Experiences of Medicaid Programs and Health Centers in Implementing Telehealth

Telehealth, the provision of health care from a distance by means of telecommunications technology, can improve the quality of care and access to it in underserved communities by increasing access to providers, reducing wait times, and improving convenience. However, despite its potential, telehealth is underutilized by safety-net providers, including Federally Qualified Health Centers (FQHCs), due to a range of policy, organizational, and logistical barriers. Research that facilitates state-to-state learning can inform both Medicaid policy and Medicare policy going forward and provide lessons learned for FQHCs interested in starting or expanding telehealth programs.

To explore the experiences of state Medicaid programs and FQHCs in supporting telehealth and delivering telehealth services, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) commissioned RAND researchers to conduct telephone discussions with representatives of seven state Medicaid programs and 19 urban and rural FQHCs in the same states. Discussions occurred from June to August 2018 and addressed how FQHCs in selected states are using telehealth, how the delivery of telehealth services is structured, barriers and facilitators of telehealth, and how Medicaid policy influences telehealth implementation.

Types and Models of Telehealth

Live video telehealth, typically telebehavioral health, was the most prevalent type of telehealth among FQHCs in our sample; however, FQHCs also engaged in store-and-forward telehealth and remote patient monitoring (RPM). A minority of FQHCs in our sample that offered telehealth served as originating sites only; the most common model was a combination model in which FQHCs both contract with external organizations for certain telehealth services (FQHC as originating site) and serve their own health center network for others (FQHC as originating and distant site).

Medicaid Policies

The telehealth policies of the seven state Medicaid programs in our sample varied across numerous dimensions. Four of the seven state Medicaid programs reimbursed for store-and-forward telehealth, and two reimbursed for RPM. Four programs had patient informed consent requirements, and three required telepresenters to be present with patients at originating sites. In addition, two programs restricted the types of specialists or services that can be provided by telehealth, and five provided a transmission and/or facility fee to eligible originating sites. Participants highlighted several weaknesses of Medicaid policies in one or more states, including general lack of clarity on which services were allowed by the Medicaid program, ambiguity around telepresenter requirements, lack of authorization for FQHCs to serve as distant sites in the federal Medicare program and in select state Medicaid programs, and insufficient reimbursement.

Barriers and Facilitators of Telehealth Implementation

FQHC stakeholders identified multiple barriers beyond reimbursement, including infrastructure issues (e.g., insufficient broadband), technology costs, telehealth as a cost center, billing challenges, lack of buy-in among FQHC providers, challenges specific to the patient population (e.g., elderly patients, homeless patients), complexities in adjusting clinic workflow, inadequate supply of specialists to provide telehealth services to FQHC patients, complex and time-consuming logistics around credentialing and licensing, and challenges in working with remote providers. Nonetheless, FQHC stakeholders generally believed they could overcome these various barriers to telehealth implementation if reimbursement, and the risk of losing revenue in offering telehealth services, were improved. Stakeholders identified several facilitators that supported telehealth implementation, including grant funding, the presence of a clinic champion, collaboration with payers, and implementation of promising practices related to workflow.

Planned Changes to Telehealth Offerings

FQHC stakeholders described a range of planned changes to expand or modify the implementation of telehealth services. While most FQHCs that offered telehealth planned to expand existing offerings by serving additional sites or increasing volume, offer additional specialties, and/or modify workflow or other aspects of implementation, a handful discussed plans to discontinue their telehealth programs or described previous pilot programs that were not sustained. These experiences suggest that telehealth is sometimes implemented as a short-term, rather than long-term, strategy (e.g., in response to a specific vacancy).

Conclusions

FQHCs are experimenting with telehealth for a range of conditions, working with different types of remote providers, and confronting different telehealth policies and implementation barriers, depending on their locations and payer mix. While diversity of experiences makes it difficult to generalize about telehealth implementation in the safety net, we identified several common themes and associated considerations for policymakers, payers, and FQHCs.

• Authorizing FQHCs to serve as both originating and distant sites may spur the growth of telehealth in the safety net.
• FQHCs and their partners would benefit from additional clarification of telehealth policies, especially as they relate to FQHCs, and education regarding these policies.
• Telehealth may be most effective if implemented as part of a suite of strategies to address workforce shortages in rural areas.
• FQHCs would benefit from case studies of profitable telehealth programs.
• Telehealth services can be implemented as a short-term or long-term solution, but likely program duration is seldom addressed in telehealth policies and practices.
• Future research should inventory telehealth policies specific to FQHCs and explore relationships between policies and implementation of telehealth by FQHCs.