Society for Education and the Advancement of Research in Connected Health SEARCH 2022 – The National Telehealth Research Symposium Abstracts Virtual Meeting November 16–18, 2022

Abstract

Telemedicine and e-HealthVol. 29, No. 3 AbstractsFree AccessSociety for Education and the Advancement of Research in Connected Health SEARCH 2022 – The National Telehealth Research Symposium Abstracts Virtual Meeting November 16–18, 2022Published Online:10 Mar 2023https://doi.org/10.1089/tmj.2023.29086.abstractsAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Please note that abstract numbering is not consecutive.There are no missing abstracts.SEARCH PRESENTATIONS1. Disparities in Video Care Use Among Veterans with Cardiovascular DiseaseRebecca Tisdale MD MPA1,2, Claudia Der‐Martirosian PhD3, Caroline Yoo MPH3, Karen Chu MS3,4, Donna Zulman MD MS1,5, Lucinda Leung MD PhD3,51Veterans Affairs Palo Alto Healthcare System/Center for Innovation to Implementation (Ci2i), Palo Alto, CA2Department of Health Policy, School of Medicine, and Stanford Health Policy, Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA3Veterans Affairs Greater Los Angeles Healthcare System/Center for the Study of Healthcare Innovation, Implementation, & Policy (CSHIIP), Los Angeles, CA4Veterans Emergency Management Evaluation Center (VEMEC), North Hills, CA5Department of Medicine, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA6Department of Medicine, Division of General Internal Medicine & Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CAPrimary Email:rtisdale@stanford.eduBackground: Video care expanded rapidly in the Veterans Health Administration (VA) at the onset of the COVID‐19 pandemic and remains a significant proportion of all VA care. Prevalence of cardiovascular disease (CVD) in Veterans is high, and ensuring access to care for CVD will likely require continued virtual care use. However, there remains a lack of evidence regarding which patients with these CVD conditions are more likely to receive video care. We sought to characterize use of video care for Veterans with two common cardiovascular diseases, heart failure and hypertension.Methods: This retrospective cohort study included Veterans established in VA primary care with diagnoses of heart failure and/or hypertension between 3/11/2019 and 3/10/2022, i.e., in the calendar year prior to the novel Coronavirus (COVID‐19) pandemic and for the first two pandemic years. We identified individual‐level predictors of one or more video‐based visits, accounting for patient‐ and site‐level clustering with a two‐level mixed‐effects logistic regression model adjusted for sociodemographic and clinical covariates and time.Results: Our analytic cohort comprised 3,807,820 Veterans with diagnoses of heart failure, hypertension, or both with 52 million visits. 456,901 Veterans had both heart failure and hypertension, 50,753 had heart failure only, and 3,300,166 had hypertension only. Veterans with heart failure and hypertension had an average baseline age of 71.6 years and mean Charlson Comorbidity Index of 3.0. 2.9% were female at birth, and 34.8% lived in a rural or highly rural setting.In our multi‐level logistic regression model, odds of using video care were highest during the first year of the pandemic, then declined in the second (AOR 15.3, 95% CI 15.1‐15.4 and 11.5, 95% CI 11.3‐11.6, respectively, compared to the pre‐pandemic year). Male patients had lower odds of ever using video care than female patients (adjusted odds ratio [AOR] 0.73, 95% confidence interval [CI] 0.72‐0.74). Age showed a gradient: patients 75 years or older had an AOR of 0.38 compared to those aged 18‐44 years (95% CI 0.38‐0.39). Rural‐dwelling Veterans had lower odds of using video care than urban‐dwellers (AOR 0.71, 95% CI 0.70‐0.71). Veterans with heart failure had slightly higher odds of video care use than those with hypertension only (AOR 1.06, 95% CI 1.05‐1.07).Discussion: Veterans with CVD had a 15‐fold increase in odds of use of video‐based care in the first year of the COVID‐19 pandemic. Male, older, and rural‐dwelling Veterans had lower odds of using video care than their respective reference groups. Video care remains an important proportion of care delivered to Veterans with cardiovascular disease. Given lower odds of video care among certain veteran groups, continued expansion of video care could make CVD services increasingly inequitable. As VA expands virtual care for CVD, these insights can inform equitable and effective triage of patients to virtual versus in‐person care.2. Telehealth‐Assisted Home BP Monitoring for In‐Center Hemodialysis Patients: A Pragmatic Implementation StudyYoshitsugu Obi MD PhD1, Yunxi Zhang PhD1, Saurabh Chandra MD PhD2, Maria Clarissa Tio MD MPH1, Catherine Wells DNP1, Neville Dossabhoy MD1, Tariq Shafi MBBS MHS1,31University of Mississippi Medical Center2Center for Telehealth, University of Mississippi Medical Center3Division of Kidney Diseases, Hypertension & Transplantation, Houston Methodist HospitalPrimary Email:yobi@umc.eduBackground: Home BP monitoring is essential to guide BP management for in‐center hemodialysis (HD) patients but is exceedingly difficult to obtain in clinical practice. We designed a pragmatic feasibility study of a telehealth‐assisted protocolized home BP monitoring program (TH‐BP) at an academic dialysis clinic.Methods: From 02/03/22 to 05/13/22, we referred 37 in‐center HD patients to the TH‐BP program, of which 25 started monitoring. All patients were provided a BP monitor with an appropriately sized cuff and a connected iPad. We averaged pre‐HD sitting systolic BP (preSBP) over 30 days before and after TH‐BP initiation and compared them with home SBP from the TH‐BP.Results: Patients had a mean age of 50 years and had been on dialysis for 6.5 years; 52% were females. The median (IQR) number of antihypertensives was 2 (1, 3). During a median follow‐up of 63 days, the mean ± SD frequencies of TH‐BP measurements (/day) were 1.1 ± 0.4 and 1.4 ± 0.9 on HD days and non‐HD days, respectively. After TH‐BP initiation, the 30‐day preSBP was 146 ± 15 mmHg (p = NS vs. the pre‐TH‐BP period). Home SBP was significantly lower than preSBP by 12 ± 18 mmHg (p = 0.005). Consistent results were observed with diastolic BP. Baseline patient characteristics did not predict patient willingness to participate in the TH‐BP or the differences between preSBP and home SBP.Discussion: This is the first report to demonstrate successful pragmatic implementation of home BP monitoring for in‐center HD patients in a routine clinical setting. Our findings of lower home SBPs suggest that BP management based on dialysis BPs alone may overtreat.This study is supported by the Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services under cooperative agreement award no. 2 U66RH31459‐04‐00. The information, conclusions, and opinions expressed are those of the authors and no endorsement is intended or should be inferred.3. In‐Person Versus Telehealth: Comparison of Behavioral Health Outcomes in Rural AmericaJames Marcin MD MPH1, Carly McCord PhD2, Fred Ullrich BA3, Kimberly Merchant MA3, Divya Bhagianadh MD3, Knute Carter PhD4, Eve‐Lynn Nelson PhD5, Kari Beth Law MD6, Jonathan Neufeld PhD7, Annaleis Giovanetti MA5, Marcia Ward PhD31UC Davis Health2Department of Psychiatry and Behavioral Sciences and Educational Psychology, Texas A&M University3University of Iowa4Department of Health Management and Policy, University of Iowa5University of Kansas6Department of Behavioral Medicine and Psychiatry, West Virginia University, Morgantown, WV, USA7University of Minnesota ‐ Great Plains Telehealth Resource & Assistance CenterPrimary Email:jpmarcin@ucdavis.eduBackground: Two large federally funded grant programs supported the evaluation of behavioral health outcomes in the United States: the Evidence‐Based Tele‐Behavioral Health Network Program (EB THNP) funded from September 2018 to August 2021 and the Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP) funded from September 2017 to August 2020. We sought to evaluate outcomes in symptoms of depression and anxiety across the 17 grantee programs and 95 associated sites, with each program providing data from patients receiving behavioral health care in‐person or via telehealth. The aim of this study was to compare changes in objectively measured symptoms of depression and anxiety over time between the two cohorts.Methods: The study design was a nonrandomized convenience sample across in‐person and telehealth cohorts from sites with similar rural characteristics and during the same time period. Patient characteristics were to be collected at treatment initiation, and clinical outcome measures were to be collected at baseline and subsequent visits on patients where clinically appropriate. The validated clinical outcome measure instruments included the Patient Health Questionnaire‐9 (PHQ‐9) for depression symptoms and the Generalized Anxiety Disorder‐7 (GAD‐7) scale for anxiety‐related symptoms. Changes between baseline and one‐month scores were analyzed using multivariable, hierarchical regression analyses.Results: For the in‐person cohort, there were 752 patients with PHQ‐9 and 652 patients with GAD‐7 data. For the telehealth cohort, there were 770 patients with PHQ‐9 and 638 with GAD‐7 data. The improvements from baseline to one‐month scores were similar between the in‐person and telehealth cohorts for both the PHQ‐9 and GAD‐7 scores. Individuals with higher baseline scores on both measures demonstrated the greatest decrease (improvements) in scores. Upon adjusting for baseline scores, patient demographics, insurance status, and clustering within grantee program, the modality of care was not found to be significantly associated with change in anxiety or depression symptoms.Discussion: In our very large pragmatic study comparing behavioral health treatment delivered to a population of patients in rural, underserved communities, we found no clinical or statistical differences in improvements in depression or anxiety symptoms as measured by the PHQ‐9 and GAD‐7 between treatments delivered in‐person or via telehealth.4. Pediatric Versus Non‐Pediatric Trained Providers and Their Antibiotic Prescribing Practices in the Setting of TelemedicineKathleen Jackson MD1, Amanda Price MD1, Shana Bondo MD MSPR1, Carrie Busch MD MSCR1, S. David McSwain MD MPH21Medical University of South Carolina2UNC HealthPrimary Email:jackkath@musc.eduBackground: Telemedicine research has shown that virtual visit encounters provide different prescribing rates for antibiotics and diverse antibiotic management in infectious processes for pediatric and adult patients (1,2). Recent literature does not directly approach differences in providers' training as it relates to diagnoses and prescriptions for pediatric patients. A unique retrospective comparison was made from November 1, 2019 – January 31, 2021 at the Medical University of South Carolina, a National Telehealth Centers of Excellence designated by the Department of Health and Human Services. An analysis of diagnoses that routinely require a hands‐on physical exam or laboratory test were evaluated along with providers' credentials. Standard of care for evaluation of infections utilized in the study were vital signs, rapid strep swab, oropharynx exam, lung auscultation or tympanic membrane visualization (3).Methods: Our objective was to assess whether being pediatric trained decreased the likelihood of prescribing antibiotics for pediatric infections on a telemedicine platform. A retrospective review was completed for virtual pediatric visits categorized by ICD‐10 codes as bronchiolitis, otitis media (OM), pharyngitis, sinusitis, and upper respiratory infections (URIs) of patients ss than 18 years old. The pediatric providers were labeled based on being general pediatricians or pediatric nurse practitioners by state credentialing. The non‐pediatric trained providers were physician assistants completing an emergency medicine fellowship at the given institution. A total of 5,035 visits were identified with the ICD ‐10 codes described with 3,858 visits completed by non‐pediatric trained providers and 1,177 by pediatric trained providers.Results: During the time 667 (13%) antibiotic prescriptions were written. Less than 25% of the visits were completed by pediatric trained providers, which was adjusted for in the analysis. Patients diagnosed with OM were given a prescription for every visit without a difference based on the provider's training. Non‐pediatric trained providers were more likely to prescribe antibiotics for sinusitis (p = 0.04), pharyngitis (p = <0.005), and URIs (p = 0.02) compared to their counterparts.Discussion: Pediatric telemedicine visits for common infections that could require antibiotic management showed majority of cases did not receive antibiotic. If antibiotics were prescribed, they were more likely to be prescribed by non‐pediatric trained providers for pharyngitis, sinusitis, and URIs. Although pediatricians prescribed antibiotics at a lower rate, training did not change prescriptions for otitis media. The general push for antibiotic stewardship over pediatric telehealth has shown improvement but getting both present and future medical providers to routinely utilize guideline‐concordant antibiotic management is essential.5. New Frontiers in Telehealth Research: A National Telehealth Data WarehouseJason Goldwater MA MPA1, Yael Harris PhD MHA1, Yunxi Zhang PhD2, Saurabh Chandra MD 2, Richard Summers MD 21Laurel Health Advisors2 University of Mississippi Medical CenterPrimary Email:jgoldwater@lh‐advisors.netBackground: The University of Mississippi Medical Center, under a Telehealth Center of Excellence Grant funded by the Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA) is working with Laurel Health Advisors to coordinate and standardize telehealth data to create a National Telehealth Data Warehouse. The purpose is to establish a central data repository that enables access to data related to telehealth services from multiple, diverse sources including payers, providers, and systems. Collectively, the Telehealth Data Warehouse will allow organizations to extract useful information that can inform program operations, financial decisions, and policy.Methods: UMMC developed a data dictionary to standardize the format for the data files that would be stored in the Warehouse. The data dictionary was based on the format developed by the Center for Telehealth and eHealth Law (CTEL), which undertook this activity in 2020 to collect data to support their national cost‐benefit analysis of telehealth during COVID‐19 study that was released in 2021. CTEL gathered data from several synchronous telehealth programs that provided data elements. including: patient demographics, patient diagnoses, patient procedures, patient medical history, insurer, and the amount reimbursed to the healthcare provider. The Warehouse will be created in Microsoft Azure with the data being initially stored and loaded through Azure Synapse. Validation checks will be present as the data is loaded to ensure fidelity to the data dictionary format. The Warehouse will follow a top‐down approach that synergizes the various data files that are submitted and provide a single source of telehealth encounter data for analysis. UMMC will also create a public‐facing website that provides information regarding the warehouse in addition to a dashboard that provide the latest statistics on telehealth utilization.Results: The use of a standardized national telehealth data set can assist researchers will exploring how telehealth was leveraged to support healthcare delivery during the public health emergency and provide preliminary data to support future research on telehealth efficacy across the healthcare delivery system not only during a national emergency but for sustained utilization post‐pandemic as well. Newly adopted and modified telehealth training modalities were assessed as essential components of the effective implementation of telehealth programs. It can also provide information on the various characteristics that affect an individual's likelihood of accessing and utilizing telehealth services, and how telehealth can be measured in terms of quality outcomes. There are an unlimited number of research topics suitable for the warehouse, and that will provide a means of conducting objective and comprehensive research.Discussion: Access to the warehouse will require potential users to submit a data request with the following: the intent and scope of the research, the specific data elements requested, how the data will be secured; and plans for discarding the data once the research is complete. The request will have to be approved by a governing board led by UMMC and the request is only valid for the specific scope of the research in which the data is needed. The warehouse will follow federal guidelines to ensure that data cannot be traced to a specific individual, and access to the data will be free.6. The Use of Telehealth To Meet Network Adequacy RequirementsJason Goldwater MA MPA, Yael Harris PhD MHALaurel Health AdvisorsPrimary Email:jgoldwater@lh‐advisors.netBackground: The Affordable Care Act (ACA) currently requires Qualified Health Plans (QHPs) offered through the Federally Facilitated Marketplace (also termed Health Marketplaces) to ensure a sufficient choice of providers and provide information to enrollees and prospective enrollees on the availability of in‐network and out‐of‐network providers. Network adequacy standards are based on provider availability, the anticipated enrollment of the Medicare and Medicaid programs, and care delivery patterns. They must include an “adequate network of primary care providers, specialists, and other ancillary health care providers.” One potential care delivery method that could help insurers meet their network adequacy requirements in both urban and rural areas and assist them in delivering care more efficiently is telehealth. Through telehealth, patients and providers living in rural or underserved areas have better access to specialists, which increases their ability to ensure accurate, timely careMethods: This research began with a comprehensive literature review, that was conducted in accordance with a prescribed review protocol that focused on the evaluation of network adequacy for Qualified Health Plans (QHPs), Medicare, and Medicaid, the use of telehealth services before and during COVID‐19, and the use of telehealth on mental and behavioral health, cardiology, and rheumatology. Three electronic databases were used: Google Scholar, Academic Search Premier, and EBSCO, as well as news articles and issue briefs by organizations such as the Robert Wood Johnson Foundation and McKinsey and Company. The search focused on material published between 2008 and 2022. Geographic Information System (GIS) analysis was used to determine the geolocation of mental and behavioral health providers, and primary care providers within the states used for the study. Providers were clustered within specific regions of a state and were geocoded using their given practice address. To get an appropriate count within each census tract, the points representing the providers were joined to the shape‐file containing the census tracts' geographic boundaries and demographic conditions.Results: The study showed a paucity of providers across the United States, particularly in areas designated as Micro, Rural, or CEAC (C (Counties with Extreme Access Considerations). The seven states used in the analysis: Maine, Texas, Mississippi, Kentucky, Arizona, South Dakota, and California, had a lack of cardiologists, rheumatologists, and mental health professionals, despite higher than average rates among their population of conditions that would require these specialties. The analysis of the data led to a proposed methodology for network adequacy that incorporates the use of telehealth that employs a tiered‐based approach that includes variables such as the use of broadband versus a 5G network, the CMS geographic classification for a county, the need for remote patient monitoring, and any other specific state requirements that should be added. Adjustments to network adequacy are derived by four distinct variables that account for the type of telehealth modality used, whether a high‐speed network is available, the current CMS classification of their county, and any additional state requirements that need to be considered.Discussion: The focus of this analysis was to understand the various components of network analysis, the mandated requirements as issued by both CMS and state legislatures, and how different telehealth modalities could be used to help issuers meet network adequacy requirements. The proposed model developed from this analysis is comprised of the following elements: 1.The percentage of credit given to an issuer for using telehealth should be based on the utilization and intensity of the service and whether telehealth can adequately substitute for an in‐person visit.2.In most cases, using telehealth as an on‐demand service when needed by a patient will meet the appointment waiting time requirements as issued b CMS.3.The use of remote monitoring devices should be given additional credit because there is more continuous care between a patient and a provider than videoconferencing or asynchronous modalities4.Additional credit should be given to Micro, Rural, or CEAC‐designated counties.7. Using Remote Standardized Patients to Train Interprofessional Learners in Telehealth CareTina Gustin DNP CNS RN1, Steven Haimowitz MD21Old Dominion University2Healthcourse, Inc./SP‐edPrimary Email:tgustin@odu.eduBackground: The pandemic induced rapid growth of care delivered through telehealth without critical consideration of provider training. Educators were challenged to prepare students from multiple disciplines and practicing practitioners on the nuances of a telehealth visit necessary for a safe and effective encounter. While online module‐based learning proved to be effective, end users did not have the opportunity to practice their new skills in a safe, supportive, and real‐time environment.The use of standardized patients (SPs) is an established training technique in clinical education that can be useful for this type of experiential training and feedback. The collaboration between C‐TIER, who provided all training, and SP‐ed, specializing in remote SP‐based education, was able to leverage this successful methodology into a digital offering that allowed all participants to engage in an authentic telehealth simulation from their connected devices.Methods: Prior to participating in the SP session, learners completed a self‐paced, asynchronous module‐based training. Throughout the course learners participated in immersive experiences aimed at preparing them for telehealth practice: narrated PowerPoints, videos, evaluation tools, and group work. At course completion, learners were directed to select a predetermined SP based on their profession: Pediatric Primary Care, Adult Primary Care, Social Work, Mental Health, Physical Therapy, Pharmacy, Anesthesiology. SP cases were built to include social determinants of health, with different genders, ages, and ethnicities. The SP experience was designed to assess learner competency in assessment, physical examination, medication reviews, patient education, and telehealth etiquette, each unique to the learner's profession. SP evaluations were completed using validated tools embedded in the course, including the Teaching Interpersonal Skills for Telehealth Checklist (TIPS‐TC) which consists of 12 items on a five‐point rating scale.Results: To date, 204 digital SP sessions have been completed within two weeks of the online telehealth certification course. SP scenarios were purposefully developed for crossover, but were divided as follows: Adult Primary Care‐education and prescribing (N = 18)2 abdominal pain cases: 1‐adult (N = 23); 1‐pediatric (N = 49)Physical Therapy‐ankle pain (N = 50)Social Work‐rule out anxiety and suicidal ideation (N = 29)Mental Health‐prescribing (N = 21)Anesthesiology‐pre‐operative (N = 14)94% of learners found their digital SP session to be more helpful / as helpful as face‐to‐face SP sessions. Initially the SP case was built for a 20‐minute experience. Many learners requested additional time and the sessions have been extended. All students agreed / strongly agreed that the digital session was helpful in improving their overall telehealth skills. All participants agreed or strongly agreed that the remote session was helpful in improving their overall telehealth skills. Data from the TIPS‐TC includes quantitative results on the five‐point scale for the 12 items and qualitative data from coaching comments added by participants as available. The research will report results from the TIPS‐TC evaluation instrument at the session.Discussion: The incorporation of the SP experience into the certificate course has proven to be effective. Due to the national outreach of the certificate program learners from different time zones have been able to schedule their sessions at times that fit their schedule easily. Early data suggests that this type of telehealth training can be effectively and conveniently delivered through digital SP sessions which may easily integrate into onsite, online, or distance learning courses, and provide the ability to increase the scale of online graduate education to meet the current demands for telehealth training. It offers a simple and affordable way for universities who don't have access to SPs or are burdened by large class sizes and hybrid teaching models, to tap into a reliable and validated program. We will review SP recruiting, training, case design specific to telehealth encounters, as well as learner preparation, SP/learner scheduling, and learner outcomes in the presentation.8. Examining Telehealth Use Among Hispanic CommunitiesCynthia Williams PhD MHA PT1, Di Shang PhD21University of Central Florida2University of North FloridaPrimary Email:cynthia.williams@ucf.eduBackground: During COVID‐19, through policy and reimbursement initiatives, telehealth was strongly encouraged to promote safe access to healthcare services. Difficulties in accessing healthcare services is a long standing challenge in the United States healthcare system and adding a telehealth platform can potentially exacerbate inequities. Health inequities are often delineated by races, ethnicities, geographic regions, socioeconomic status and other social determinants of health. While there were significant increases in telehealth use across racial and ethnic groups, the Hispanic community did not share this trend. The purpose of this study was to investigate demographic, socio‐economic, education, and behavioral causes for low telehealth utilization among Hispanic communities .Methods: The COVID‐19 Research Database Consortium provided data for the study. The study period was March 2020 to April 2021. Office Ally database provided access to U.S. claims data from 100 million unique patients and 3.4 billion medical claims. The Analytics IQ PeopleCore Consumer database provided individual level data across demographics, behaviors, and economic indicators. Analytics IQ PeopleCore consumer database is a national representation of 242.5 million U.S. adults aged 18 and older. Descriptive statistics used an analysis of variance and chi‐squared test for continuous and categorical variables, respectively, to compare demographic, socioeconomic and health behavior characteristics. Multiple logistic regression was used to determine the odds of using telehealth servicesResults: We examined 3,478,287 unique Hispanic persons, 16.6% used telehealth; 56% were female. Results suggested that across age groups, Hispanic patients who had a primary care physician (Odds Ratio, OR 1.1), higher incomes (OR 1.34), full‐time employment (OR 1.1), and private insurance (OR 1.2) were more likely to use telehealth. Patients across age groups who had unhealthy behaviors such as smoking (OR 0.69), high alcohol consumption (OR 0.63) and high school education or less (OR 0.96) were less likely to use telehealth. Hispanic females were more likely than males (OR 0.94) to use telehealth in persons aged 65 years and older.Discussion: COVID‐19 magnified the burden of telehealth inequities in the Hispanic community. Social determinants of health do not differ between traditional and digital means to access to healthcare. Factors that affect traditional means to access care also affect digital means to access care. While federal policies promoted telehealth use, and overall telehealth use increased, the Hispanic community did not share in this benefit. Community based interventions must support vulnerable communities. Increasing access to telehealth must go beyond federal policy promulgation and include local, actionable interventions that encourage Hispanic groups to use telehealth. Therefore we recommend the following strategies: increase access to health insurance, primary care, and instilling digital access as foundational in the public health infrastructure.9. Telehealth Utilization Among Medicaid Recipients with Chronic DiseasesCynthia Williams PhD MHA PT1, Di Shang PhD21University of Central Florida2Univ of North FloridaPrimary Email:cynthia.williams@ucf.eduBackground: Despite the growing demand for telehealth services, Medicaid beneficiaries have not experienced the increase in utilization as noted in other populations. People enrolled in Medicaid Insurance programs often reflect individuals who experience substantial inequities in the healthca