COVID-19 boosted virtual health in Medicaid, but the future could be complicated

By Scott Dillingham, senior manager, Deloitte Consulting LLP

The idea of using cell phones to engage with Medicaid members has been around for years—primarily as an adherence tool that helped them stick to care plans, remind them of upcoming appointments, or urge them to refill prescriptions. Using a phone or other virtual platform for clinical visits and care delivery takes this concept to the next level and could help Medicaid beneficiaries stay more connected to clinical teams. This technological lifeline also could help members more effectively manage medical conditions and avoid costly emergency room visits.

Virtual health can be a powerful tool for improving care coordination and care delivery in home-based settings. Our 2018 survey of US health care consumers found that most Medicaid beneficiaries have the technology and appetite needed to take advantage of digital health. However, it can be tactically more difficult to execute in the Medicaid population than in the commercial sector or Medicare Advantage (MA).

The COVID-19 pandemic pushed states across the country to relax rules around virtual health, which helped boost adoption among Medicaid members. About one-third of Medicaid members have had a virtual visit or consultation, and four out of five of those members are receptive to having another, according to Deloitte’s 2020 survey of US health care consumers, which was conducted prior to the lockdown.

The combined catalysts of policy modifications and necessity brought on by the pandemic seem to be having a profound impact on accelerating adoption trends. In one state, for example, the number of Medicaid recipients who used virtual care increased from 23,616 at the end of 2019 to nearly 200,000 as of June. During the same period, the number of providers in the state using telehealth jumped from 657 to nearly 16,000.¹ Another state recently processed more than 1.1 million telehealth and 350,000 telephonic visits for its Medicaid members.²

Five challenges that impact virtual health adoption in Medicaid

Virtual health could support Medicaid members through care-management programs. An ongoing connection to a clinician—or care delivered in a home-based setting—could help people get their health conditions treated. However, engaging with Medicaid members has its own set of technology challenges and implementation nuances. Before COVID-19, virtual health in Medicaid was trailing adoption in commercial markets and MA. However, that gap appears to be closing, shedding light on the unique aspects of care delivery within this population. Here’s a look at five challenges that could affect the use of virtual health in Medicaid: 

1. Temporary rules that expanded virtual health are fluid: While every state Medicaid program temporarily expanded its coverage of telehealth services to some degree, many states are now in the process of determining which changes should be made permanent and which ones might end now that hospitals and physician offices are seeing patients in person. As the landscape shifts, Medicaid plans might need to take a strategic look at how virtual health is managed and supported from a technological, operational, and clinical perspective. They also should consider establishing agile models that allow them to react quickly in a market buffeted by a public health emergency and sometimes reactionary rulemaking.
2. The potential for fraud, waste, and abuse is growing as rules and usage patterns evolve: On September 30, the US Department of Justice (DOJ) announced that it had filed charges against 86 doctors, nurses, and other providers in 19 judicial districts for making more than $4.5 billion in false and fraudulent telehealth-connected claims to Medicare, Medicaid, and private insurers. According to court documents, telemedicine executives allegedly paid doctors and nurse practitioners to order unnecessary supplies and medications, either without any patient interaction or with only a brief telephonic conversation with patients they had never met or seen.³  Given the veritable explosion of services made available through virtual health, Medicaid plans should look for ways to ramp up their capabilities to detect fraud, waste, and abuse.
3. The intersection of mobile technology and unstable living situations can create unique challenges: Only about half of Medicaid recipients are digitally literate⁴ (e.g., comfortable finding, evaluating, and composing information through various digital platforms). Moreover, some Medicaid members might not have regular access to the internet or a stable living environment. It might also be difficult for some members to find a private area where they can conduct a personal virtual visit with a clinician. And while many Medicaid beneficiaries have a smartphone, they might not have access to home-based Wi-Fi, or internet access might vary from month to month or they might have concerns about the cost of data plans. Medicaid managed care organizations should consider ways to ensure their members have access to technology (platforms, equipment, and services). They might also need to take a greater role to help members find stable housing, alternate sites for care delivery, and private areas where members can have virtual conversations with clinicians.
4. Virtual visits might not generate as much health data and insight as in-person visits: An in-person clinical visit typically generates a tremendous amount of data. Fewer data points might be generated through a virtual health visit depending on the modality. Non-verbal cues and body language can be missed and certain data points such as accurate weight or blood pressure readings may be harder to capture. This could lead to information gaps about a member’s condition. Medicaid managed care organizations and clinicians are still learning how to effectively combine data to create both a body of evidence and an auditable trail that can help assess risks and coordinate initiatives and follow-ups to close gaps in care. Medicaid plans should evaluate how they and their provider network mine data from virtual health visits. This information could be used to plot a path for maximizing the impact and value of this platform to drive engagement and insight.
5. Limited connectivity or no access to a smartphone can make it difficult to reach some members: Members who don’t have a stable home or living situation can still stay connected to their plan and their doctors through a phone. While some Medicaid plans have offered basic connectivity programs to their members for years, the pandemic created an urgent need to use technology to reduce feelings of isolation, head off potential behavioral health issues, and ensure member engagement. Establishing a multipronged strategy to foster greater communications, engagement, and access to virtual health is critical. One Medicaid managed care company recently announced it had partnered with Samsung to give 13,000 smartphones to members who live in rural and underserved areas.  

Medicaid provides health benefits to 97 million low-income Americans⁵ with the potential for significant growth as the impacts of COVID-19 continue to be felt and reverberate through communities. Opening new roads to meet them (and serve them where they are) can be critical, particularly during the pandemic. Cohesive approaches—including an appropriate virtual health infrastructure and lower-tech options along with operational, clinical, and engagement strategies—should be put in place. Virtual health has the potential to help maintain continuity and engagement with caregivers, provide a bridge and connection to social supports, and continue to advance opportunities for the efficient delivery of care in this vulnerable population. Deploying the right virtual health infrastructure and strategies can help ensure that Medicaid plans have the agility to react nimbly in a rapidly changing environment.

Endnotes

^{1. Telehealth use jumped in Medicaid system as pandemic swept Florida, News Service of Florida/News4 JAX, September 24, 2020}

^{2. NC Medicaid Surpasses 1 Million Telehealth Visits Since Beginning of COVID-19 Pandemic, NC Dept. of Health and Human Services, October 1, 2020}

^{3. National health care fraud and opioid takedown results in charges against 345 defendants responsible for more than $6 billion in alleged fraud losses}

^{4. Why achieving health equity is so hard in the telehealth age, American Medical Association, October 21, 2020}

^{5. Policy basics: Introduction to Medicaid, Center on Budget and Policy Priorities, April 14, 2020}

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