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September 26, 2023
Issue Brief
Shannon Dowler
Sam Thompson
Michelle Savuto
Jacqueline Marks-Smith
Jared Augenstein
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The onset of the COVID-19 pandemic in early 2020 catalyzed a dramatic rise in telehealth adoption and use in the United States. In response, North Carolina rapidly evolved its telehealth coverage and reimbursement policies and subsequently evaluated the impact on equitable access to care. The North Carolina Department of Health and Human Services (NC DHHS) found that telehealth use in Medicaid and the Children’s Health Insurance Program (CHIP) varied by race and ethnicity between early March 2020 and the end of 2022. In particular, there were persistent inequities in telehealth offer rates and utilization for Black and Hispanic members. North Carolina’s experience highlights that enabling broader access to telehealth modalities alone does not resolve gaps in access to care, and different strategies may be needed to improve equitable access to and delivery of telehealth services. This includes strategies such as maintaining broad telehealth access postpandemic, creating remote “hubs” where patients can access secure technology, and harnessing benefits such as digital technologies to broaden access.
Telehealth holds great potential as a tool to support improved access to and continuity of care.1 For a variety of logistical, technical, and regulatory reasons, this promise is largely unfulfilled.2 Additionally, there is a suggestion of disparate offerings of telehealth services that could be a result of implicit bias by medical providers. The onset of the COVID-19 pandemic in early 2020 spurred a dramatic rise in telehealth adoption and use that was facilitated by the relaxation of federal and state rules and regulations.3-5 North Carolina rapidly evolved its telehealth coverage and reimbursement policies as a result of the pandemic and studied the impact on access to care.
NC DHHS’s prepandemic telehealth policy was restrictive relative to that of other states, allowing reimbursement for only a narrow set of provider site–to–provider site telehealth encounters.6 Originating site restrictions prohibited Medicaid members from participating in a telehealth visit from their homes; members were required to travel to Medicaid-enrolled sites to receive telehealth care. Because of these barriers, telehealth use among the state’s Medicaid and CHIP members accounted for a negligible proportion of total claims.
NC DHHS took action early in the COVID-19 pandemic to promote expanded delivery of Medicaid and CHIP services via telehealth by:
In 2021, NC DHHS codified many temporary policy changes into permanent policy, incorporating health equity into criteria to guide temporary and permanent policymaking, and engaged key partners to promote equitable access to telehealth providers, required technologies, and services.7
In parallel, North Carolina made significant investments in telehealth infrastructure and provider supports throughout the COVID-19 pandemic. The governor’s office leveraged federal grants to build broadband infrastructure and enroll residents in the Affordable Connectivity Program, which offered eligible low-income households discounts on high-speed internet service and laptops, tablets, and desktop computers.8-10 For three years, NC DHHS doubled the per member per month payment to primary care medical homes to create financial stability and allow for unexpected and rapid investments to build telehealth capacity. The department also provided, for a limited time in 2021, $50 million in enhanced “equity” payments to primary care practices serving members from areas with high poverty rates to, among other aims, enable permanent enhancements to telehealth access.11
NC DHHS invested in expanding analytic capacity to measure and understand the impact of the state’s pandemic-related telehealth flexibilities. For example, DHHS’s analytic team created a detailed internal utilization dashboard based on claims data that differentiated provider type (e.g., medical, behavioral, speech), service type (e.g., telehealth vs. telephonic), and geography (e.g., rural or urban areas). The tool allowed insight into member access, and data could be stratified by important demographic characteristics such as race and ethnicity.
NC DHHS leveraged these data to closely monitor telehealth use trends and member experience to identify how availability of telehealth services impacted access to care. In particular, NC DHHS was concerned about access gaps for members who are less likely to use or have access to telecommunications and information technologies, particularly given previous analyses in the state demonstrating rural access issues.12-14
NC DHHS’s analyses demonstrate that, though a higher volume of telehealth encounters were conducted in urban areas than rural areas, telehealth usage as a percentage of total claims did not differ markedly by geography (see Figures 1 and 2; the methodology for the figures in this article are described in detail below). By contrast, telehealth use varied dramatically by member characteristics over the course of the pandemic.15 Black members had the lowest telehealth use rates over time (see Figure 3). Figures 4 and 5 further illustrate lower relative probability of telehealth use among Black and Hispanic members, which persisted through the end of 2022.
Differences in telehealth offer rates may have contributed to disparities in telehealth use by race and ethnicity. Results from North Carolina’s 2022 Consumer Assessment of Health Providers and Systems Survey (CAHPS)16 found that there was a meaningful (though not statistically significant) difference in telehealth offer rates for Black and White members (19.1% and 24.1%, respectively) and a statistically significant difference in offer rates for Hispanic and non-Hispanic members (14.6% and 22.5%, respectively). (Note that sample size for Hawaiian or Pacific Islander, Asian, and American Indian are small. Results should be interpreted with caution.)
Source: North Carolina Medicaid final-day paid fee-for-service (FFS), prepaid health plan (PHP), and local management entity–managed care organization (LME-MCO) encounters with dates of service starting March 1, 2020. See Methological Notes below for more information.
Source: North Carolina Medicaid final-day paid FFS, PHP, and LME-MCO encounters with dates of service starting March 1, 2020. See Methological Notes below for more information.
Source: North Carolina Medicaid final-day paid FFS and LME-MCO encounters with dates of service starting March 1, 2020. See Methological Notes below for more information. Note: Sample size for Hawaiian or Pacific Islander, Asian, and American Indian are small. Results should be interpreted with caution.
North Carolina’s data highlight that gaps in telehealth use by race and ethnicity are persistent despite policy change and investment by the state in expanding access to telehealth services and technologies. Notably, rural use, controlling for volume, nearly matched urban use during the COVID-19 pandemic, which may be due to NC DHHS’s heavy investment in building broadband infrastructure in recent years. These findings illustrate that addressing health equity may require different strategies than those needed to improve access to telehealth services in rural areas. This could mean evaluating strategies such as ensuring providers offer telehealth services to all patients and completing implicit bias training.
Telehealth utilization has declined significantly in use from its peak in 2020, but NC DHHS is continuing to develop policies and initiatives to promote health equity in collaboration with the governor’s office, other state departments, providers, and Medicaid members. NC DHHS’s Telehealth Work Group leads the development of future telehealth-related policy changes and is collaborating with the newly created Office of Digital Equity in the North Carolina Department of Information Technology to expand digital offerings and partnerships across the state.17 Continued monitoring and investment will support North Carolina’s effort to identify whether and to what extent different investments, programs, and policies have a meaningful impact on digital equity.
Funding and Support: This paper was funded by the North Carolina Department of Health and Human Services, which is a client of Manatt Health. More information on the department’s telehealth policy and its policy evaluation brief “Tele-Transformation in North Carolina: Telehealth Policy Lessons Learned During the COVID-19 Pandemic and Beyond” can be found on the NC DHHS website.
Figures 1–3. Service utilization data sets are based on NC Medicaid final-day paid fee-for-service (FFS) and local management entity–managed care organization (LME-MCO) encounters with dates of service starting March 1, 2020, forward, with weeks defined as starting on Sunday and ending on Saturday. Both health plans, Medicaid and NC Health Choice, are included in the analysis. The NC Medicaid Telehealth Billing Summary was used as the master list for modality breakout into telehealth, virtual patient communication (telephonic), and general/in-person/in-office visits, in addition to referencing Medicaid COVID-19 special bulletins. Telehealth claims were then represented as a proportion of the total claims submitted for that service week. Member demographic data were used to create stratifications by race and geography (rural vs. urban).
Figure 4 and 5. Claims and encounter data from March 2020 to December 2022 were collapsed into four time periods for each person (3/2020–10/2020, 11/2020–6/2021, 6/2021–1/2022, and 2/2022–12/2022). Data were coded according to whether the beneficiary had any telehealth use during the time period, had no telehealth use but had outpatient use during the time period, or didn’t have either telehealth or outpatient use during the time period. Race and ethnicity were identified during each time period. We ran a set of logistic regression models on the use of telehealth as a function of Black race and Hispanic ethnicity for each time period, and generated average marginal effects, which express the difference in probability of telehealth use for each group compared to the referent population (e.g., Black vs non-Black).
