Increased flexibility in the delivery and payment of telehealth across many coverage programs, but particularly in Medicaid and CHIP, throughout the COVID-19 pandemic has been a significant shift for some states. Many state officials are considering if and how to adapt rapidly implemented telehealth policies as the nation emerges from the public health emergency. Existing and emerging patient-centered research can help inform these important decisions.
The Patient-Centered Outcomes Research Institute (PCORI), a nonprofit research institute that funds comparative, patient-focused healthcare research, has made substantial investments in telehealth studies. As a result, there is available evidence on patients’ willingness to use various technology supports, as well as their health outcomes using varied telehealth methods versus receiving care in person. The dynamic nature of telehealth, including rapid acceleration of technology, can present challenges for how best to apply existing evidence to new and evolving contexts. However, there may be relevant research targeting a specific question that is likely not related to the pandemic, but that can be used to inform current policymaking.
For instance, patient-centered evidence released this past year based on a study comparing care delivered online versus in person for patients with psoriasis indicates no major difference in health outcomes. The findings also illustrate that patients receiving care online had access to specialists, but saved time traveling to and waiting at the doctors’ offices. Although the study focused narrowly on patients with psoriasis, the results may help inform policymakers on whether to continue to allow reimbursement for broader dermatological services provided via telehealth.
The National Academy for State Health Policy (NASHP) recently convened a discussion with Medicaid and CHIP state officials and Robyn Liu, MD, MPH, who is a family physician and expert in evidence-based policy decision making. The group discussed how to assess patient-centered research that isn’t targeted toward the specific policy questions officials are currently weighing. Dr. Liu highlighted the PICOT Framework, which is a tool that can help policymakers identify valuable pieces of information, even from research that may not appear to directly address the policy issues at hand. PICOT helps to analyze evidence by evaluating it in the following ways:
- Population: What population is the research focused on? What similarities or differences might the study population have to the population of interest to a state? By looking to the demographics of the population included in the study, states can evaluate how applicable the study is to their own populations.
- Intervention: What is the intervention being studied? What are similarities between what is being studied to the intervention the state is exploring? As states attempt to balance the numerous telehealth interventions being implemented, lessons may be drawn from similar efforts.
- Comparator: What are the researchers comparing the studied intervention to? How does the comparator compare to “usual care” provided in a specific state? While a study might show promising results when compared against one model of care, states need to consider whether the results would apply when compared to care typically provided to their constituencies.
- Outcome: What are the results of the study? How can these outcomes be applied to a given state’s population? Policymakers can look to the outcomes of the study, paying particular attention to how these outcomes are measured and reported and whether the outcome would be of interest to their patients.
- Timeframe: How long did the study last? Can the results be applied to long-term success? While officials continuously express a desire for speedy research, studies with short timeframes may not be representative of long-term outcomes.
Above all, Medicaid and CHIP officials strive to provide the best services possible for enrollees while being good stewards of public funds. By leveraging available patient-centered evidence and related tools, state officials can inform how to adapt (or not) their current telehealth policies to ensure that care will result in equal or better outcomes than if those services are accessed in person. As states continue to look to understand and refine their telehealth policies, NASHP will continue to convene with groups of state officials and share lessons on their emerging issues and how patient-centered research can be applied to their work.
Studies from the Patient-Centered Outcomes Research Institute
- The research team assigned patients by chance to get either usual hospice care or hospice care plus the PAINRelieveIt program.
- All patients had a tablet computer. They used the tablets to record information about their pain and pain medicine each day for six days.
- Before and after the study, patients filled out surveys about their pain, and patients and caregivers filled out surveys about how to manage pain.
- The study found no differences between patients who used PAINRelieveIt and patients who got regular hospice care in:
- How often patients took their pain medicine as prescribed;
- How well patients understood how to manage pain;
- How satisfied patients were with their pain levels.
- Caregivers who used PAINRelieveIt understood more about how to manage pain than caregivers who didn’t use the program.
- The research team assigned babies and their parents by chance to one of two groups. In one group, clinic staff tested the babies every month during visits to see if they should receive more, less, or the same amount of oxygen.
- Babies took part in a sleep study, where doctors watch babies’ oxygen levels overnight in the clinic, to see if they were ready to stop receiving oxygen.
- Babies in the second group also visited the clinic monthly for testing. In addition, parents in this group checked their babies’ oxygen levels at home.
- Parents filled out surveys about their quality of life at each clinic visit and three months after home oxygen therapy ended.
- Babies who had their oxygen checked at home safely stopped home oxygen therapy sooner than babies who had their oxygen checked only at monthly visits.
- Parents’ quality of life didn’t differ between the two groups. Compared with the start of the study, parents in both groups reported higher quality of life three months after stopping home oxygen therapy.
- In this study, the research team compared four ways to treat arm weakness due to stroke, including options for patients to do more at home:
- In-person Constraint-Induced Movement Therapy (CIMT);
- In-person CIMT with gaming;
- Video chat CIMT with gaming;
- Standard care.
- All types of CIMT improved daily arm use more than standard care right after treatment. In-person CIMT had the greatest improvement.
- Overall, patients maintained about 61 percent of the improvement in arm use six months later.
- Types of CIMT with the most therapist contact—in-person CIMT and video chat CIMT with gaming—maintained the most improvement in arm use.
- In-person CIMT and video chat CIMT with gaming improved arm control and speed more than standard care right after treatment but not six months later.
- The research team assigned patients to one of three groups by chance.
- Patients in the first group received text messages on their cell phones with reminders to check their blood sugar and take their medicine and received text messages to encourage behaviors to control their illness;
- Patients in the second group talked on the phone or in person with a community health worker. At first, community health workers had frequent calls with each patient and often attended patients’ clinic visits. After two months, patients decided how often they would be in contact with the community health worker, mostly once a month;
- The third group received both text messages and talked with a community health worker. All programs lasted for one year.
- The team looked at:
- How patients managed their illness;
- How often patients needed urgent care or went to the hospital or emergency room;
- How much stress diabetes caused the patients.
- The study found that all three methods worked about the same to improve patients’ health and encourage healthy behaviors.
- At the end of the study, patients in all three groups met more of their healthcare goals. They also had lower blood sugar and cholesterol levels.
- Patients in all groups were more likely to monitor their blood pressure than at the start of the study, and their worry about diabetes decreased.
- Patients in all groups had fewer hospital and urgent care visits but didn’t have fewer emergency room visits.
- State Use of Patient-Centered Outcomes Research in Telehealth Policymaking by Amanda Attiya, Christina Cousart, and Maureen Hensley-Quinn; December 8, 2020.
- Patient-Centered Outcome Research Institute Informs States’ Use of Telehealth by Amanda Attiya, Christina Cousart, and Maureen Hensley-Quinn; September 8, 2020.
- Questions Remain as States Look to Evidence-Based Research to Inform Adoption of Telehealth by Christina Cousart and Maureen Hensley-Quinn; April 13, 2020.
- States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth by Johanna Butler and Christina Cousart; September 30, 2019.
- State Officials Consider Patient Preferences when Evaluating Telehealth Evidence by Johanna Butler; December 2, 2019.