Menu
Vinagolu-Baur J, Morgan A, Goodman D. Benefits of audio-only telehealth reimbursement by Medicaid for rural pregnant patients beyond the COVID-19 Pandemic . HPHR. 2024. 82. https://doi.org/10.54111/0001/DDDD6
The purpose of this policy brief is to discuss barriers to prenatal care faced by rural, low-resource patients, assess telemedicine’s potential to reduce these barriers, and inform health policy development to optimize those benefits through continued audio-only Medicaid reimbursement.
For pregnant and postpartum patients, telemedicine offers a modality for frequent interaction with healthcare providers, reducing barriers including taking time off from work and familial responsibilities, commute time, and transportation costs. However, challenges exist in providing equitable access to telemedicine.
The COVID-19 pandemic shifted traditional forms of healthcare delivery towards telemedicine to minimize overcrowding in health facilities, conserve personal protective equipment and reduce the transmission of SARS-CoV-2. Telemedicine— the remote diagnosis, treatment, and management of disease— reduces patient and staff exposure to infection and helps provide necessary care to patients by making healthcare more accessible for underserved patient populations who are especially vulnerable amidst the pandemic, including low-resource and rural patients.
In March 2020, driven by the steep rise of COVID-19 prevalence across the United States, Governor Sununu signed Emergency Order #8, pursuant to Executive Order 2020-04, to temporarily expand telehealth services across the state of New Hampshire for the duration of the COVID-19 State of Emergency Declaration. This order expanded commercial insurance and Medicaid coverage with regards to telehealth platforms, sites of origin, and eligible providers. Prior to the current pandemic, telehealth reimbursement required both live video and audio. Due to the COVID-19 pandemic, audio-only telehealth became eligible for reimbursement throughout the State of Emergency period.1
Eligible telehealth providers in New Hampshire include: “Physicians, Physician Assistants, APRNs/Clinical Nurse Specialists/Nurse Midwifes, Certified Registered Nurse Anesthetists, Clinical Psychologists and School Psychologists licensed by the Board of Psychologists, Clinical Social Workers, master’s level psychiatric nurses, Pastoral psychotherapists, marriage and family therapists, clinical mental health counselors, and any other provider licensed by the Board of Mental Health Practice, LADCs, MLADCs, CRSWs, applied behavioral analysts, Registered Dietitians or nutritional professionals, Dentists, and community mental health providers.” Billing and documentation follow routine practices with the addition of standard language identifying the encounter as telemedicine, with Medicaid reimbursing services at the same rate as if the visit was face-to-face. With the onset of the pandemic, reimbursement for audio-only telehealth at the same rate was temporarily authorized.1
Although not typically billable before the COVID-19 pandemic, audio-only telehealth has nevertheless proven to be a promising modality for care delivery, especially for vulnerable populations with limited access to technology. One study investigating telephone-based continuing care for alcohol and cocaine dependence, researchers found that an audio-only/telephone-based approach to counseling was an effective step-down treatment for addiction patients compared to face-to-face interventions.2 A more recent study noted the benefits of audio-only telepsychology to treat anxiety, depression, post-traumatic stress disorder and adjustment disorder.3
Table 1: Programs Utilizing Telemedicine for Prenatal Care
Institution | Program Description | Program Outcomes |
Mayo Clinic | Launched an “OB Nest” program offering telemedicine for pregnancies classified as “low-risk” 8 in person visits with an obstetrician and midwife, 6 phone visits with a nurse. In-home monitoring for weight, blood pressure, fundal height and fetal heartbeat. (Butler et al., 2019) | 300 people randomized to OB Nest vs. traditional care, comparable maternal and fetal clinical outcomes (Butler et al., 2019) OB Nest reported decreased rates of pregnancy related stress, higher patient satisfaction, no difference in perceived quality of care. Offered increased confidence, sense of control, greater participation in pregnancy care. (De Mooij et al., 2018) |
MultiCare, Washington State
| Virtual obstetrics appointments for “low risk pregnancies” 7-9 prenatal appointments and 1 postpartum appointment in person, 5 prenatal and 1 postpartum video visits with a nurse practitioner At home weight, blood pressure, fetal heartbeat monitoring and urine screening. (Pflugeisen et al., 2016) | Comparable pregnancy and birth outcomes between virtual care group and traditional care group. (Pflugeisen et al., 2016) There was higher patient satisfaction in the telemedicine (virtual care) group. (Pflugeisen & Mou, 2017) |
University of Texas Southwestern Medical Center and Parkland Health and Hospital System
| Implemented audio-only prenatal telehealth visits, in response to the COVID-19 pandemic “within a large, county-based prenatal care system serving predominantly women with low socioeconomic status and limited resources” (Holcomb et al., 2020) | Completed more than 4,000 audio-only virtual prenatal visits from March to May of 2020. 99% of respondents noted that the audioonly prenatal visits met their needs. (Holcomb et al., 2020) |
A number of institutions have piloted studies on telemedicine and prenatal visits. Table 1 provides examples of these programs while summarizing various outcomes related to stress levels, patient participation in pregnancy care, perceived quality of care, pregnancy/birth outcomes and satisfaction with audio-only telehealth specifically.
Mayo Clinic’s “OB Nest” program, for example, implemented a hybrid in-person and audio-only telehealth model with 8 in person visits and 6 phone visits among 300 people with pregnancies classified as low-risk. Mayo Clinic reported decreased rates of pregnancy related stress, higher levels of patient satisfaction, increased participation in pregnancy care as a result of increased sense of control, and no differences in perceived quality of care.4 In a telehealth study for perinatal care by MultiCare at Washington State, comparable pregnancy and birth outcomes were noted between in-person and telemedicine groups.5 Savings for patients, cost savings for health centers and hospitals, and increased appointment adherence rates were also found.6 In a study assessing patient perspectives on audio-only prenatal visits amidst the current COVID-19 pandemic, 99% (280/283) of participants reported satisfaction with their telehealth appointment.7 In addition to these benefits of telehealth, a recent issue brief on telemedicine and pregnancy care lists additional outcomes such as time savings for patients, cost savings for health centers and hospitals, and increased appointment adherence rates.
Despite these favorable outcomes, the current expansion of telehealth services to include audio-only encounters is limited to the duration of the public health emergency order only.8 However, although reimbursement for audio-only telehealth may cease, the need for this low barrier option to ensure access to care for economically stressed rural and remote rural patients will not go away. The purpose of this policy brief, therefore, is to advocate for continued coverage of audio-only modalities for telehealth, given the obstacles for in-person pregnancy care for New Hampshire residents and rural patients across the United States.
The use of telemedicine has grown in popularity over the last decade, and its use expanded rapidly amidst the COVID-19 pandemic as a means to remotely deliver healthcare. Audio-only telehealth provides additional accessibility to telemedicine, especially for low-income, low-resource and/or rural-residing patients who lack access to a webcam enabled device or adequate internet service to allow participation in video telehealth visits. This paper discusses how telemedicine can equitably address barriers to prenatal care, and advocates for the continued Medicaid reimbursement of audio-only telehealth.
Pregnant patients are particularly vulnerable group, because of the need for increased engagement with healthcare services, including frequent surveillance to ensure healthy pregnancy and positive perinatal outcomes. Therefore, the barriers which exist to accessing traditional, in-person health care are magnified, particularly for patients with limited access to economic resources, and those who are rural residing.
In addition to the high cost of healthcare, lack of insurance, and underinsurance leading to high co-pays, patients with limited economic resources face many hidden costs limiting access to healthcare. These may include barriers related to family responsibilities, reduced job security and limited work flexibility. Hourly wage workers without medical benefits or paid time off for sick leave, often find themselves deciding between taking care of their own health or financially supporting their family.9 Many also lack a reliable means of transportation to get to or from appointments, in addition to the high costs of gas, vehicle maintenance and tolls they might encounter transporting themselves to and from appointments.10
While video telehealth addresses some of these obstacles, low resource individuals also face financial hardship with webcam enabled cellphone (smartphone) ownership and maintenance. According to a study from the Pew Research Center, 23% of smartphone owners surveyed have to cancel or shut off their cell phone service due to maintenance fees.11
Barriers that rural patients additionally face include geographic barriers, such as mountains, unmaintained and/or poorly lit roads, and extreme weather conditions, which physically isolate patients from readily accessing care.12 Furthermore, there is a deficiency of healthcare professionals in rural areas and often extensive distances between a rural patient and their closest health center, leading to increased travel time for medical appointments.13 Rural residents are also less likely to be covered by Medicaid or secure employer-provided health or prescription drug coverage, based on recent work by Allen and colleagues.14 While research has demonstrated adverse health impacts for all rural populations, those within low-income communities are especially at risk due to a compounding of barriers to care.15
Rural workers in the private sector also have less access to paid sick days compared to their urban counterparts, and often face more unpredictable employment, according to an issue brief utilizing data from the National Study of the Changing Workforce survey.16 In terms of cellphone ownership, according to the same smartphone report by the Pew Research Center, 66% of adults in the United States use a smartphone while only 52% of rural adults utilize one.11
Social determinants also affect a rural residing individual’s perception of, and ability to access, healthcare. These determinants include cultural and social norms surrounding health behaviors, low health literacy levels, incomplete perceptions of health, educational disparities, limited access to healthy foods or physical activity opportunities and fewer mental health programs, all of which pose challenges for rural residing patients who are seeking care.12
Due to the frequency of healthcare visits necessary during pregnancy and the postpartum period, pregnant and postpartum people are an especially vulnerable to inequities in access to care caused by lack of social supports including public transportation, the ability to get time off work for regular and urgent prenatal care, lack of affordable childcare, and difficulty scheduling timely appointments that work with schedules of other household members and children.17 With regards to mental health, low-income and rural pregnant people are also at higher risk of mental health problems, as food insecurity, unsafe housing, underemployment, lack of social support and stress are all contributing factors for depression.18 Mental health problems impact the health of the pregnant person, increase the chances of a premature or low birth weight baby, and can in turn, also make it more difficult to access care.19
In New Hampshire’s rural and remote rural communities, transportation is particularly difficult for low income pregnant people, who may lack gas money for frequent healthcare visits, or have to access transportation services through the Medicaid system if they don’t have a car. The recent closure of labor and delivery units in community hospitals has decreased the availability of local maternity care providers, increasing the problems of access highlighted above. The confluence of these factors directly contribute to worse outcomes for pregnant people in rural areas. When sociodemographic factors and clinical conditions were controlled, a recent study found that pregnant people in rural areas had a 9% greater probability of severe maternal morbidity and mortality compared to their urban resident counterparts.10
Figure 1: Labor and delivery center closures in New Hampshire community hospitals (2002-2020)
In New Hampshire, the focus of this brief, the overlap between broadband deserts and maternity care deserts also poses a significant barrier to care due to the greater distance that pregnant people are required to travel (Figure 1). The loss of maternity care programs in rural and remote rural areas of the state unfortunately also intersects with areas of limited broadband access and weak cell phone signal.
The current pandemic adds yet another layer of concern for pregnant people as they are at increased risk of severe COVID-19 illness compared to their nonpregnant peers.20 To reduce infection risk, many obstetrics providers shifted to a hybrid model of care that utilizes telehealth for some prenatal visits in order to limit pregnant peoples’ exposure to Sars-CoV-2 in healthcare facilities. However, due to the inequities in access to telemedicine described above, this approach unfortunately widened disparities in care and outcomes for rural, low resource pregnant people.
The confluence of barriers that rural, low-resource, pregnant people face as discussed above lead to inequities in access to care, and put these patients at an increased risk for poor health outcomes. These barriers are often associated with a higher prevalence of chronic conditions such as heart disease, stroke, cancer, chronic respiratory disease, and diabetes, and often lead to higher mortality and disability rates than residents in urban counterparts. Additionally, they limit access to health promotion and preventive health programs, further hindering an individuals’ access to health care.12
In addition to these barriers and risks to physical and mental health that these patient population face, disparities in access to video-telehealth specifically (as a result of barriers to cellphone ownership), adds additional vulnerability for already disadvantaged groups, leading to the larger issue of unequal access to care, something that could be mitigated with policy change focused on maintaining audio-only reimbursement for telehealth visits beyond the COVID-19 pandemic.
Figure 2: Triple Aim considerations for telemedicine and prenatal care, including per capita costs, experience of care, and population health.
According to the Institute for Healthcare Improvement (IHI), new design proposals for healthcare delivery should provide benefits in three domains, referred to as the Triple Aim: improving the patient experience in terms of quality and satisfaction of care, improving the health of populations, and reducing the per capita cost of healthcare.21 Using the Triple Aim framework we assess the potential impact of removing barriers to telemedicine for prenatal patients through extending reimbursement for audio-only telehealth (Figure 2).
Medicaid programs are required to provide transportation services to ensure equity in access to care. From a financial perspective, maintaining Medicaid reimbursement of audio-only telehealth is less costly than utilizing transportation services for visits that are appropriate to conduct virtually, especially when time-savings are taken into account, including time off of work, planning for travel, costs to/from a clinic, scheduling childcare and taking care of other family responsibilities. Additionally, Medicaid transportation services in New Hampshire require at least 48 hour notice, which can delay care if special authorization is not approved in a timely fashion. Reduction in hospital and health center expenditure might also be anticipated with additional virtual visits, through reduced crowding, lower waiting room utilization and resource allocation.22
Patient experience of care is influenced by both quality of care and satisfaction. Existing research demonstrates that audio-only telehealth programs perform well in terms of safety and effectiveness, patient-centeredness, timeliness, efficiency, and equity.23 As demonstrated in Table 1, audio-only prenatal care visits are viewed positively by patients while not sacrificing quality.4,5,7,24
On the larger scale of population health, it would be important to assess health outcomes from audio-only telehealth, and address scalability of telehealth programs in different populations. Audio-only telehealth also shows comparable prenatal health outcomes when compared to traditional modes of care as indicated in Mayo Clinic’s “OB Nest” study.4
As noted earlier in this brief, audio-only telehealth has shown favorable health outcomes in addiction medicine and in treating anxiety, PTSD and adjustment disorders.4,25 Telehealth visits have led to substantial cost savings in the treatment of postpartum and maternal depression.26 The market opportunity that telehealth presents in the behavioral health sector is the ability to expand access to care while reducing costs, simply by diverting patients from high-cost care settings. This leads to reduced hospital expenditure for appointments that do not require an in-person visit, while also increasing utilization of behavioral health services by reducing the existing treatment gap, thereby dually benefitting both health systems by reducing costs, and patients by increasing their access to behavioral health services.27
It is also important to note that having access to a phone offers benefits other than the ability to participate in telehealth, such as the ability to contact health care teams to reach a decision about whether or not to schedule an appointment, or address any questions and concerns. Pregnant people of childbearing age, and those with less economic resources, are more likely to use cellphones as a principal means for accessing the internet; in fact, many of them even prefer using a cellphone over a tablet or personal computer.28 Continued reimbursement of audio-only telehealth would address these disparities to cellphone and/or smartphone ownership by providing patients with the opportunity to utilize a lower-cost device and less data for telehealth visits.
Another means of reducing disparities with regards to perinatal care would be increasing access to audio-only telehealth for certain sociodemographic patient groups. In an analysis of over 148,000 patients by the University of Pennsylvania Health System during the earlier phase of the COVID-19 pandemic, “older age, female sex, Black race, Latinx ethnicity, and lower household income” patients were associated with lower use of video-telemedicine visits for primary and specialty ambulatory care, with “older age, Asian race, non-English language as the patient’s preferred language, and Medicaid” patients (independently) associated with fewer completed telemedicine visits overall, indicating a need for continued audio-telehealth among certain sociodemographic groups to reduce disparities.29
While these strategies would increase access to telemedicine overall, it is important to prevent other factors from inadvertently increasing disparities.
In a recent commentary on equitable telemedicine in perinatal care, researchers at the University of California, San Francisco, discuss several implementation factors for individual practitioners, health care delivery systems, payers, policymakers and researchers to ensure that telemedicine does not further widen disparities. In the context of audio-only telehealth, Ukoha et al. recommend individual practitioners acknowledge implicit biases and document/attempt to mitigate unique language or literacy barriers, such as identifying additional tools required to support digital visits for these patients. With regards to healthcare delivery systems, the researchers recommend allowing for audio-only visits when video-visits are not feasible or desired, while partnering with community-based organizations to promote digital literacy on a larger scale. They also note they importance of establishing telemedicine as a standard covered benefit for payers, and providing a mobile device and/or data plan to those who cannot afford one. On a policy level, they recommend requiring reimbursement of audio-only visits and eliminating outdated coverage restrictions for those with Medicaid/Medicare insurance, and encourage researchers to further analyze data on telemedicine use and access in different populations.30
In closing, this policy brief explored how access to digital technology might address barriers to telemedicine, and advocates for the equitable deployment of technology to reduce health disparities for low-resource, pregnant people throughout the COVID-19 pandemic and beyond.
Around 26% of all births in New Hampshire are insured by Medicaid.31 Based on the assessment above, a short-term policy imperative is to continue Medicaid reimbursement for audio-only telehealth visits, even now after the State of Emergency Order has been lifted across the United States. Failing to renew Medicaid reimbursement of this form of telehealth will increase disparities in access and perinatal outcomes, especially for rural and remote-rural residing pregnant patients in New Hampshire’s widening maternity care deserts. In the medium term, since Medicaid covers transportation for patients, Medicaid Managed Care Organizations should also subsidize cell phones/data minutes in an attempt to reduce disparities in access to telemedicine caused by the costs of cellphone ownership. Finally, in the longer term, policymakers should ensure increased access to low-cost broadband networks (Table 2).
Table 2: Short and long term policy imperatives to reduce disparities for New Hampshire’s perinatal population
Timeframe | Recommendation |
Short-term | Continued Medicaid reimbursement of audio-only telehealth visits after the COVID-19 State of Emergency Order is lifted (in the State of New Hampshire and across the U.S.) |
Medium-term | Subsidization of cell phones and/or data minutes to reduce disparities in access to telehealth as a result of cellphone ownership costs |
Long-term | Increased access to low-cost broadband networks, ensuring network connectivity and reliability for telehealth visits |
We would like to acknowledge Dr. David LaFlamme for his generosity in allowing us to display his real-time tracker of maternal care/L&D facilities in the State of New Hampshire. We would also like to thank Courtney Tanner for her continued advice, support and expertise in the legal realm of health policy and legislation.
The author(s) have no relevant financial disclosures or conflicts of interest.
Julia R Vinagolu-Baur, MBA, MS is an incoming MD candidate at SUNY Upstate Medical University. She holds an MS in Medical Technology from SUNY Upstate Medical University and an MBA from Rensselaer Polytechnic Institute. She is a recent alum of Harvard’s Premedical Postbaccalaureate Program (’22) and has experience in public health, healthcare, program management and research.
Allie Morgan, MD, MPH, is a resident physician in the Department of Obstetrics and Gynecology at Dartmouth-Hitchcock Medical Center.
Daisy Goodman, DNP, MPH, CNM is an Assistant Professor of Obstetrics and Gynecology and Community and Family Medicine at the Geisel School of Medicine at Dartmouth, as well as The Dartmouth Institute (TDI) for Health Policy and Clinical Practice. Daisy is also a Women’s Health Nurse Practitioner in the Department of Obstetrics and Gynecology at Dartmouth-Hitchcock Medical Center.
BCPHR.org was designed by ComputerAlly.com.
Visit BCPHR‘s publisher, the Boston Congress of Public Health (BCPH).
Email [email protected] for more information.
Click below to make a tax-deductible donation supporting the educational initiatives of the Boston Congress of Public Health, publisher of BCPHR.
© 2024 BCPHR: An Academic, Peer-Reviewed Journal