Exploring Equitable Access to Care and Outcomes Using Telehealth in the Transition to Medicaid Managed Care
Overview
The shift to Medicaid Managed Care and value-based payment may disrupt care networks and inadvertently create new barriers to equitable, timely, person-centered care. While telephonic outreach and virtual visits (hereafter telehealth) can enable trusting patient-provider relationships for high quality care, the use of telehealth in new care arrangements may not be feasible, acceptable, or appropriate with all populations. Payment reform for telehealth use with NC Medicaid beneficiaries in 2020 creates the ideal scenario for studying current practice to inform Medicaid Managed Care.
Our overall goal is to establish data-driven policy that advances equitable care and outcomes for Medicaid beneficiaries. We will apply econometric methods to NC Medicaid claims data and estimate disparities in access and outcomes by examining in-person, telephonic, and virtual visits from 2018-2021. Using interviews, listening sessions, and convenings with patients/caregivers, clinicians, administrators, payers, and policymakers, we will explore barriers and experiences with telehealth and further expand our understanding of contributors to observed disparities. Our findings will generate context-specific interventions and clinical, payment, and regulatory options to optimize remote care delivery and payment to facilitate health for financially disadvantaged and historically marginalized North Carolinians.
Populations of Focus
We studied Medicaid-insured children and adults identified to be living with behavioral health or musculoskeletal (MSK) disorders (e.g., back pain). Within these disease categories, we sought to maximize involvement among immigrant and non-native English-speaking communities, individuals of different race/ethnicities, and representing different geographies. It is critical that we study disparities in access and outcomes, incorporating the lived experience, to inform policies that shape population health.
Funding
Funding for this project is provided by the Kate B. Reynolds Charitable Trust.
Virtual Town Hall
In May 2022, our research team hosted a virtual town hall to share research findings. During the town hall, our research team shared patients’ and health care providers’ experiences with accessing and delivering care via telehealth. Invited guests discussed and explored opportunities to use research findings to design community-specific solutions to reduce health inequities and improve health outcomes for people enrolled in Medicaid. Click here to find out more about our town hall.
Fact Sheets
The fact sheets below summarize our research findings on access to health care and telehealth use among North Carolina's Medicaid beneficiaries with behavioral health (BH) and musculoskeletal (MSK) health conditions during the COVID-19 pandemic.
Fact Sheet #1: Access to Health Care and Telehealth Use among North Carolina's Medicaid Beneficiaries with Behavioral Health Conditions
Fact Sheet #2: Access to Health Care and Telehealth Use among North Carolina's Medicaid Beneficiaries with Musculoskeletal Health Conditions
Explainer Videos
These videos were created by the Duke-Margolis Center for Health Policy through a project funded by the Kate B. Reynolds Charitable Trust. These videos are Duke-Margolis products and are to be used for educational purposes only, and not for commercial purposes. For more information about the project and/or how to use these videos appropriately, please contact Yolande Pokam.
Telehealth Disparities Explainer Video for Policymakers and Clinicians
Telehealth Disparities Explainer Video for the Broader Community
Describing Perspectives of Telehealth and the Impact on Equity in Access to Health Care from Community and Provider Perspectives: A Multimethod Analysis
Research Article - July 2023
This research article describes community and provider perspectives of telehealth and its impact on equity in access to health care. Through multiple qualitative methods (surveys, interviews and focus groups), researchers found that participants perceived telehealth helped maintain access to health care; however, barriers to care such as availability of technology and broadband internet remain and continue to limit equitable access to care. This research highlights important facilitators and barriers to accessing telehealth, as well as policy recommendations to further improve equitable access to care.
Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic
Research Article - August 2023
This research article describes telehealth utilization during the COVID-19 pandemic among adult Medicaid beneficiaries with behavioral health condition using descriptive and multilevel modified Poisson regression analyses. Research findings reveal that during the pandemic, telehealth facilitated continuity of care for adult beneficiaries with behavioral health conditions; however, barriers to equitable access to care persist.
Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries with Musculoskeletal Conditions: Insights from the COVID-19 Pandemic
Research Article - November 2023
This research article explores factors associated with telehealth utilization during the COVID-19 pandemic among Medicaid beneficiaries with musculoskeletal (MSK) conditions. This study also assessed whether telehealth availability helped mitigate disparities in access to care or affected emergency department (ED) visits among these beneficiaries. Given the lack of insurance coverage for MSK services delivered via telehealth prior to the pandemic, this study reveals important insights on telehealth uptake for newly covered services and telehealth's potential impact on addressing existing barriers to care such as limited provider availability, transportation, and patient mobility. Using descriptive and regression analyses, this study reveals that factors associated with telehealth utilization included race and ethnicity, internet access, age and Tailored Plan eligibility. However, no statistical difference in ED utilization was observed between telehealth users and non-users.
What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?
Research Article - May 2024
This research article explores the degree to which inequalities in telehealth use among North Carolina Medicaid members during the COVID-19 pandemic could be explained by observed individual- and area-level factors. Applying non-linear regression-based decomposition analyses based on the Kitagawa-Oaxaca-Blinder method to NC Medicaid claims data, this study identified statistically significant differences in telehealth use by race, ethnicity, and rurality across analytic cohorts. However, researchers found that racial and ethnic inequalities in telehealth use were not well explained by variables observed in claims data. Rural disparities in telehealth use, on the other hand, were explained by observed variables, particularly county-level rates of residents without a broadband Internet subscription.
Duke-Margolis Affiliated Research Team Members
Rebecca Whitaker, PhD, MSPH
Research Director, North Carolina Health Care Transformation
Core Faculty Member
Senior Team Member
Samantha Repka, MS
Research Associate
Rushina Cholera, MD, PhD
Assistant Professor, Department of Pediatrics and Population Health Sciences
Medical Instructor in the Department of Pediatrics
Margolis Core Faculty
Additional Research Collaborators and Team Members
- Piedmont Health Services
- Word Tabernacle Church
- The Robeson County Partnership for Children
- The Parents as Teachers Program led by the Robeson County Health Department
- Janet Prvu Bettger, Professor, Chair and Director in the Department of Health and Rehabilitation Sciences at Temple University (formerly with Duke University and the Duke-Margolis Institute for Health Policy)
- Gary Maslow MD, Duke University Department of Psychiatry and Behavioral Sciences
- Karen Swietek PhD, NORC at the University of Chicago
- Alexis French PhD, Duke University Department of Psychiatry and Behavioral Sciences
- Kelley Jones PhD, Duke University Department of Population Health Sciences
- Ashley Lake DPT, PT, SCS, Duke University Department of Physical Therapy & Occupational Therapy
- Annise Weaver MSEd, CRC, Associate Director of Diversity, Equity and Inclusion, Duke University Department of Psychiatry and Behavioral Sciences
- Chris Lea, MD, Former Duke Medical Student and Duke-Margolis Scholar
- Duke-Margolis Interns
- Ana DeCesare, 2021 Margolis Intern
- Nadia Bey, 2021-2022 Margolis Intern and Margolis Scholar
- Cynthia Dong, 2021-2022 Margolis Intern and Margolis Scholar
- Karina Vasudeva, 2022 Margolis Intern
- Duke NIH Clinical and Translational Science Award (CTSA) Community Engaged Research Initiative team, including:
- L. Ebony Boulware MD, Director for Duke Clinical and Translational Science Award
- Leonor Corsino MD, Rosa Gonzalez-Guarda PhD, Mina Silberberg PhD, Julius Wilder MD PhD, Co-Directors for CTSA Community Engaged Research Initiative
- Eve Marion, Research Program Leader
- Sabrena Mervin-Blake, Senior Staff Director
- Kiah Gaskin MPH MSW, Research Program Leader
- Daphne Lancaster, Program Coordinator
