JMIR Publications

ABSTRACT

Background:

When HHS instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many new telehealth flexibilities were fast-tracked to care for sick populations that were isolated at home. These flexibilities allowed for State Medicaid programs to issue reimbursement for new telehealth specialty services, new sites of care, and new mediums such as Skype to communicate with patients. Effectively, a new system of care was created that allowed many financially vulnerable patients in the Medicaid space to more easily access care, as evidenced by an uptick in telehealth utilization rates. Research-to-date has mostly focused on telehealth reimbursement for more narrow use cases such as rural primary care, with limited consideration for how telehealth can be appropriately mainstreamed and sustained.

Objective:

This study sought to do the following: (1) evaluate the continuation of telehealth reimbursement flexibilities more broadly beyond the COVID-19 pandemic, (2) analyze the clinical effectiveness of the new telehealth services, and (3) offer code-by-code reimbursement guidance to State Medicaid leaders.

Methods:

We surveyed 10 State Medicaid Medical Directors who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an online survey with a list of CPT/HCPCS codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis beyond the PHE. Additional questions covered more detailed recommendations, such as: reimbursing video-with-audio vs audio-only, guardrails for certain specialty services, and motivations behind responses.

Results:

State Medicaid Medical Directors felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, although some were more comfortable with video combined with audio compared to audio-only. More than half of supportive respondents also felt that there should be continued guardrails for reimbursement. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health which had the most support for audio-only. The full list of code-by-code guidance is attached in the appendix. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity amongst the Medicaid patient population.

Conclusions:

There is strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video-combined-with-audio telehealth with caution for audio-only telehealth. This endorsement is scoped to services approved by HHS during the pandemic. Disapproval was shown for clinical situations where visualization or hands-on-intervention was necessary for diagnosis or treatment. These results are primarily from a perspective of clinical appropriateness and health equity on a state-by-state level and should be complemented with other factors such as fiscal and technical implementation.