Experiences of Medicaid Programs and Health Centers in Implementing Telehealth

by Lori Uscher-Pines, Kathryn E. Bouskill, Jessica Sousa, Mimi Shen, Shira H. Fischer

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Research Questions

  1. What have the experiences of state Medicaid programs and FQHCs been in supporting telehealth and delivering telehealth services?
  2. How does Medicaid policy influence the delivery of telehealth services to underserved populations?

Despite telehealth's potential to improve access to care, it 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 and Medicare policies going forward and provide lessons learned for FQHCs interested in starting or expanding telehealth programs. The authors conducted telephone discussions with representatives of seven state Medicaid programs and 19 urban and rural FQHCs to address 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. Live video telehealth, typically telebehavioral health, was the most prevalent type of telehealth among FQHCs in the sample. Stakeholders highlighted several weaknesses of Medicaid policies in one or more states, including general lack of clarity regarding which services were allowed by Medicaid programs, 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. FQHC stakeholders also identified multiple barriers to telehealth implementation beyond reimbursement. 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. While diversity of experiences makes it difficult to generalize about implementation of telehealth in the safety net, the authors identified several common themes and associated considerations for policymakers, payers, and FQHCs.

Key Findings

  • Live video telehealth, typically telebehavioral health, was the most prevalent type of telehealth among FQHCs in the sample; however, FQHCs also engaged in store-and-forward telehealth and remote patient monitoring (RPM).
  • The telehealth policies of the seven state Medicaid programs in the study varied across numerous dimensions.
  • 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.
  • FQHC stakeholders described a range of planned changes to expand or modify the implementation of telehealth services.

Table of Contents

  • Chapter One

    Introduction

  • Chapter Two

    Methods

  • Chapter Three

    Results

  • Chapter Four

    Conclusions

  • Appendix

    Descriptions of Policies in Each State

Research conducted by

This research was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) and conducted by the Payment, Cost, and Coverage Program within RAND Health Care.

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