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Research Questions

  1. What staffing, programmatic, and process changes were implemented to expand telemedicine during the initiative?
  2. What barriers did health centers face in expanding telemedicine?
  3. What was the impact of health center activities on telemedicine volume and realized access to telemedicine services?
  4. Were high-volume telemedicine programs and dedicated telemedicine staff likely to be sustained in participating health centers, and what factors contribute to sustainability?
Telemedicine, or the provision of health care services at a distance by means of telecommunications technology, can improve access to care by bringing medical care into communities with limited access to providers or facilities, reduce wait times, and improve convenience. However, when telemedicine is offered in safety-net settings, it tends to be a low-volume service. To explore this issue, the California Health Care Foundation invested in the Sustainable Models of Telehealth in the Safety Net (SMTSN) initiative, which was in place from 2017 to 2020 and provided funding for telemedicine staff for 24 months. RAND researchers evaluated the experiences of health centers that participated in the initiative. Although the SMTSN initiative and this evaluation occurred before the coronavirus disease 2019 (COVID-19) pandemic dramatically altered the regulation, reimbursement, and use of telemedicine services across the health care system in spring 2020, the findings presented in this report are relevant to health centers that are trying to rapidly expand telemedicine in response to the pandemic. Also, the barriers and strategies identified in the evaluation are likely to have ongoing relevance once some of the changes in place for the duration of the emergency are rolled back.

Key Findings

All nine centers received funding to increase their telemedicine volume

  • Growth in volume was largely achieved by dedicated telemedicine staff who added new service lines, contracted with new vendors and/or purchased additional blocks of time with existing vendors, began offering telemedicine services at new clinic locations, and purchased new equipment.

Barriers included insufficient reimbursement, technical difficulties, and challenges working with remote specialists

  • Nearly all health centers reported lack of reimbursement as the dominant barrier to growing their telemedicine programs. Even though most health centers were pursuing telemedicine services that theoretically could be reimbursed, many health centers were being reimbursed for only a subset of their telemedicine visits.

Eight of the nine health centers in the initiative experienced a significant increase in telemedicine volume over the implementation period

  • On average, prior to the initiative, health centers had 153 telemedicine visits per month. This increased to an average of 239 visits per month after the initiative began, which represents a 56-percent increase.

Staff from most health centers argued that telemedicine services were likely permanent

  • Although there was near-universal agreement among participating health centers that telemedicine would continue after the initiative for a variety of reasons, including ongoing patient need and alignment with strategic priorities and health center values, staff did not specify a particular volume goal. Staff also noted that financial factors would determine the scope of services.


  • Health centers should add dedicated telemedicine staff; implement promising strategies to improve the efficiency and quality of telemedicine services; offer telemedicine services to patients in their homes; participate in a learning community of peer organizations if the health center is beginning to implement telemedicine or seeking to expand it; consider the opportunity cost for telemedicine when deciding whether to expand existing telemedicine programs; and track telemedicine-related costs.
  • Policymakers and payers should clarify telemedicine policies; align telemedicine policies; explore the impacts of telemedicine in the home versus health care settings on access, quality, and costs; allow federally qualified health centers to serve as distant sites; support health centers in pooling demand for telemedicine visits across health centers to facilitate contracting; and support health centers in contracting with third-party telemedicine providers.

Research conducted by

This research was funded by the California Health Care Foundation and conducted by the Access and Delivery Program within RAND Health Care.

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