 70 PCORI-funded studies that focus on a variety of populations and telehealth intervention strategies. The workgroup reviewed two of the recently completed studies:
- One study compared the effectiveness of using telehealth to monitor African-American and Latino patients from disparity communities who had been hospitalized for chronic heart failure with patients from the same community who received usual care, without the telehealth intervention. The patients in the study group used telehealth self-management (TSM), which included weekly video-visits with a provider (accessed from the patient’s home) and daily patient self-monitoring, combined with usual care. The study found that TSM patients used the emergency department four-times less and had two-times fewer hospitalizations than the “usual care” group. Although the number of participants was small (104), the study showed potential for improving patient care and lowering costs.
- Another study tested the impact of video house calls on the quality of life and care of people with Parkinson’s disease. The study compared patients who received usual care with patients who received usual care and up to four video house calls with specialists over a 12-month period. Patients who received the virtual house calls found them convenient, however, they reported no differences in quality of life and their quality of care measures were similar to patients who received only usual care.
Insurance Coverage Impacts Telehealth Implementation
While most state Medicaid programs cover telehealth, policymakers in the workgroup reported limited usage of telehealth by providers, citing inconsistent coverage as a potential reason for the lag in implementation. State officials attributed the limited uptake to providers’ hesitance to integrate telehealth when there is not uniform insurance coverage of telehealth across payers. Clinicians, not wanting to provide different types of care based on a patient’s insurance, may avoid telehealth because of the coverage disparity. Additionally, large hospital systems that operate in multiple states grapple with varying insurance coverage between states.
Many states have passed laws to better coordinate telehealth coverage in an effort to increase its utilization. For example, Washington State recently passed SB 5175 that requires all private insurers to cover telehealth services, creating better alignment across public and private payers. Currently, 34 states and Washington, DC require private insurers to cover some degree of telemedicine, such as e-visits, when a patient in one location virtually connects with a provider in another location. While Medicaid and some private insurers cover telehealth services, coverage varies greatly depending on the insurance plan, state requirements, local community resources, and patient circumstances. As a result, providers must navigate a patchwork of telehealth coverage.
Facility Fees and Telehealth
Workgroup members noted that hospitals and health systems may delay telehealth due to a lack of coverage for transmission or facility fees. Currently, health care organizations charge facility fees for patients’ use of hospital facilities and equipment. For telehealth services, some states allow coverage of transmission fees, which is the amount paid to the originating site for providing real-time communication.
One state official cited providers’ reluctance to use telehealth if they do not receive a facility fee or compensation for the use of equipment during telehealth services. As of 2018, 32 state Medicaid programs allowed payment of a transmission or facility fee when telehealth is used, while other states may not cover these fees due to budget concerns. Many states that don’t currently reimburse transmission or facility fees have large rural populations (e.g., Alabama, Alaska, Arizona, Arkansas, Idaho, Kentucky, and Wyoming). As a result, the inability to charge facility fees may pose an obstacle to enabling telehealth to expand access in rural areas. Some states have begun to troubleshoot this issue by creating carve-outs for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs), which may serve as potential access points for rural communities to obtain telehealth services. Georgia’s Medicaid program allows RHCs, FQHCs, and Local Education Agencies to collect a facility fee when telehealth services are used. Similarly, Missouri’s Medicaid program allows FQHCs and RHCs to be reimbursed for facility fees when telehealth services are delivered.
Sustaining Pilot Projects
Many states have actively integrated telehealth through pilot projects. For example, the Alabama Department of Public Health Telehealth Program established telehealth clinics in most of the state’s county health departments by distributing telehealth “carts,” or mobile medical kiosks with video conferencing, and digital medical tools, such as a digital stethoscope, that allow patients to connect with remote specialists from local clinics. Alabama plans to install telehealth capacity in all 67 of its county health departments, and it has entered into partnerships for specific telehealth services, such as pre-colonoscopy counseling and monthly consultations with neurologists for children with special health needs. Other states, including Oregon, have supported telehealth pilots through delivery reform grants such as State Innovation Model Initiatives. While pilot projects help states advance their understanding of telehealth, including implementation challenges, time-limited grants or short-term demonstration projects are often not financially sustainable. Outside of sustained funding mechanisms, pilots often have only a limited impact on care delivery.
More research and work continues on telehealth initiatives, and NASHP will continue reporting updates in the months ahead.
Photo credit: Shutterstock.com.
Thursday, August 16th
1:30pm – 3:00pm
A robust, health care workforce enables states to ensure accessible, affordable, and high-quality health care. However, workforce and population demographics are changing and posing new challenges. As innovation in health care and an aging population increase the need for services, states face critical shortages of nurses, doctors, and other professionals, especially in rural areas. This session highlights how states are working across public and private sectors to leverage resources and use data and technology to address critical health care workforce shortages.
ModeratorDr. Norman Thurston, Representative, Utah State Legislature
Director, Office of Health Care Statistics, Utah Department of Health
Dr. Thurston has a Masters and Ph.D. in economics from Princeton University. Dr. Thurston has been a policy analyst and health economist for the Utah Department of Health in various roles for 15 years, including work on health systems reform. Currently, he is the Director of the Office of Health Care Statistics
Before joining the state, Dr. Thurston worked for eight years as an assistant professor of economics at Brigham Young University.
In 2014, Dr. Thurston was elected to the Utah House of Representatives.
SpeakersFrederick Payne, Commissioner, Indiana Department of Workforce Development
Fred Payne was appointed Commissioner of the Indiana Department of Workforce Development in November 2017 and assumed his new role a month later. He leads DWD’s Executive Team in developing, communicating, executing and sustaining the agency’s strategic initiatives, including establishment of key performance indicators.
Mr. Payne came to DWD from Honda Manufacturing of Indiana, LLC (HMIN), where he served as Chief Administrator, Secretary and Compliance Officer, after being General Counsel and Manager of Corporate Affairs.
Prior to Honda Mr. Payne was in private practice.
Dawn Hunter, Deputy Cabinet Secretary, New Mexico Department of Health
Dawn Hunter is a Deputy Cabinet Secretary for the New Mexico Department of Health. In this role, she has oversight of four program areas, including Public Health, Epidemiology and Response, the State Laboratory, and Health Facilities Licensing and Oversight. Dawn is the former Policy Director and continues to oversee the policy office. Dawn first joined the New Mexico Department of Health as a Visiting Attorney in Public Health Law through the Robert Wood Johnson Foundation Visiting Attorney Program. Prior to this, Dawn was a microbiologist in the Advanced Biosensors Laboratory in the Center for Biological Defense at the University of South Florida, specializing in the rapid detection of food- and waterborne pathogens. Dawn also has experience in residential foster care, child protective services, and foster care adoptions. Dawn has an AB in English Literature from Princeton University, a BS in Microbiology and an MPH in Global Communicable Disease from the University of South Florida, and a JD from Stetson University College of Law. She is a member of the Florida Bar, and is Certified in Public Health by the National Board of Public Health Examiners.
States with large rural populations face unique challenges in ensuring access to care. While approximately 16 percent of the U.S. population lives in rural America, only about 11 percent of physicians practice in rural locations. Additionally, individuals in rural areas face long travel distances to see primary care providers and specialists. Many states are using technology to overcome these barriers to accessing care and to improve the health of rural populations.
Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Telehealth allows patients in one location to connect with providers in another location through interactive video conferencing, telephone or another type of technology. States are using these methods to help make care more easily accessible to rural populations and eliminate the long travel or wait times to see providers located in clinics or hospitals far from their home communities.
States have adopted different definitions for telehealth. While there are many similarities in how states have defined telehealth, states have tailored their definitions to meet the needs of the population and healthcare landscape in their state.
- Forty-eight states and the District of Columbia have a definition in law, regulation, or their Medicaid program for telehealth, telemedicine (which is less broad in scope than telehealth and is generally used to describe the delivery of remote clinical services), or both.
- In Alaska, Kentucky, and Nevada the term is explicitly defined in law or policy.
- A number of states such as Hawaii and Louisiana have put restrictions within their definition to exclude the use of specific technology like audio-only telephone, fax machine and/or email.
Forty-six states provide some form of Medicaid reimbursement for telehealth services but there may be limitations on the types of providers or services covered. States may reimburse for telehealth under Medicaid as long as the service satisfies federal requirements of efficiency, economy and quality of care. States have the flexibility to decide how to structure and administer their Medicaid telehealth policy.
- Only physicians can provide and receive reimbursement for telehealth services in Florida while in Georgia a physician, physician assistant, clinical psychologist, nurse practitioner or clinical nurse specialist qualify.
- Nine state Medicaid programs reimburse for “store and forward” technology, which allows for the electronic transmission of digital images, documents and pre-recorded videos through secure email transmission. Arizona’s Medicaid program covers the most extensive list of services including cardiology, dermatology, and surgery follow-ups.
- Fourteen states offer Medicaid reimbursement for remote patient monitoring (RPM) to collect patient clinical data such as vital signs and blood pressure, but many of these states have restrictions associated with its use. For example, in Minnesota, RPM reimbursement is only available for skilled nursing visits and in the Elderly Waiver and Alternative Care programs. InColorado, patients must be receiving services for at least one of the following conditions: congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes.
States are using telehealth to provide mental health services to rural populations.Telehealth can allow rural health clinics to expand their expertise to include behavioral health specialists who are not located in the community. The scope of services providers can deliver via telehealth may include mental health assessments, substance abuse treatment, counseling, medication management, and monitoring.
- To address high rates of suicide and substance abuse in remote areas, the Alaska Medicaid program reimburses for critical behavioral health treatment and follow-up services delivered through telehealth.
- Idaho Medicaid will reimburse for a limited number of mental health conditions and developmental disabilities, and only for participants who live in designated rural health professional shortage areas. Maryland Medicaid also reimburses for certain telemental health services in specified rural geographic areas.
States are addressing provider training and licensing issues associated with telehealth. Ten state medical boards issue special licenses or certificates related to telehealth. The licenses may allow an out-of-state provider to deliver services using telehealth in a state where they are not located, or allow a clinician to provide services via telehealth in a state if certain conditions are met. The Federation of State Medical Boards has a model policy state medical boards can use as a guide for regulating the use of telemedicine across state lines.
- New Mexico offers out-of-state providers a special telemedicine license to practice within its borders for up to three years. Providers can renew their license at the end of the three-year period.
- Louisiana can issue a telemedicine license to out-of-state physicians as long as they hold a full, unrestricted license in another state. However, out-of-state telemedicine providers cannot open an office, meet with patients, or receive calls from patients within Louisiana.
- Similarly, in Oregon, out-of-state physicians may receive a license to practice telehealth within Oregon, as long as they are fully licensed in another state and meet certain requirements.
While telehealth is a promising strategy for connecting rural populations to health care services, remaining challenges and limitations may include the speed, quality and availability of Internet connections in rural areas. States with rural populations can consider adopting policies to support telehealth to expand access to necessary health care services as well as improve on existing reimbursement and licensure policies for telehealth services.
For additional information, see the Rural Assistance Center’s page on telehealth use in rural healthcare. Let us know what your state is doing related to telehealth in a comment below.