Is Telehealth Key to Achieving Health Equity in Long-Term Care?

Five strategies for states and providers to embed telehealth into home and community-based services programs.

By: Lance Robertson & Poorna Suresh

The adoption of telehealth soared in response to the COVID-19 pandemic and has become an integral platform of healthcare for many—especially vulnerable populations.

Many older, low-income, disabled, and rural Americans, for instance, have appreciated the ease of virtual medical check-ins and immediate access to care when in-person visits weren’t necessary— one less trip to the doctor for those who have difficulties traveling outside of their homes, or who have a shortage of providers in their communities.

The question: Can telehealth truly drive down healthcare costs and improve health equity and accessibility?

Recently, a New York-based managed care plan claimed that telehealth services led to fewer ER visits and lower healthcare costs for members with intellectual and/or developmental disabilities.

Understanding the value of telehealth is especially important for long-term care programs such as home and community-based services (HCBS). Nearly every state expanded telehealth in HCBS delivery via Social Security Act §1915(c) Appendix K emergency waivers in response to the COVID-19 public health emergency. States centered changes to their telehealth policies around:

  • Relaxing requirements around 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.
  • 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 the adoption of telehealth in HCBS.

States and community providers need long-term strategies to maintain HCBS program integrity and oversight.

As states further expand efforts to adopt, normalize, and reimburse telehealth services for HCBS patients, agency stakeholders and community providers should align on five key areas.

1. Understand the Care Journey for Various Caregivers and Patients

Stakeholder surveys, focus groups, town halls, and interviews can help states engage with providers and patients who have firsthand insights using telehealth during the pandemic. As with all Medicaid populations, 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 telehealth service delivery. This also includes their 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 upon policies enacted during the pandemic. Stakeholder engagement can also help states navigate competing interests, prioritize intended outcomes, and create win-win situations to reinforce to telehealth caregivers and patients that their thoughts and concerns matter to the state’s HCBS program design.


2. Examine Payment Methods and Rates for Telehealth to Support Value-Based Care

It is important for states to account for potential cost and utilization outliers resulting from the COVID-19 pandemic when studying telehealth data to gauge future demand trends. 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 will need to consider the expanded scope and coverage of remote support resulting from the pandemic, including the duration of service, provider qualifications, service delivery methods, and service locations.

States should also consider the role telehealth and virtual care delivery can more broadly support their market’s value-based goals. Offering tiered or bundled payments based on identified characteristics of patients and providers will support future reimbursement. Complete, consistent, and sufficiently documented information on states’ financing and payment methodologies for telehealth HCBS will be integral to CMS’s monitoring processes, as well as approval of federal matching funds.


3. Establish a Process to Monitor Fraud, Waste, and Abuse

In September 2020, the Department of Justice, Health and Human Services, and the Drug Enforcement Administration partnered to charge 86 criminal defendants with $4.5 billion in alleged false and fraudulent claims involving telemedicine, highlighting the potential for unmonitored and unregulated use of telehealth.

Despite the benefits of widespread telehealth adoption and the bipartisan support for ensuring access to telehealth services, states must recognize the need to continually evaluate and implement policies and procedures that mitigate fraud, waste, and abuse. As such, to support the use of telehealth during the pandemic, many states waived certain Health Insurance Portability and Accountability Act guidelines around technology and safety requirements. Some states also waived out-of-state provider limitations, allowing for more relaxed rules regarding which providers are eligible to provide services to individuals.

Although states may not permanently adopt many of these changes, they will need to more closely monitor paid services to make sure that providers are not abusing or exploiting the flexibilities allotted during and after the pandemic, per the Government Accountability Office’s recent testimony to Congress. 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 as a Tool to Prioritize Equity and Access in Service Delivery

States should consider how their guidance advancing the adoption of telehealth as a response to the pandemic can also bolster efforts to enhance equity and eliminate disparities in service delivery. By removing barriers such as physical distance and multiplying the number of providers able and available to deliver services, telehealth can level the options for people who may be seeking different methods or modalities of care.

Reviewing where disparities in service delivery, outcomes, patient satisfaction, and other metrics exist; where disparities may be accentuated by the pandemic; and where disparities can be mitigated by the wider adoption of telehealth is critical. States may need to make technology investments and develop training to accommodate those who need additional support.

Flexibility with provider choice (e.g., provider’s language aligns with individual’s preference) and methods of receiving telehealth (e.g., phone calls or asynchronous technologies) beyond the pandemic may help advance equity in availability of services. But more broadly, people in rural communities may not have access to any provider, let alone the service providers or workers who can best aid them.

5. Build on Existing Quality and Oversight Processes to Assure Patient Health and Welfare


A major challenge for states will be to ensure that they have adequate policies and processes in place to identify or investigate adverse incidents. Due to decreasing face-to-face contacts in lieu of remote or virtual communication, current policies set by states may need to be modified to accommodate the new guardrails required for telehealth service delivery.

Guidehouse assessed the impact of COVID-19 on incident management and encourages states to:

  • Capitalize on changes made to incident reporting and investigation requirements.
  • Improve the processes for reporting incident management quality findings to CMS.
  • 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.

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