States must make access to telemedicine easier for Medicaid patients

Medicaid patients are among the country’s most vulnerable, as these millions of Americans include low-income adults, children, pregnant women, elderly adults and people with disabilities. They live in every corner of the US — in densely populated cities, remote rural regions, towns and cities of every size. In setting up the Medicaid system, the federal government required every state to manage its own program. While this setup may have seemed reasonable, the result has been less than adequate. We now have a system that limits access to care via restrictions on medicaid telemedicine and telehealth services.

Many of these restrictions are similar to those experienced by Medicare patients — including the need for an “established relationship” with the onsite “attending physician” and care only provided in specific “originating hospitals.”

During the COVID-19 crisis, the Centers for Medicare and Medicaid Services (CMS) and state governors relaxed the majority of these restrictions. We covered the impact of CMS changes in our article, COVID-19 CMS Changes Could Save Rural Hospitals.

However, Medicaid patients’ access to telemedicine services is further complicated by three factors:

• Each state individually manages its Medicaid services and regulates the use of telemedicine.
• Reimbursement is limited.
• Additional licensure or certification requirements and barriers to interstate licensing limit access to care.

Eagle Telemedicine believes states should reconcile the differences and authorize live video teleconferencing in two scenarios — in homes and in hospital inpatient settings.

When there is inadequate coverage by medical specialists, patients in hospital emergency rooms and ICUs are often at higher risk. In addition, Medicaid patients in rural areas often have inadequate access to healthcare, and some must drive up to 100 miles to reach a specialist. When minutes count, as with neurological emergencies, like stroke, travel time can exacerbate the problem. Telemedicine offers these underserved patients access to specialist care, like a neurologist, at the patient’s community hospital.

When a patient in a rural area needs critical care in an ICU, there is higher risk of mortality when the local hospital is understaffed or lacks a specialist — a situation that telemedicine is very equipped to handle. In one study, the adoption of ICU telemedicine statistically significant reduction in the odds of 90-day mortality.

States’ inconsistent Medicaid telemedicine regulations increase costs

Live video is the most commonly reimbursed form of telehealth; Eagle Telemedicine physicians use live video to assess, diagnose and recommend treatment for patients using a cart and monitor in the patient’s hospital room.

Every state offers some type of live video reimbursement in their Medicaid program. However, the way this form of patient care is reimbursed varies widely. The inconsistency and complexity among different state regulations makes it difficult for businesses to provide telemedicine services to hospitals across state lines — increasing the costs of telemedicine and often preventing the services from being affordable for hospitals and state-run Medicaid programs.

The physician shortage and maldistribution of specialists in the US compounds this problem. Specialists are more readily available in states with large urban populations, but this leaves wide swaths of the country without access. Allowing licensed telemedicine physicians to care for patients, and bill for that care, regardless of the provider’s physical location, increases the likelihood that a telemedicine provider is available.

Some states have laws related to telemedicine, but these laws are often complicated and difficult for under-resourced (rural and Community Access Hospitals) to manage. Layered legislation has created problems, as states tack on Medicaid-related legislation each year as part of their healthcare bills.

The Medicaid rules in some states are different from Medicare. In other states, the telemedicine policy is included in the state’s Medicaid Program Guidelines. With so much variation and complexity in state laws, providers and telehealth companies struggle. This complexity creates confusion that results in fewer physicians available to treat patients via telemedicine. Alabama provides an excellent example of the complexity of offering telemedicine across state lines.

Alabama requires physician enrollment with Alabama Medicaid under the specialty type, 931 — Telemedicine Service. The submission of a telemedicine Service Agreement/Certification form is also required. At the same time, Alabama has one of the highest maternal death rates — 36.4 maternal deaths per 100,000 live births. According to the Kaiser Family Foundation, the state also ranks 49^th in life expectancy and heart disease deaths per 100,000 people. Further, Medicaid or Children’s Health Insurance Program (CHIP) covers 21% of the Alabamans. Simplifying the process to enroll as a telemedicine provider and removing special conditions related to specialty consultations is likely to increase access to care for the more than 800k people covered by the state’s Medicaid program.

There are some bright spots. Unlike Medicare, most states do not require that patients be located in rural settings. Nevada, Michigan and Missouri removed their geographic restrictions in recent years, and Colorado removed its location requirement in 2015.

Limited reimbursement; limited services

While reimbursement is available for some form of live video in Medicaid fee-for-service, the limitations preclude adequate delivery.

Federally Qualified Health Centers (FQHCs) and rural health centers (RHCs) bill as entities rather than as providers, and states often exclude billing by an entity or do not explicitly approve billing by an FQHC or RHC.

In fact, some state Medicaid programs don’t reimburse for Specialist consults in the Emergency Department (ED). In Georgia, the originating site can bill a facility fee for telehealth but there is no separate reimbursement for telehealth consults performed during an inpatient stay, outpatient clinic or the emergency room (ER) visit or outpatient surgery.

Surely, Medicaid patients deserve to get an emergency consult with a neurologist if they suspect a stroke. However, Indiana Medicaid patients are only eligible to receive a consult in the ED when the patient has two qualifying events, and only, for Chronic Obstructive Disease (COPD), chronic heart failure or Diabetes. Certainly these patients deserve Specialist services if they need emergency care for a stroke or seizure.

This is the type of difficulty experienced every day, especially in rural hospitals that have difficulty recruiting and retaining specialists. These hospitals can’t provide proper care for their patients.

Some states limit the:

• Specialty of providers that can provide services at the distant site through telehealth.
• Type of services (office visits, inpatient consultations or outpatient care).
• Provider type (physician, nurse, nurse practitioner, physician assistant or therapist).
• Location of the patient, referred to as the originating site.

These lists vary from being extremely selective with the eligible provider types (for example, only physicians, certified registered nurse practitioner and certified nurse midwives in Pennsylvania), to more expansive eligible provider lists, such as in Virginia, which includes over 16 provider types. However, New Jersey will only reimburse for telepsychiatry services — whereas California reimburses for live video across a wide variety of medical specialties.

It’s clear that inconsistencies in states’ Medicaid telemedicine regulations are limiting residents’ access to care. For those who believe that high-quality healthcare should be available for all Americans, this is unacceptable.

Additional licensure requirements and barriers to interstate licensing limit access to care

Once again, inconsistency is a barrier for providers, hospitals and the companies, like Eagle, that deliver telemedicine. It’s nearly impossible for stakeholders to keep up with changes to licensing requirements.

• Forty-nine state boards, plus the medical boards of District of Columbia, Puerto Rico, and the Virgin Islands, require that physicians engaging in telemedicine are licensed in the state or territory in which the patient is located.
• 12 state boards issue a special purpose license, telemedicine license or certificate, or license to practice medicine across state lines to allow for the practice of telemedicine.
• Six state boards require physicians to register if they wish to practice across state lines.

In addition to removing inconsistent and complicated licensure requirements, states should consider creating a consortium similar to the IMLC to facilitate more consistent telemedicine regulations.

What’s the solution?

Most importantly, it is critical that Medicaid patients have readily available access to the healthcare they need since this population already struggles with enough barriers to care as it is. A Commonwealth Fund study of 100+ Medicaid beneficiaries found that lower income familes often skip medical care because of cost. Other barriers to healthcare for these vulnerable patients include:

• Lack of paid sick leave, so they lose precious income when they take time off to go to the doctor.
• Difficulty getting time off approved by supervisors or inconsistent work schedules that do not facilitate planning a trip to the doctor.
• Even when patients manage to schedule an appointment, they often have to wait for hours to see a provider – which can lead to more problems at work and further lost income.

The participants in the aforementioned Commonwealth Fund study provided suggestions for improving their access to care:

First, they want care itself to be more affordable, and providers to be upfront and transparent about what it will cost patients.

Second, they want providers to offer appointments outside of regular business hours.

And, they want e-visits and telehealth services — to ensure they can get appointments quickly and conveniently.

These are consistent with other studies showing that greater affordability, availability of after-hours appointments, telehealth and enhanced patient trust can significantly improve access to needed care.

States can lower the cost of care and the hassle for Medicaid patients by:

• Aligning telemedicine guidelines with the guidelines for Medicare patients. This will allow patients greater access to care and help hospitals gain billing efficiency and reduce the complexity of scheduling care for more patients.
• Expanding reimbursement for telemedicine services.
• Eliminating requirements for additional certifications and special licenses for remote care provided by a licensed physician.
• Creating a consortium or board to develop consistent rules around how and when telemedicine can be accessed by Medicaid patients.

These changes are in the best interest of patients, hospitals, and the states themselves. Medicaid costs are rising, with a 3.0% increase to $597.4 billion in 2018, or 16 percent of total National Health Expenditure.

State Medicaid spending accounted for 37.5 percent of the $593 billion in overall Medicaid spending in federal fiscal year 2018.  Reported data for this survey shows that average state Medicaid spending is budgeted to increase by 5.7 percent in state fiscal year 2020, after rising 1.1 percent in 2019.

While the Federal government provides some financial support, states take-on 30 to 40 percent of the financial burden for Medicaid patients.

Eagle Telemedicine supports efforts to develop consistent rules so a full range of telehealth medical services can be accessed by all Medicaid patients, while keeping costs reasonable.

The National Conference of State Legislatures Supports Telehealth

Expanding telemedicine is in the best interest of all parties to increase access to care, improve patient outcomes, and reduce costs. Enhancing and increasing access to health care services through telehealth is widely viewed as one strategy to help address workforce shortages and reach patients in rural and underserved areas, according to the National Conference of State Legislatures (NCSL).

Though it does not increase the size of the provider workforce, it can help increase efficiency and extend the reach of existing providers, says the NCSL.

With its potential to overcome workforce and access barriers, telehealth can reduce health disparities for aging and underserved populations, as well as reduce patient costs and burdens associated with lost work time, transportation and childcare, the NCSL explains.

Telehealth gives patients living in rural areas access to more providers and allows them to receive care in their own communities, instead of traveling long distances — for both acute and chronic issues.

The use of telehealth has expanded greatly over the last seven years, with significantly more adoption of reimbursement policies for live video services. Other programs, including Medicare, continue to adopt new policies that expand reimbursement for telehealth services to include more specialties, eligible originating site locations, and fewer restrictions — so it’s expected that many state Medicaid programs will continue to do the same. Eagle Telemedicine remains hopeful that this effort will continue gaining momentum, for the good of all Medicaid patients.

Logistically and financially, consistency and transparency around state Medicaid reimbursement provides an incentive for telemedicine companies and providers to offer services to smaller, rural hospitals and provide care to Medicaid patients.