Think convenient health care is only for the wealthy? Think again.
Medicaid recipients often have significant barriers to care
Throughout my residency, I worked in a primary care clinic that was in one of the poorest areas of Boston. Fully two-thirds of our patients were on Medicaid, and many came from families that had unstable work, transportation, housing, and access to food. It was not uncommon for many of our appointments during the day to be “no-shows,” which we defined as the patient showing up more than an hour late, only to have distraught families appear at the end of the day, apologizing for late buses, unforgiving managers at work, and other life circumstances largely out of their control, but still a staple of day-to-day life.
Many of these appointments were scheduled to follow up from previous and ongoing care. We had learned that keeping a close tab on the children in our clinic meant that they were less likely to fall through the cracks with lapsed medication, end up in the emergency room for what could be routine care, or end up admitted to the hospital for what otherwise would have been preventable illnesses. If we had a child newly diagnosed with asthma, for example, we would have him come back into the clinic a few weeks in a row, to make sure that his parents had picked up the correct medication, that he was using it correctly, and that the dose of the medication was correct to keep the asthma symptoms in check. Sometimes parents didn’t have enough money to pay for both an inhaler that keeps kids from having an asthma attack as well as an inhaler that helps rescue a child from an asthma attack, although both are necessary for good care.
Traditional means of accessing health care is often time and resource intensive
Each of these visits was a significant burden on the family. The parent would often have to miss work (usually meaning those hours went unpaid) and the child would also have to miss school. Many families took more than one bus to get to the clinic, making a 15-minute appointment a several hour-long venture. The hours we had available were always during the day and during the week, so the option of trying to schedule around a day job was essentially impossible. In short, we were trying to do our best by our patients, but in the process, were causing major disruptions to their health and well-being. In the end, I truly believe that on balance we were helping more than hurting, but I always wondered if there were some way that we could have brought them the same level of care and attention, without the negative side effects of having them bend their lives around a health care system centered on the provider.
Advances in telemedicine can make accessing appropriate health care easier
Fast-forward a few years, and I find myself on the front-line of health care innovation. At American Well, we use the technology that most people are used to having in many areas of their lives (talking to others through video, scheduling appointments online, being able to conveniently log into a mobile app), to connect health care providers and patients quickly and easily, without requiring patients to re-wire their day for a trip into the office. I recently heard someone say, “Patients have a workflow too. It’s called Life.” That comment really resonated with me, from not only my own life and the expectations I have, but also for my many former patients who were trying to do the right thing, but just couldn’t get their life aligned with my workflow.
“Patients have a workflow too. It’s called Life.”
With telemedicine, we work consistently to make the most appropriate care also the most accessible care for all patients. For Medicaid recipients who use our technology, that often means that we treat people at home who otherwise would have gone to the emergency room, because historically the emergency room has been the easiest way to get care. Very few people actually want to spend hours waiting at an emergency room, but previously there wasn’t a great alternative for someone who may need care unpredictably and at any hour. But when some partners of American Well let their populations receiving Medicaid know that they can now access urgent care from home, they found that patients were more than happy to use a service that kept them out of the ED. It was a win for everyone!
Technology is not the limiting factor
When I talk about using telemedicine for patients who receive Medicaid, one of the first questions is always around access to technology. Do people with lower incomes actually have the type of phone or computer that could allow them to see a physician online? The answer is “Absolutely, yes.” The Pew Research Center actually tracks statistics like these, and they found that in 2017, 67% of people with incomes of $30k or less have a smartphone. In fact, in 2016, 21% of those who earn $30k or less are smartphone dependent, meaning that they have a smartphone but not broadband internet at home.
Anecdotally, we’ve had partner health systems tell us that their Medicaid populations are actually the most savvy about finding free sources of wifi, and often know how to make video calls through this free wifi alone, saving them any data usage or call minute fees. Generally, we’ve found that the barrier to introducing telemedicine through Medicaid has not been technology, but has been reimbursement. Or, rather, the confusion around reimbursement.
“Generally, we’ve found that the barrier to introducing telemedicine through Medicaid has not been technology, but has been reimbursement.”
Reimbursement through Medicaid is varied, but favorable
Unlike Medicare (which is for people over the age of 65), a federally administered program, Medicaid is administered by states. This design means that every state has slightly different rules for what they allow Medicaid to cover. Not only that, but states are regularly updating what they will and will not cover. So if you don’t like your state’s Medicaid reimbursement for telemedicine, just wait 5 minutes, it will likely change.
The good news is that as of the time of writing this post, almost all states have favorable reimbursement policies for telemedicine, with 48 states reimbursing for live video. Many even pay the same for visits that happen through live video as ones that happen in person (parity). Since changes to reimbursement are happening all the time, it’s best to go to a site such at the Center for Connected Health Policy to find out what’s happening in your state.
How to start using telemedicine for Medicaid recipients
Telemedicine is medicine, just using technology to make it easier and more convenient. This principle holds just as true for populations receiving Medicaid, as for any other population.
So, if you’re wondering how to introduce telemedicine and whether or not it’s covered under your state’s Medicaid program, go to the Center for Connected Health Policy website to look up reimbursement regulations, and then set up any programs that would benefit patients if their care were delivered where they needed it most. From urgent care to chronic disease management, health care is only effective if it reaches the patient. My patients already had enough standing in the way of reaching me, I’m happy to be tearing down at least some of those barriers.
Sylvia Romm, MD, MPH, is a pediatrician and VP of Medical Affairs at American Well. She lives with her family in New York City.