What Explains Inequalities in Telehealth Utilization Among North Carolina Medicaid Beneficiaries?

Background: Increased availability of telehealth can improve access to health care. However, there is evidence of persistent disparities in telehealth usage, as well as among people from minoritized racial and ethnic groups and rural residents. The objective of our work was to explore the degree to which disparities in telehealth use for behavioral health (BH) and musculoskeletal (MSK) related services during the COVID-19 pandemic are explained by observed beneficiary- and area-level characteristics. Methods: Using North Carolina Medicaid claims data of Medicaid beneficiaries with BH or MSK conditions, we apply nonlinear regression-based decomposition analysis-based models developed by Kitagawa, Oaxaca, and Blinder to determine which observed variables are associated with racial, ethnic, and rural inequalities in telehealth usage. Results: In the BH cohort, we found statistically significant differences in telehealth usage by race in the adult population, and by race, Hispanic ethnicity, and rurality in the pediatric population. In the MSK cohort, we found significant inequities by Hispanic ethnicity and rurality among adults, and by race and rurality among children. Inequalities in telehealth use between groups were small, ranging from 0.7 percentage points between urban and rural adults with MSK conditions to 3.8 percentage points between white adults and people of color among those with BH conditions. Overall, we found that racial and ethnic inequalities in telehealth use are not well explained by the observed variables in our data. Rural disparities in telehealth use are better explained by observed variables, particularly area-level broadband internet use. Conclusions: For inequalities between rural and urban residents, our analysis provides observational evidence that infrastructure such as broadband internet access is an important driver of differences in telehealth use. For racial and ethnic inequalities, the pathways may be more complex and difficult to measure, particularly when relying on administrative data sources in place of more detailed data on individual-level socioeconomic factors.

Describing Perspectives of Telehealth and the Impact on Equity in Access to Health Care from Community and Provider Perspectives: A Multimethod Analysis.

Introduction: The rapid adoption of telehealth as a result of the COVID-19 pandemic provided the opportunity to examine perceptions of health care access and use of telehealth for delivery of effective and equitable care in low-income and historically marginalized communities. Methods: Focusing on communities with high social vulnerability, a multimethod analysis of combined perspectives, collected February through August 2022 from 112 health care providers, obtained from surveys and interviews, and 23 community members via 3 focus groups on access to care and telehealth. Qualitative data were analyzed using the Health Equity and Implementation Framework to identify barriers, facilitators, and recommendations for the implementation of telehealth using a health equity lens. Results: Participants perceived that telehealth helped maintain access to health care during the pandemic by addressing barriers including provider shortages, transportation concerns, and scheduling conflicts. Additional benefits suggested were improved care quality and coordination attributed to convenient avenues for care delivery and communication among providers and patients. However, many barriers to telehealth were reported and considered to limit equitable access to care. These included restrictive or changing policies regarding allowable services provided via telehealth, and availability of technology and broadband services to enable telehealth visits. Recommendations provided insight into care delivery innovation opportunities and potential policy changes to address equitable access to care. Conclusion: Integration of telehealth into models of care delivery could improve access to health care services and promote communication among providers and patients to improve care quality. Our findings have implications that are critical for future policy reforms and telehealth research.

Evaluating Telehealth Uptake Among North Carolina Medicaid Beneficiaries With Musculoskeletal Conditions: Insights From the COVID-19 Pandemic.

BACKGROUND: The shift from in-person to virtual visits, known as telehealth (TH), during the COVID-19 pandemic was a significant change for North Carolina (NC) Medicaid beneficiaries seeking treatment for musculoskeletal (MSK) conditions, as remote care for these conditions was previously unavailable. We used this policy change to investigate factors associated with TH uptake and whether TH availability mitigated disparities in access to care or affected emergency department (ED) visits among these beneficiaries. RESEARCH DESIGN: Using 2019-2021 NC Medicaid claims, we identified beneficiaries receiving treatment for MSK conditions before COVID-19 (March 2019-February 2020) and analyzed uptake of newly available TH during COVID-19 (April 2020-March 2021). We used descriptive analysis and Poisson generalized estimating equations to quantify TH uptake, factors associated with TH uptake, and the association with ED visits during COVID-19. RESULTS: Black and Hispanic beneficiaries were less likely to use TH compared with White and non-Hispanic counterparts (10%, P <0.001 and 20%, P =0.03, respectively). Adults eligible for Tailored Plans, specialized NC Medicaid plans for those with significant behavioral health needs or intellectual/developmental disabilities, were less likely to use TH [adjusted risk ratio (ARR):0.83, 95% CI (0.78, 0.87)]; youth eligible for Tailored Plans were more likely to use TH [ARR:1.28, 95% CI (1.16, 1.42)]. Lower county-level internet access was associated with lower TH use [ARR: 0.85, 95% CI (0.82, 0.99)]. No statistical difference in ED utilization was observed between TH users and non-users. CONCLUSIONS: TH has the potential to deliver convenient care to beneficiaries with MSK conditions who can access it. Further research and policy changes should explore and address underlying factors driving disparities and improve equitable access to care for this population.

Telehealth Utilization Among Adult Medicaid Beneficiaries in North Carolina with Behavioral Health Conditions During the COVID-19 Pandemic.

OBJECTIVE: We examined factors associated with telehealth utilization during COVID-19 among adult Medicaid beneficiaries with behavioral health conditions. DATA SOURCES AND STUDY SETTING: NC Medicaid 2019-2021 beneficiary and claims data. STUDY DESIGN: This retrospective cohort study examined and compared behavioral health service use pre-COVID-19 (03/01/2019 to 02/28/2020) and during COVID-19 (04/01/2020 to 03/31/2021). Telehealth users included those with at least one behavioral health visit via telehealth during COVID-19. Descriptive statistics were calculated for overall sample and by telehealth status. Multilevel modified Poisson generalized estimating equation examined associations between telehealth use and patient- and area-level characteristics. DATA COLLECTION/EXTRACTION METHODS: We identified individuals ages ≥ 21-64, diagnosed with a behavioral health condition, and had at least one behavioral-health specific visit before COVID-19. PRINCIPAL FINDINGS: Almost two-thirds of the cohort received behavioral health services during COVID-19, with half of these beneficiaries using telehealth. Non-telehealth users had steeper declines in service use from pre- to during COVID-19 compared to telehealth users. Beneficiaries identifying as Black, multiracial or other were significantly less likely to use telehealth (ARR = 0.86; 95% CI: (0.83, 0.89)); (ARR = 0.92; 95% CI: (0.87, 0.96)) compared to White beneficiaries. Those eligible for Medicaid through the blind/disabled programs and who qualified for a state-specific specialized behavioral health plan were more likely to use telehealth (17% and 20%, respectively). CONCLUSIONS: During the pandemic, telehealth facilitated continuity of care for beneficiaries with behavioral health conditions. Future research should aim to investigate how to reduce the digital divide and ensure equitable access to telehealth.