By Clarissa Donnelly-DeRoven

Before the pandemic, Valerie Fox almost never used telehealth — nobody did at the Veterans Affairs Medical Center in Durham, where she works as a behavioral health occupational therapist.

Now, many patients request it. 

“Especially with the VA, a lot of people come from a lot of different parts of the state to here,” Fox said. “When we go to transition to outpatient work, it’s a lot easier.” With telehealth, people can more easily incorporate OT into their daily schedules — an hour here, an hour there. 

“It doesn’t become this big thing,” she said. 

But that’ll likely be changing soon. By July 1, North Carolina Medicaid will no longer cover occupational and physical therapy services done via telehealth — and getting to and from appointments will become, yet again, a big thing. The change was supposed to take place March 31, but the state extended coverage for 90 more days. 

Kimberly Godwin, the advocacy chair at the state’s occupational therapy association, has been getting a lot of emails over the last few months from therapists such as Fox telling her how telehealth has helped them serve more clients. 

“We’ve heard from a lot of businesses within the pediatric as well as other outpatient settings or specialized care, like mobility clinics, that have been able to just really broadly reach clients,” she said. “There’s been less cancellations, less no shows.” 

Many providers have noted how telehealth increased access for people who can’t afford transportation to and from a clinic, or those who don’t have any transportation to begin with. 

Even the state’s Medicaid program sounds supportive of keeping telehealth for physical and occupational therapy. 

Data from the North Carolina Department of Health and Human Services shows that claims from people on Medicaid for telehealth services hit their height at the start of the pandemic, and have declined since. Credit: NCDHHS.

“Over the past two years, telehealth flexibilities helped children and families access valuable PT/OT services during the unprecedented circumstances of the COVID-19 pandemic,” said state health department spokesperson Catie Armstrong. 

But she said that right now, the federal Centers for Medicare & Medicaid Services is not allowing any permanent changes to telehealth services. During the first few months of the public health emergency, the state recorded nearly 60,000 telehealth claims from people on Medicaid. In the months since, that number has declined.

That means, even if it wanted to, North Carolina doesn’t have the authority to permanently authorize the state Medicaid program to cover virtual OT and PT services. The coverage rollback has left many who work in the field worried about the impact it will have on people across the state, especially those in rural areas. 

Unique role telehealth plays in OT and PT

Since the start of the pandemic, researchers at Duke University have been investigating the role telehealth plays in expanding access to care in general. One study is examining the impact virtual care has had for people receiving OT and PT. 

Katherine Norman, a pediatric occupational therapist, is one of the investigators on the study.

“The population we looked at was children and adolescents, so that was anybody from zero to 20, enrolled in Medicaid from April 2020 to March 2021,” she said. The researchers analyzed the Medicaid claims data of about 137,000 children with a musculoskeletal health diagnosis who visited a provider during the time period. 

“The data that we uncovered really suggests that removing access via telehealth could impact as many as one in five kids who were using physical therapy and one in three kids who are using occupational therapy,” Norman said. To add a qualitative dimension to their study, the researchers are also speaking with people on Medicaid, health care providers, and community leaders statewide.

Physical and occupational therapy can be critical for helping kids meet developmental milestones. PT can help children learn how to do critical physical tasks with more ease: walk and run, get on and off the floor, and play, while OT helps kids with the development of fine motor skills, such as brushing their teeth or holding a comb. 

Imagining all those kids missing out on this kind of care deeply worries Norman. 

Also, she says, telehealth holds a unique value within occupational therapy because of the nature of the care. If she’s seeing a patient, rather than just telling her about the stairs they have trouble climbing, or the corner they want to be able to stand behind to surprise their sibling, they can literally bring her into the room.

“They can show me exactly how they do it,” she said, “so that I can see that and be like, ‘OK, so we need to work on your ability to crouch, or your ability to jump, or [whatever] specific movement pattern.’”

Fox agrees. 

In OT, “We think a lot about the environment, and how that impacts function and somebody’s ability to participate,” she said. “When it comes to having somebody leave their natural environment to come to an outpatient clinic, you have to ask a lot of questions: What does your home look like? And how do you move through your home? And what is the environment?

“Telehealth allows you to truly see that in the moment and kind of be there with someone and I think that’s another layer, in addition to accessibility.”

Also, Fox says, it doesn’t have to be all or nothing. In a perfect world, care going forward could be a blend of telehealth and in-person care. 

“I just had that with a veteran,” she said. “He’s 75. He lives about an hour and a half away. So the first visit was that we do a lot of assessments, and now that we kind of know each other and I have more of an idea of his level of function, the next few sessions could be telehealth.”

“What is the harm in keeping it as an option?” 

Fox, who in addition to her full-time job at the VA is also the president of the North Carolina Occupational Therapy Association, said she was unaware of any outreach the state health department had done to ask occupational and physical therapists how virtual coverage was going for them and if they’d want it to continue going forward. 

“This came to our attention when we were informed of the date of the sunset,” Fox said. Medicaid refers to the end of coverage for certain services as ‘sunsetting.’ 

“So, we did not realize that this was coming, and definitely not that it was coming as fast as it was,” she said. “We’ve been told that they did not have the data showing that the telehealth modality was utilized enough. We are unclear on what type of data that was, or how it was collected or what their cutoff is for ‘enough,’ but that was what we’ve been told so far.”

Spokespeople from DHHS did not directly answer the question of if they conducted outreach to providers, but said that they have qualitative data from families showing support for telehealth. Still, they said, the data the department has collected and analyzed “did not demonstrate the use of these services.”

In a public webinar presentation on March 17, the associate director of program evaluations at North Carolina Medicaid, Sam Thompson, presented the data collected by Norman and the other Duke researchers, but came to a different conclusion than the researchers.

“As a proportion of care, telehealth is just substantially lower in this group,” he said. “Because it’s such a small proportion of care, it’s a little bit less meaningful”

But, Fox argues, even if utilization rates were low, if anyone used it, it’s worth keeping. 

“It’s about access,” she said. “And so if five people throughout the year use it, what is the harm in keeping it as an option?” 

Data collected by researchers at Duke University that NC Medicaid officials presented at the end of March. Though Thompson said utilization of these services was proportionally small, NCDHHS extended temporary Medicaid coverage of tele-OT and tele-PT services after the presentation. Credit: NCDHHS; Duke University.

The state Medicaid office did worry at first that adding telehealth as an option would increase costs, but that’s not what they’ve seen. 

“We have not found it to be significantly more expensive,” Thompson said. “We have some evidence to suggest that it can help prevent complicating factors that might be more expensive.”

It’s unclear if private insurance plans will continue to cover tele-OT and PT or sunset their coverage as well. But historically, Godwin said, private insurance plans often follow what Medicaid does, meaning there’s a good chance that if telehealth for OT and PT is made permanent by the federally funded health care program, other insurance plans may follow. 

While the state Medicaid office is limited in its ability to make permanent changes to its telehealth coverage policy, providers spoken to for this story want to encourage officials to do everything they can to make sure the coverage remains permanent. 

If it goes away, they argue, fewer people will get the care they need. 

“And that makes me really sad,” Godwin said.

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Clarissa Donnelly-DeRoven

Clarissa Donnelly-DeRoven covers rural health and Medicaid. She previously worked at the Asheville Citizen Times where she reported on the police, courts, and other aspects of the criminal justice system....