At the outset of the COVID-19 pandemic, Medicaid agencies in all 50 states and the District of Columbia issued emergency guidance that vastly expanded access to telehealth services, in some cases to include virtual maternity care. Before the pandemic, only nine states explicitly reimbursed Medicaid providers for providing pregnancy care via telemedicine. As the federal and state governments consider extending all or parts of pandemic-era telehealth policies, it’s important to consider how these changes will affect maternity care and whether they will ameliorate or exacerbate racial and ethnic disparities in outcomes.
In the United States, maternal deaths have been increasing since 2000; Black and Native American women are between two and four times more likely than white women to die of pregnancy-related complications. Medicaid covered 42.1 percent of all births in 2019, and an even larger share of births among Black women (65.3%). The low-income women who qualify for Medicaid services often have less access to devices and broadband connections needed for video visits, making it vitally important to consider how telemedicine policy will affect access to care.
State Policies to Expand Access to Telematernity
To understand how state policy influences the adoption of telemedicine in maternity care, we interviewed medical directors from Medicaid programs in three states that focused on expanding access to telematernity. Our goal was to identify promising approaches and challenges states face in reaching women at high risk for poor maternal outcomes.
In Arizona, the state’s Medicaid agency broadly expanded coverage for telehealth services to all specialties in October 2019 by eliminating diagnostic criteria and place-of-service restrictions that had limited its use. The state also expanded coverage for remote patient monitoring and asynchronous communication (when you send a message without expecting an immediate response) and required managed care organizations to pay the same rate for telehealth visits as other visits deemed medically necessary. The state is also allowing payment for audio-only telemedicine visits through September 30, 2021, which ensures those without broadband connections can maintain contact with their clinicians.
Dr. Sara Salek, chief medical officer of Arizona’s Medicaid agency, told us that during the COVID-19 pandemic Arizona Medicaid has equalized reimbursement between in-person and virtual visits, including audio-only visits, in part because “in their Medicaid population, not everyone has access” to the broadband coverage or data speeds needed to support synchronous video visits.
Prior to the pandemic, the Wyoming Department of Health, which administers the state’s Medicaid program, also covered routine maternity care via telemedicine including risk assessments and blood pressure monitoring, as well as depression screening in the postpartum period. As the pandemic unfolded, state leaders removed barriers to remote monitoring by purchasing equipment like blood pressure monitors and partnered with Wildflower Health, a virtual health company that offers a telehealth platform for providers.
The state has allowed audio-only visits for prenatal care during the pandemic. “We know there are fewer missed appointments when we cover telehealth. And if we shut off telephonic care, that closes access to care in frontier, isolated, and tribal areas, which creates problems of equity,” said James Bush, M.D., the medical director for Medicaid in Wyoming. “Remote patient monitoring is critical for prenatal visits — weight, blood pressure, doppler — but all of these services require access to a certain level of broadband, and this is a challenge,” he added.
North Carolina Medicaid issued new guidance to clinicians at the start of the pandemic to communicate changes in coverage. These included lifting “site-to-site” restrictions that required clinicians and patients to be in medical facilities when conducting telemedicine visits, which allowed pregnant people to connect to clinicians from their homes. The agency also began paying providers for remote monitoring, including reimbursement for blood pressure cuffs and scales, and added coverage for audio-only visits and depression screenings during telehealth visits.
Recommendations for Policymakers
The lifting of restrictions on telemedicine before and during the pandemic appears to be producing benefits, including reducing the number of missed appointments, which could improve health outcomes and reduce health inequities. Karen Dale, R.N., M.S.N., market president for AmeriHealth Caritas in the District of Columbia says many providers have told her their no-show rates plummeted to zero after they began offering telehealth, including audio-only calls. When combined with remote patient monitoring and health coaching, these visits have helped to increase health literacy among patients, she says.
Additional studies can help quantify these effects and also can differentiate the benefits of care delivered via telehealth and its effects on health disparities. For example, studies could help determine if blood pressure cuffs or fetal dopplers for home monitoring are effective and what supports patients and families need to engage with them.
To ensure widespread adoption of evidence-based approaches by practices of all sizes, it is also critical to think through the barriers providers face and the supports they need, from technical assistance to billing guidance from managed care organizations. Some providers may be reluctant to invest in new technologies and workflows if quality metrics do not take telemedicine services into account. Enlisting champions to promote the benefits of telemedicine or encouraging the adoption of telehealth for lower-risk services like breastfeeding consults may help ease the transition. Policymakers also can play a role by creating incentives for clinicians to offer telematernity services and by providing supports to help them do so.
While some policymakers have raised concerns regarding fraud and abuse in telehealth, such as billing for visits that did not occur, others note the risk of abuse is no greater than for other health care services and can be addressed through auditing and enforcement. Finally, and perhaps most important, states and health plans should consider whether discontinuing audio-only visits allowed during the pandemic harms people without broadband access and can result in disconnection from the health care system.
The authors thank Brittany Blizzard, Jennifer Bohn, Neko Castleberry, and Jo Palmer for their contributions.
