By Lance Robertson and Poorna Suresh
Telehealth has become an integral health care platform for many, especially marginalized populations, amid the COVID-19 pandemic. The ease and immediate access of virtual medical check-ins ensured continuity of care when in-person visits weren’t possible or necessary — and it was one fewer trip to the doctor for those who struggle with transportation barriers and live in provider shortage areas.
Understanding the value of telehealth is especially important for long-term care programs, such as home- and community-based services (HCBS). In response to the COVID-19 public health emergency, nearly every state expanded telehealth in HCBS delivery via Social Security Act §1915(c) Appendix K emergency waivers. Changes to state telehealth policies included:
- relaxing requirements on level of care and person-centered plan development;
- expanding or redefining the role of providers, caregivers, and family members;
- conducting more training through audio and video conferencing; and
- modifying methods for monitoring incident reporting requirements, medication management, and other patient safeguards to ensure individual health and welfare.
While these and other Appendix K waivers are temporary, telehealth has a critical future as federal and state agencies continue to integrate it within HCBS policies and settings. For instance, the American Rescue Plan Act included provisions to support telehealth adoption in HCBS.
States and community providers need long-term strategies to maintain HCBS program integrity and oversight as they expand efforts to adopt, normalize, and reimburse telehealth services for HCBS patients. Agency stakeholders and community providers should ensure alignment in five key areas: understanding caregiver and patient perspectives, payment methods and rates, fraud monitoring, equity, and leveraging existing processes.
1. Understand the care journey for caregivers and patients.
Stakeholder surveys, focus groups, town halls, and interviews can help states engage with providers and patients who have firsthand insights on using telehealth during the pandemic. Satisfaction and uptake for telehealth HCBS is influenced by the ability of individuals with specific physical, intellectual, developmental, and mental health needs to adapt to this method of care delivery. This includes caregivers’ access to technologies that support telehealth, knowledge of available resources, and willingness to interact through the technology.
State Medicaid agencies can use stakeholder forums as a platform to understand lessons learned and evaluate provider and patient satisfaction to build on telehealth policies enacted during the pandemic. Stakeholder engagement also can help states navigate competing interests, prioritize intended outcomes, and assure caregivers and patients that their thoughts and concerns matter in program design.
2. Examine telehealth payment methods and rates to support value-based care.
When studying telehealth data to gauge future demand, it is important for states to account for potential cost and utilization outliers resulting from the COVID-19 pandemic. States must be diligent about tracking changes related to cost projections and service utilization for remote support services to evaluate whether changes will attract and maintain a qualified provider pool.
As states work to select, review, and document payment methodologies for telehealth HCBS, they should consider the expanded scope and coverage of remote support resulting from the pandemic, including duration of service, provider qualifications, service delivery methods, and service locations.
States also should consider the role telehealth and virtual care delivery can play in broader value-based goals. Offering tiered or bundled payments based on patient and provider characteristics will support future reimbursement. Complete, consistent, and sufficiently documented information on states’ financing and payment methodologies for telehealth HCBS will be integral to the Centers for Medicare & Medicaid Services’ (CMS’) monitoring processes, as well as approval of federal matching funds.
3. Establish a process to monitor fraud, waste, and abuse.
The Department of Justice, Department of Health and Human Services, and Drug Enforcement Administration in September 2020 partnered to charge 86 criminal defendants with $4.5 billion in alleged false and fraudulent telemedicine claims, highlighting the potential for unmonitored and unregulated telehealth use.
Despite the benefits of widespread telehealth adoption and bipartisan support for access to telehealth services, states must continually evaluate and implement policies and procedures that mitigate fraud, waste, and abuse. To support telehealth during the pandemic, many states waived certain Health Insurance Portability and Accountability Act guidelines and out-of-state provider limitations, allowing for more relaxed rules on providers’ eligibility to provide services to individuals. Although states might not permanently adopt many of these changes, they will need to more closely monitor paid services to make sure providers are not abusing or exploiting the flexibility allotted during and after the pandemic.
Continued abuse will rightfully weaken support for this critical service platform, leading all players to bear the responsibility for turning in abusers.
4. Leverage telehealth to prioritize equity and access in care delivery.
States should consider how their guidance advancing the adoption of telehealth as a response to the pandemic can bolster efforts to enhance equity and eliminate disparities in service delivery. By removing barriers — such as physical distance — and multiplying the number of available providers, telehealth can level the playing field for people seeking different methods or modalities of care.
It is critical to review existing disparities in care delivery, outcomes, patient satisfaction, and other metrics; where the pandemic might accentuate disparities; and where telehealth adoption can mitigate disparities. States might need to make technology investments and develop training to accommodate those who need additional support.
Beyond the pandemic, flexibility on provider choice (e.g., ensuring the provider’s language aligns with an individual’s preference) and methods of receiving telehealth (e.g., phone calls or asynchronous technologies) could help advance health equity. More broadly, people in rural communities might not have access to any provider, let alone the clinicians or workers who can best aid them.
5. Build on existing quality and oversight processes to ensure patient health and welfare.
Ensuring the adequacy of policies and processes to identify or investigate adverse incidents will be a major challenge for states. Due to decreasing face-to-face contact, states might need to modify existing policies to accommodate new guardrails for telehealth service delivery.
Guidehouse assessed COVID-19’s effect on incident management and encourages states to:
- capitalize on changes to incident reporting and investigation requirements;
- improve processes for reporting incident management quality findings to CMS; and
- conduct a gap analysis of incident management systems based on Appendix K changes.
Now is the time for states to adopt long-term strategies to define, implement, and expand remote and telehealth procedural changes within HCBS delivery systems. Long-term services and support tools, including those offered by association corporate affiliate member Guidehouse, can help essential hospitals remain leaders in telehealth care.
Lance Robertson is a director in the health segment of Guidehouse, an America’s Essential Hospitals corporate affiliate member, as well as the former U.S. assistant secretary for aging and the administrator of the U.S. Department of Health and Human Services Administration for Community Living. Poorna Suresh is a managing consultant in the health segment of Guidehouse.
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