The State of Ohio’s strategy to mitigate mortality tied to the novel coronavirus, which causes coronavirus disease (COVID-19), centers on two tactical threads. The first thread is a set of actions to suppress the spread of the virus through distancing measures such as school closures, the prohibition on large public events and the stay-at-home order. By limiting spread, or “flattening the curve,” the state can limit the rate of transmission and the delivery system is then able to use its current capacity to screen, test, treat and hospitalize patients in need in order to prevent mortality. The second tactical thread to address COVID-19 deals with the system’s capacity itself, which includes ways the health system can be enhanced to treat COVID-19 patients, protect the workforce and ensure other individuals in need of services are not put at unnecessary risk. While we have previously looked at the ways Medicaid can play a role to address the workforce, benefit and coverage needs of Ohioans, this blog takes a deeper look at how telehealth, both inside and outside of Medicaid, can support system capacity and what some of the current and future challenges may be.
Telehealth can happen synchronously (live) or asynchronously (recorded).
Services and payment
The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services defines telehealth as “the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.” Telehealth can happen synchronously (live) or asynchronously (recorded). It can also be remote (e.g., wearables) and through mobile devices (e.g., sending a note to your physician through an app). While this technology has been in place for a while, its prevalence, use, accessibility and reimbursement varies greatly. With COVID-19, what we see is a rapid expansion in the use of telehealth which can complement the ability to limit spread (by physically limiting contact) and increase capacity (by allowing many services to be managed without the need for a clinical visit).
Depending on the source of coverage, telehealth access, reimbursement and implementation can impact patients and providers differently.
Depending on the source of coverage, telehealth access, reimbursement and implementation can impact patients and providers differently. For those with private insurance, telehealth will vary plan-to-plan, depending on the nature of the contract between an insurer and the providers a person sees. In Medicare, the Centers for Medicare and Medicaid Services (CMS) has rolled out guidance for providers that outlines the more than 80 additional telehealth services billable through Medicare including common office, skilled nursing facility and hospital visits, check-ins, hospice and home health. Since many individuals enrolled in Medicare also have their benefits covered through a private insurance “Advantage” plan, consumers will also need to see how this coverage may change from plan to plan. In Medicaid, Ohio built upon existing telehealth services in Ohio Administrative Code 5160-1-18 and established emergency rules to expand telehealth to individuals with behavioral health needs and additional provider types. This includes services from nurses, speech-language pathologists and dieticians in locations such as federally qualified health centers, emergency rooms and community behavioral health providers. These rules apply to populations both inside and outside of managed care.
Key considerations
Telehealth is not available to all
First, telehealth relies on an assumption that individuals who need services have access to a phone, the internet or both. When looking at broadband access in Ohio, research shows that 1 in 11 Ohioans have no access to reliable, affordable broadband, including 1 in 3 rural residents. And, even though rural Americans face this challenge, access isn’t limited to geography. Nationally, all but 10 percent of white households have access to broadband, but 18 percent of Black households do not - an issue acutely felt in the City of Cleveland. When looking at recent research from The Brookings Institution about broadband access and race in Cleveland, and then comparing that information to chronic disease data collected by The Center for Community Solutions, we see that there is a clear relationship between the legacy of redlining, chronic disease and the potential for gaps in care through telehealth.
Telehealth relies on an assumption that individuals who need services have access to a phone, the internet or both.
Additionally, there are peripheral impacts in access to education, work opportunities and, with the closure of public libraries, census participation. The simultaneous need for distance and combined with the challenge of so many people who lack of access to regular, reliable internet service will have a negative impact.
Longitudinal impact on care
The public health benefits of telehealth during the outbreak are clear. Even though telehealth has been shown to hamper the necessary relationship-building that is useful to establish a regular source of care, evidence has demonstrated numerous positive effects in terms of outcomes. With behavioral health services, however, things are more complex. Unlike hospital systems, community behavioral health center (CBHC) providers did not receive resources through the Affordable Care Act (ACA) to develop their electronic health record systems. CBHCs are also not eligible for the same supplemental, medical, education or capital reimbursement payments that are made to hospitals. As such, the workforce and operational needs for CBHCs to accommodate telehealth are high, especially as they are acutely challenged in each of these operational areas.
Recommendations
While some internet service providers are offering reduced or no-cost access, there are still specific, infrastructural gaps for Ohio’s rural and urban residents. These gaps not only inhibit individuals’ ability to access timely, appropriate care in and outside the context of COVID-19, they also have longitudinal implications beyond the outbreak in regards to educational and workforce access disparities.
Ohio Medicaid and the state, generally, should enable access to internet, including cell phone minutes, as a covered benefit.
In the short run, however, Ohio Medicaid and the state, generally, should enable access to internet, including cell phone minutes, as a covered benefit. The state should also work with the public utilities in the state to target, if not compel, investments to permanently close these digital divides as a matter of public health. Though the Medicaid population uses technology at a rate similar to that of the general population, the proliferation of telehealth access should be accompanied by an effort to publicize the availability of these services and offer digital skills trainings. To do this, the state should make sure the telehealth management tools come with some level of training as a part of the benefit, if possible, or as an “in lieu of” case management requirement. By combining an expansion of access to broadband, generally, with an intentional design to increase access, health-wise, the state could proactively avoid repeating the legacy of redlining that created the housing-based wealth disparities that inhibit economic mobility we know today.
The state should make sure the telehealth management tools come with some level of training as a part of the benefit
Secondarily, the state should work with behavioral health providers to outline a strategy to build the capacity of the CBHC system to deliver effective, electronically-facilitated care. We can now see that excluding these providers from the ACA incentives, in the context of Ohio’s COVID-19 response, have left them inadequately prepared to facilitate access to behavioral health services. The state should examine ways to build the capacity of electronic records alongside its partners on the local and federal levels, and foundations interested in this space should examine their roles to support these providers’ needs.
