NOTE: Click here to download a new article just published by the Millbank Memorial Fund that assesses the impact of Medicaid telehealth policy changes on equitable access to telehealth services in North Carolina.

Introduction

The COVID-19 pandemic catalyzed a dramatic rise in the use of telehealth nationwide to deliver services to individuals enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). The federal government and states implemented temporary policy flexibilities in response to the COVID-19 pandemic to increase access to care and limit risk of viral exposure by allowing members to receive telehealth services in their homes. The North Carolina Department of Health and Human Services (the Department) took early action to promote evidence-based, equitable delivery of Medicaid and CHIP services via telehealth during the COVID-19 pandemic and has transformed its telehealth policy based on this experience.

The following article summarizes the Department’s “Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond,” which includes a detailed policy evaluation brief and chart pack.

North Carolina’s Evolution in Telehealth Policymaking

Similar to other states, North Carolina’s pre-COVID-19 pandemic telehealth policy was restrictive and allowed limited reimbursement for telehealth services. At the onset of the COVID-19 pandemic, a Department-led COVID-19 telehealth response team engaged partners from across the state and within the Department to implement immediate, foundational policy changes needed to enable remote access to care. The Department then developed a set of criteria to guide ongoing pandemic-related telehealth policymaking (e.g., continuity of care, patient safety, confidentiality and privacy standards, alternative modalities; see the full evaluation brief for more information), leveraged partnerships to provide technical assistance to providers (e.g., North Carolina Area Health Education Centers, medical associations), implemented a robust communications strategy to adapt to changing needs on the ground and expanded internal data analytic capabilities to monitor the impact of policy changes on telehealth utilization, cost and quality of care.

At the end of 2020 and into early 2021, the Department began considering which telehealth flexibilities to continue beyond the COVID-19 pandemic. Permanent decisions were made through a formal telehealth policy decision-making process that considered new and additional criteria for policymaking (see Table 1). Ultimately, many of the policy flexibilities implemented during the COVID-19 pandemic were integrated into permanent policy as a result of this process.¹

Table 1: Permanent Telehealth Policymaking Criteria

Lessons Learned

The Department’s investment in building its analytic capacity during the COVID-19 pandemic enabled Department leadership to make data-informed telehealth policy decisions and understand the value of and continued challenges associated with expanded use of telehealth. Key findings from the Department’s telehealth utilization analyses conducted between early 2020 and the end of 2022 are:

• Telehealth utilization varied by age, race, ethnicity and other demographic categories. Medicaid members who used telehealth less frequently included adults over age 65, individuals who identified as Black or Hispanic and individuals living in rural areas. Disparities in telehealth use by race and ethnicity may be attributable to differences in how often providers offered telehealth to Medicaid members, as demonstrated in practice-level survey data.
• Telehealth may have helped Medicaid members maintain access to medications and care for conditions that require ongoing monitoring (e.g., opioid use disorder, type 2 diabetes).
• Despite initial concerns that telehealth might result in overutilization of services, outpatient care provided via telehealth was not correlated with increased acute care utilization compared with in-person services during the COVID-19 pandemic.
• Most Medicaid members expressed satisfaction with care received via telehealth.

North Carolina’s experience during the COVID-19 pandemic forever changed the way the Department approached policymaking. Factors that supported the successful evolution of the state’s telehealth policy include:

• Decisive Leadership. Fast decision-making by Department leadership and the support of the COVID-19 telehealth response team facilitated implementation of necessary foundational policy changes identified prior to the pandemic.
• Unique Partnerships to Support Practices. The Department leveraged key partnerships with statewide organizations and medical professional groups (e.g., the state’s Office of Rural Health, North Carolina Medical Society, North Carolina Pediatric Society, North Carolina Academy of Family Physicians, North Carolina Psychiatric Association) to disseminate information related to telehealth policy changes and support practices’ adoption of telehealth.
• Strong, Transparent Communication Channels and Feedback Loop. Close collaboration with other state agencies, intra-Department officials, medical professional groups and other key community partners drove temporary policymaking over the course of the pandemic and informed permanent changes. The Department’s feedback loop with the community provided insight into practice- and member-level challenges that it could respond to in near real time through a variety of mediums and forums, reaching a vast audience. The Department demonstrated throughout the COVID-19 pandemic that it could be nimble and responsive to concerns, which in turn built trust.
• Robust Data Collection and Evaluation Efforts. Prior to the implementation of the first telehealth policy flexibility, an evaluation plan had been developed that (1) guided development of the Department’s analytic infrastructure, (2) established a critical system to inform policymaking decisions and (3) helped the Department present to the community a clear rationale for decision-making.

Conclusion

North Carolina is now tackling challenges that pose a barrier to further integration of telehealth into the Medicaid delivery system, including ensuring equitable access to telehealth services, maintaining the highest quality of care for services delivered via telehealth, supporting hybridized models that feature multiple telehealth modalities and understanding the workforce implications of telehealth use. The Department is well positioned to leverage the policymaking framework and supporting infrastructure it developed during the COVID-19 pandemic to address these and other issues going forward.

_{¹ Specifically, the Department allowed providers to offer, on a permanent basis, telehealth delivery of outpatient evaluation and management services at parity, select behavioral health services, telephone evaluation and management services, interprofessional consultations, remote patient monitoring, and select specialty services (e.g., maternal health and family planning, diabetes education and management). Temporary telehealth-eligible services that the Department sunsetted included outpatient specialized therapies, optometry, unrestricted telephonic care, fully remote well-child services, most in-home and facility-based intensive behavioral health program services, and skilled nursing facility/hospice services.}