Background: When the US Department of Health and Human Services instituted a State of Public Health Emergency (PHE) during the COVID-19 pandemic, many telehealth flexibilities were fast-tracked to allow state Medicaid agencies to reimburse new specialty services, sites of care, and mediums such as FaceTime to communicate with patients.. This resulted in expanded access to care for financially vulnerable Medicaid patients, as evidenced by an uptick in telehealth use. Research has mostly focused on telehealth reimbursement for limited use cases such as rural primary care, without broader consideration for how telehealth can be appropriately mainstreamed and maintained. Objective: This study sought to (1) evaluate the continuation of flexible telehealth reimbursement broadly, beyond the COVID-19 pandemic; (2) analyze the clinical effectiveness of the new telehealth services; and (3) offer code-by-code reimbursement guidance to state Medicaid leaders. Methods: We surveyed 10 state Medicaid medical directors (MMDs) who are responsible for the scientific and clinical appropriateness of Medicaid policies in their respective states. Participants were asked to complete an internet-based survey with a list of medical billing codes, grouped by service type, and asked if they believed they should be reimbursed by Medicaid on a permanent basis. Additional questions covered more detailed recommendations, such as reimbursing video with audio versus audio-only, guardrails for certain specialty services, and motivations behind responses. Results: The MMDs felt that the majority of services should be reimbursed via some modality of telehealth after the PHE, with the most support for video combined with audio compared to audio-only. There were exceptions on both ends of the spectrum, where services such as pulmonary diagnostics were not recommended to be reimbursed in any form and services such as psychotherapy for mental health had the most support for audio-only. The vast majority of MMDs were supportive of reimbursement for remote monitoring services, but some preferred to have some reimbursement guardrails. We found that 90% (n=9) of MMDs were supportive of reimbursement for telehealth interprofessional services, while half (n=5) of the respondents felt that there should be continued guardrails for reimbursement. Motivations for continuing reimbursement flexibility were largely attributed to improving access to care, improving outcomes, and improving equity among the Medicaid patient population. Conclusions: There is a strong clinical endorsement to continue the telehealth flexibility enabled by the PHE, primarily for video combined with audio telehealth, with caution against audio-only telehealth in situations where hands-on intervention is necessary for diagnosis or treatment. There is also support for reimbursing remote monitoring services and telehealth interprofessional services, albeit with guardrails. These results are primarily from a perspective of improving access, outcomes, and equity; other state-specific factors such as fiscal impact and technical implementation may need to be taken into account when considering reimbursement decisions on telehealth.

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对临床上适合美国医疗补助人群报销的远程医疗服务的评估：混合方法研究

背景：当美国卫生与公众服务部在 COVID-19 大流行期间宣布公共卫生紧急状态 (PHE) 时，许多远程医疗灵活性得到了快速发展，以允许州医疗补助机构报销新的专业服务、护理场所、以及 FaceTime 等媒介与患者沟通。这导致经济困难的医疗补助患者获得护理的机会扩大，远程医疗使用量的增加就证明了这一点。研究主要集中在农村初级保健等有限用例的远程医疗报销上，而没有更广泛地考虑如何适当地将远程医疗纳入主流和维持。目标：本研究旨在 (1) 广泛评估灵活远程医疗报销的持续性，超越 COVID-19 大流行； (2) 分析新型远程医疗服务的临床效果； (3) 向州医疗补助领导人提供逐个代码的报销指导。方法：我们调查了 10 名州医疗补助医疗主任 (MMD)，他们负责各自州医疗补助政策的科学性和临床适当性。参与者被要求完成一项基于互联网的调查，其中包含按服务类型分组的医疗帐单代码列表，并询问他们是否认为他们应该永久获得医疗补助报销。其他问题涵盖了更详细的建议，例如报销带有音频的视频与仅音频的视频、某些专业服务的护栏以及响应背后的动机。结果： MMD 认为，大部分服务应在 PHE 之后通过某种远程医疗方式进行报销，与仅音频相比，视频与音频相结合的支持最多。两端都有例外，不建议以任何形式报销肺部诊断等服务，而心理健康心理治疗等服务则最多支持纯音频。绝大多数 MMD 支持远程监控服务报销，但有些人更愿意有一些报销护栏。我们发现，90% (n=9) 的 MMD 支持远程医疗跨专业服务的报销，而一半 (n=5) 的受访者认为应该继续对报销进行限制。继续保持报销灵活性的动机主要归因于改善医疗补助患者群体获得护理的机会、改善结果和改善公平性。结论：临床界强烈支持继续 PHE 实现的远程医疗灵活性，主要针对视频与音频远程医疗相结合，但在诊断或治疗需要亲自干预的情况下，应谨慎使用纯音频远程医疗。尽管有护栏，但还支持补偿远程监控服务和远程医疗跨专业服务。这些结果主要是从改善机会、成果和公平的角度出发；在考虑远程医疗报销决定时，可能需要考虑其他国家具体因素，例如财政影响和技术实施。