Facilitators of and barriers to Medicaid investment in electronic consultation services.

Abstract

Objective: Electronic consultation, or e-consult, programs have enhanced access to specialty care for primary care providers and their patients, reducing unnecessary in-person visits and maintaining cost-effectiveness. In California, there is great variability in access to e-consult programs for low-income patients who rely on Medicaid managed care plans (MCPs) for covered benefits. This study aimed to understand MCP facilitators of and barriers to e-consult investment in California.

Study design: Interviews conducted with California Medicaid MCPs' leaders to learn about the facilitators of and barriers to investment in e-consult programs.

Methods: Interviews were analyzed using content analysis with multistage coding. The Exploration, Preparation, Implementation, and Sustainment framework was used to organize facilitator and barrier themes into 4 contexts: outer context (landscape of health care delivery in California), inner context (components within the medical neighborhood), innovation factors (characteristics of e-consult programs), and bridging factors (MCP actions).

Results: Twelve themes emerged from 16 interviews. Outer context themes were regulatory policies and financial policies (barriers), limited specialty care (facilitator), and patient perceptions (both). Inner context themes were workforce characteristics (both), clinical leadership (facilitator), and clinical workflows (both). Innovation factor themes were adjunct e-consult vendor services (both) and software integration (facilitator). Bridging factor themes included collaboration with other plans (facilitator), financial risk delegation (barrier), and quality improvement considerations (facilitator).

Conclusions: Medicaid regulatory and reimbursement policies posed the most significant barriers to e-consult investment by Medicaid MCPs in California. Recognition of e-consult as a mode of specialty care delivery and reimbursement for clinicians could help future e-consult programs succeed in enhancing access to specialty expertise for low-income patients.