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August 16, 2017

Telemedicine useful for easier access to medical specialists

New research indicates telemedicine consults for specialty referrals could improve much-needed access for Medicaid populations. It also could offer support to an innovative telehealth platform now being used in nine states to connect doctors, Medicaid patients and specialists online. That concludes a study, published in the online edition of JAMA Internal Medicine.

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The study focussed on the effect of state Medicaid managed care (MMC) specialty access standards on enrollees’ timely accessibility to specialist physicians. It found that specialty access standards adopted by some state Medicaid programs did not make specialty care more accessible for beneficiaries. The researchers instead suggested “more innovative solutions,” such as a digital health platform enabling beneficiaries to meet specialists online. One such possibility is telemedicine, providing less time consuming access to care specialists.

Medicaid recipients have less timely access to specialists

Medicaid recipients have consistently reported less timely access to specialists than patients with other types of coverage. By 2018, state Medicaid agencies will be required by the Center for Medicare and Medicaid Services (CMS) to enact time and distance standards for managed care organizations to ensure an adequate supply of specialist physicians for enrollees; however, there have been no published studies of whether these policies have significant effects on access to specialty care.

The objective of the study was therefore to compare ratings of access to specialists for adult Medicaid and commercial enrollees before and after the implementation of specialty access standards. The researchers  found that using a difference-in-differences study design, state standards were not associated with significant improvement in timely access to specialty services for MMC enrollees relative to enrollees in matched control states, nor any improvement in insurance-based disparities relative to commercial beneficiaries.

More policy interventions needed

This means that the adoption of specialty access standards by state Medicaid agencies will likely not lead to meaningful improvements in access to specialty care for Medicaid recipients, suggesting other policy interventions may be needed to address access problems.

“One way to make specialty care more available is to facilitate electronic or telemedicine specialty consultation,” Mitchell H. Katz, MD, of the Los Angeles Department of Health Services, wrote in an accompanying editorial. “Whether time synchronous (i.e. patient and physician are connected audibly and/or visually at separate locations) or dyssynchronous (electric consultation sent by a primary care physician to a specialist who responds in a matter of days) these alternative type of consultations allow patients to receive rapid specialty advice without the need for traveling and typically at lower cost.”

Katz also highlighted a big barrier to telemedicine consults: reimbursement. “For these visits to be financially sustainable, the provider must be in a capitated system or there must be billing codes for such visits,” he pointed out. “[A]t the moment electronic consultations cannot generally be billed under Medicare, fee-for-service Medicaid or private insurance. The move toward fee-for-value and away from fee-for-service encourages use of these innovative specialty services.”

About the study

The study used Consumer Assessment of Healthcare Providers and Systems survey data to conduct a quasiexperimental difference-in-differences (DID) analysis of 20?163 nonelderly adult Medicaid managed care (MMC) enrollees and 54?465 commercially insured enrollees in 5 states adopting access standards, and 37?290 MMC enrollees in 5 matched states that previously adopted access standards.

7.698 (69%) Medicaid enrollees and 28.423 (75%) commercial enrollees reported that it was always or usually easy to get an appointment with a specialist before the policy implementation (or at baseline). This compared with 11?889 (67%) of Medicaid enrollees in states that had previously implemented access standards.

Overall, there was no significant improvement in timely access to specialty services for MMC enrollees in the period following implementation of standard(s) (adjusted difference-in-differences, -1.2 percentage points; 95% CI, -2.7 to 0.1), nor was there any impact of access standards on insurance-based disparities in access (0.6 percentage points; 95% CI, ?4.3 to 5.4). There was heterogeneity across states, with 1 state that implemented both time and distance standards demonstrating significant improvements in access and reductions in disparities.

The researchers conclude that specialty access standards do not lead to widespread improvements in access to specialist physicians. Meaningful improvements in access to specialty care for Medicaid recipients may require additional interventions.

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