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Policy Facilitators Versus Structural Barriers: Integrative Therapy Telehealth Changes in the United States During the COVID-19 Pandemic

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Introduction

The opioid epidemic is among the most urgent public health priorities facing patients and prescribers alike, with nearly 70% of deaths in 2018 involving opioids.1 A variety of health policies have sought to reduce the number of opioid overdoses, with less attention focused on bolstering access, as well as utilization of nonpharmacological pain management therapies. Nonpharmacological complementary and integrative pain management therapies may reduce the reliance on opioid-centric treatment.2–4 Two complementary and integrative therapies, physical therapy (PT) and occupational therapy (OT), have been shown to improve functional outcomes and reduce opioid use.5–7 Despite benefits of PT/OT, access and utilization of these therapies may be limited by compounding structural barriers.

Considering the international emergency due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19), both PT and OT practices have experienced many additional challenges. To continue to aid patients with pain-related conditions in the midst of a pandemic, telehealth has become an essential tool that is utilized by PT and OT professionals. Before the COVID-19 pandemic, each state had telehealth policies in place that were either underdeveloped or regularly changing. In addition, telehealth was not readily accessible to many, largely due to the lack of telehealth service reimbursement from commercial insurance companies, Medicare, and Medicaid.8

However, in response to COVID-19, states are providing guidance for telehealth and making amendments to assist practices in offering OT.9 As for PT, the American Physical Therapy Association advocates for the use of telehealth when possible and even supports its usage beyond COVID-19 safety precautions.10 Taken together, recent policies have started to reduce some of the barriers to care accessibility during COVID-19, but the degree to which these policies can have large and long-lasting impacts may be contingent on other structural barriers.

Despite the advances made in telehealth and loosening of restrictions by insurance companies, telehealth is not accessible to all patients. Telehealth accessibility is contingent on broadband access, which in turn may be impacted by physical location, policies or laws, or socioeconomic factors.11 Policies to improve telehealth accessibility do not account for broadband access barriers and therefore will have a differential effect on the population.

The objective of this cross-sectional analysis was to evaluate the changes in PT and OT telehealth provisions during the COVID-19 pandemic and the degree to which structural barriers could mitigate the intended impact of such policies. This analysis will examine each states’ existing telehealth policies in relation to PT/OT, rank each state on their telehealth readiness, identify relationships between existing telehealth policies and opioid prescription rates, and discuss how social determinants of health may be associated with telehealth availability and accessibility.

Data and Methods

Telehealth and Telemedicine Policies

Telehealth and telemedicine policies across each U.S. state and the District of Columbia are assembled in Supplementary Table ST1. The table lists if that state or the District of Columbia has a telehealth and/or telemedicine policy; if that state or the District of Columbia has PT, OT, or generic telehealth/telemedicine policies; any updates to telehealth/telemedicine policies due to COVID-19; if these changes specifically addressed PT/OT; and whether these changes were permanent. Data from State Telehealth Laws and Reimbursement Policies, Telemedicine Policies, COVID-19-Related State Actions, State Actions Affecting Occupational Therapy in Response to COVID-19, Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19, and State Actions Permitting Physical Therapists to Provide Telehealth Services were compiled and compared.9,12–16 Information from these sources was also analyzed and verified by further examination of each state’s respective legislative branch website.

Opioid Prescription Rates and Broadband Data

State-level opioid prescribing rates per 100 residents were obtained from the Centers for Disease Control and Prevention’s U.S. Prescribing Rate Maps for the year 2018. These data were composed of initial and refilled prescriptions from retail pharmacies across the United States. These rates can be used as a proxy for individuals who may benefit from the PT/OT care. The state population without broadband access rate was obtained from the Federal Communications Commission’s (FCC) Mapping Broadband Health in America platform. In general, telehealth requires a broadband connection, which the FCC defines as 25 megabits per second (Mbps) for downloads and 3 Mbps for uploads.17

A bivariate map showing the relationship between the opioid prescription rates per state and the rate of individuals without broadband access was created using the tmap package in R statistical software.18 The bivariate map consists of a nine-class bivariate sequential color scheme representing the multiple intersections of low to high percentages of opioid prescribing rates and population without broadband access between the state. The top right cell of this grid, the black color, represents cases when both variables are high.

Social Vulnerability Index Data

The CDCs 2018 social vulnerability index (SVI) was used to compare the social vulnerability of a state with that state’s telehealth policies. Social vulnerability is defined as qualities that may make one more susceptible to stressors.19 The 2018 SVI utilizes the American Community Survey (ACS) from 2014 to 2018 at the county level to evaluate 15 factors that contribute to social vulnerability, including poverty, unemployment, and minority status. These 15 factors were grouped into 4 categories: (1) socioeconomic status, (2) household composition/disability, (3) minority status/language, and (4) housing type/transportation.

For this analysis, categories were converted from county level to state level by totaling all county estimates by state. Dplyr and plyr R packages were used to select columns of interest and filter the data by state in R.20,21 The totals of each variable of interest were found using the janitor package in R.22 Five additional variables were created to reflect state-level percentages and used data from percent disabled population, percent of population in poverty, percent of population older than 65 years, and percent of population uninsured. Data and statistical analysis were performed in R, and all missing and unknown numbers were converted to missing.

Telehealth and Social Vulnerability Ranking Analysis

States’ telehealth accessibility and social vulnerability for PT/OT were ranked using the following indicators: population rates of individuals without broadband access, with a disability, with poverty, older than 65 years, without insurance, and the opioid prescription rate. Each indicator was sorted from least to greatest value and then ranked from lowest to highest; lower state individual rankings indicate higher estimated accessibility to broadband and lower social vulnerability barriers. Variables that tied in rate received the same ranking. After the variables were ranked for each state, they were totaled into an overall ranking. The overall ranking was sorted from least (best) to greatest (worst), and a final ranking was developed to rank from 1 to 43, as some states tied ranking. Data analysis was performed using R software.

Results

Telehealth and Telemedicine Policies

As described in Table 1, 20 states (39.2%) had both telehealth and telemedicine policies. Before the pandemic, 38 of the 51 (74.5%) states and the District of Columbia had telehealth policies, whereas 33 of the 51 (64.7%) had telemedicine policies in place during the pandemic. Additionally, 26 states (50.98%) had PT-specific policies and 18 states (35.3%) had OT-specific policies. Three states (5.9%) did not clearly have nor lack a policy in place in regard to PT, whereas 13 states (25.5%) did not clearly have nor lacked an OT policy, and were marked as “unknown.”

Table 1. Descriptive Statistics of Telehealth and Telemedicine Policies Across Each U.S. State and the District of Columbia
VARIABLE LEVEL OVERALL (n = 51)
Telehealth policy (%) Yes 38 (74.5)
No 13 (25.5)
Telemedicine policy (%) Yes 33 (64.7)
No 18 (35.3)
PT specific (%) Yes 26 (51.0)
No 22 (43.1)
Unknown 3 (5.9)
OT specific (%) Yes 18 (35.3)
No 20 (39.2)
Unknown 13 (25.5)
Changes to telehealth/medicine due to COVID that specifically mention OT (%) Yes 32 (62.7)
No 19 (37.3)
Changes to telehealth/medicine due to COVID that specifically mention PT (%) Yes 31 (60.8)
No 20 (39.2)
General telehealth/medicine policy changes due to COVID (%) Yes 51 (100.0)
Updates to policies changes due to COVID (%) Temporary 40 (78.4)
Attempting to make changes permanent 3 (5.9)
Permanent 8 (15.7)

The rapid onset of the COVID-19 pandemic influenced changes across policies in nearly all states. Almost all states and the District of Columbia (90.2%) had general telehealth/medicine policy changes as a result of the pandemic. Thirty-two states and the District of Columbia (62.8%) had policy changes that specifically mentioned PT, and 31 states and the District of Columbia (60.8%) specifically mentioned OT. Of these changes, 8 (15.7%) were permanent, 40 (83.3%) were temporary with either a specific end date or an open-end date, and 3 (5.9%) were currently in the process of making the changes permanent.

Bivariate Map

To depict the potential impact of telehealth and telemedicine policies for individuals with pain-related conditions, a bivariate map was created to show the relationship between the opioid prescription rates per state and the rate of individuals without broadband access (Fig. 1). Results of the bivariate map show that 14% of states had a combination of lower opioid prescription rates and lower rates of individuals without broadband access. These states were largely located in the Northeast Region and included, in alphabetical order, California, Connecticut, Maryland, Massachusetts, New Jersey, New York, and Rhode Island. Almost one of four states (26%) had both higher opioid prescription rates and higher rates of individuals without broadband access. These states were primarily in the Southwest and Southeast Regions and included, in alphabetical order, Alabama, Arkansas, Idaho, Indiana, Kansas, Louisiana, Mississippi, Missouri, Oklahoma, South Carolina, and West Virginia. The map also showed 14% of the states had both moderate opioid prescription rates and moderate broadband access. These states were, in alphabetical order, Arizona, Iowa, Maine, Ohio, Oregon, Texas, and Wisconsin.

Fig. 1.

Fig. 1. A bivariate map showing the relationship between the opioid prescription rates per state and the rate of individuals without broadband access across each U.S. state and the District of Columbia. The bivariate map consists of a nine-class bivariate sequential color scheme representing the multiple intersections of low to high percentages of opioid prescribing rates and population without broadband access between the state. The top right cell of this grid, the black color, represents cases when both variables are high. Arrows indicate an increase in percentage of either variable.

Telehealth and Social Vulnerability Rankings

To identify states that have the best telehealth accessibility by broadband accessibility and social vulnerability, we explored the individual and combined ranking of percent population rates of residents: without insurance, without broadband access, with a disability, with poverty, older than 65 years, and opioid prescription rate. Table 2 depicts all rankings from individual and master rankings of the summarized individual rankings. The states that encompassed the top five rankings of telehealth access and social vulnerability include Hawaii, Massachusetts, Maryland, Connecticut, and Minnesota. These states are recognized for having the lowest percent of resident without broadband access as well as lowest social vulnerability. The states that identify as needing the most improvement in telehealth access and social vulnerability include Louisiana, South Carolina, Alabama, Oklahoma, Mississippi, West Virginia, and Arkansas.

Table 2. Social Vulnerability Rankings Across Each U.S. State and the District of Columbia
NAME OPIOID PRESCRIBING RATE PER 100 PERSONS RANKING % POPULATION WITHOUT BROADBAND ACCESS RANKING % DISABILITY RANKING % POVERTY RANKING % AGED 65 YEARS OR OLDER RANKING % UNINSURED RANKING RANKING TOTAL OVERALL RANKING
Hawaii 33.4 2 1.8 3 10.8 6 9.7 3 17.3 25 3.9 2 41 1
Massachusetts 35.3 5 2.8 5 11.5 10 10.4 6 15.8 17 2.8 1 44 2
Maryland 45.1 14 4.4 7 10.7 5 9.2 2 14.6 9 6.4 13 50 3
Connecticut 43 11 1.3 1 10.9 7 9.7 3 16.4 21 5.5 8 51 4
Minnesota 35.5 6 11.7 21 10.7 5 9.9 4 15 12 4.6 5 53 5
New Jersey 38.9 8 3.2 6 10.3 2 10.2 5 15.5 14 8.4 19 54 6
District of Columbia 25 1 1.7 2 11.6 11 16 35 11.9 3 4 3 55 7
Colorado 45.1 14 10.1 17 10.4 3 10.7 9 13.4 6 8 16 65 8
North Dakota 37.4 7 11.9 23 10.5 4 10.5 7 14.6 9 7.2 15 65 8
California 35.1 4 5.2 8 10.4 3 14 25 13.6 7 8.4 19 66 9
New York 34 3 2.2 4 11.3 8 14.3 27 15.6 15 6.4 13 70 10
Utah 57.1 29 6 9 9.6 1 10.2 5 10.5 1 9.9 26 71 11
Washington 49.3 20 2.8 5 12.5 13 11.3 12 14.7 10 6.7 14 74 12
Rhode Island 43 11 1.7 2 13.4 19 12.6 17 16.5 22 5.1 7 78 13
Virginia 44.8 12 11.1 20 11.3 8 10.6 8 14.6 9 9 22 79 14
New Hampshire 46.1 17 7.4 13 12.5 13 7.6 1 17 24 6.4 13 81 15
Illinois 45.2 15 9.1 16 10.8 6 12.8 18 14.8 11 7.2 15 81 15
Iowa 49.3 20 14.6 27 11.4 9 11.3 12 16.4 21 4.9 6 95 16
Wisconsin 45.8 16 15 28 11.6 11 11.6 13 16 18 5.7 9 95 16
Delaware 60.6 31 3.2 6 12.1 12 11.6 13 17.6 27 5.9 10 99 17
South Dakota 42.6 10 11 19 11.6 11 13.1 19 15.8 17 9.2 23 99 17
Nebraska 50.6 23 16.2 31 11.4 9 11.2 11 15 12 8.3 18 104 18
Pennsylvania 49.9 22 6.2 10 13.7 21 12.3 16 17.4 26 6.1 12 107 19
Vermont 42.4 9 16.9 33 14.3 24 10.7 9 18.2 28 4.1 4 107 19
Alaska 44.9 13 26 42 11.6 11 10.5 7 10.6 2 13.9 37 112 20
Texas 47.2 18 11 19 11.3 8 15.1 31 12 4 17.1 38 118 21
Ohio 53.5 25 8.5 15 13.8 22 14.1 26 16.3 20 6.4 13 121 22
Nevada 55.5 28 8.4 14 12.6 14 13.5 21 15 12 11.8 33 122 23
Kansas 64.3 37 15.8 30 12.7 15 12 14 15.1 13 8.8 20 129 24
Oregon 57.3 30 10.4 18 14.3 24 13.8 24 16.7 23 7.2 15 134 25
Maine 48.1 19 12.1 24 15.7 29 12.1 15 19.4 30 8.2 17 134 25
North Carolina 61.5 32 7.3 12 13.3 18 15 30 15.5 14 10.8 30 136 26
Georgia 63.2 35 9.1 16 12.1 12 15.6 33 13.1 5 13.5 36 137 27
Michigan 62.7 34 11.8 22 14.1 23 14.6 29 16.3 20 6 11 139 28
Wyoming 57.1 29 23.3 40 12.8 16 10.9 10 15.1 13 11.2 32 140 29
Florida 53.7 26 6.5 11 13.2 17 14.5 28 19.7 31 13.3 35 148 30
Indiana 65.8 38 17 34 13.6 20 13.7 23 15 12 9 22 149 31
Idaho 61.9 33 18 35 13.2 17 13.6 22 15 12 10.9 31 150 32
Arizona 50.7 24 13.1 26 12.7 15 15.7 34 16.7 23 10.8 30 152 33
Montana 54 27 31 45 13.4 19 13.3 20 17.6 27 10.1 27 165 34
Missouri 63.4 36 20.5 39 14.3 24 13.8 24 16.1 19 9.5 24 166 35
Tennessee 81.8 45 12.6 25 15.2 28 15.7 34 15.7 16 9.9 26 174 36
New Mexico 49.4 21 20 37 14.9 27 19.1 41 16.3 20 10.5 29 175 37
Kentucky 79.5 44 15.7 29 17.1 41 17.4 39 15.6 15 6 11 179 38
South Carolina 69.2 39 16.6 32 14.4 25 15.5 32 16.7 23 10.8 30 181 39
Louisiana 79.4 43 19.2 36 14.7 26 18.8 40 14.5 8 10.4 28 181 39
Alabama 97.5 47 20.1 38 16 30 17 36 16.1 19 9.8 25 195 40
Oklahoma 79.1 42 27.5 43 15.7 29 15.5 32 15 12 13.9 37 195 40
Mississippi 76.8 41 34.3 46 16 30 20.1 42 15 12 12.4 34 205 41
West Virginia 69.3 40 29.6 44 19.2 42 17.2 38 18.8 29 6.4 13 206 42
Arkansas 93.5 46 24.7 41 16.9 49 17.1 37 16.3 20 8.9 21 214 43

Discussion

In this study, about 39% of states have both telehealth and telemedicine policies, whereas the majority of states have either a PT- or OT-specific policy in place. Many of these policies are temporary and may change due to the COVID-19 pandemic. Our study noted that many states that lack broadband access and have high social vulnerability, specifically in southern regions of the United States, need more improvements to make these policies beneficial to their inhabitants. The present analysis indicates that overall policies to mitigate PT and OT services during the COVID-19 pandemic may have limited and variable benefit to large proportions of the U.S. population.

Our study found that states in the southwest and southeast regions have the greatest proportion of states with higher opioid prescription rates, higher rates of those without broadband access, and lowest telehealth and social vulnerability rankings. These states also had the lowest ranking for telehealth and/or telemedicine policies. Northeastern states represented the majority of the states with appropriate broadband access, low opioid usage rates, and highest telehealth and social vulnerability rankings. These states tended to have better telehealth and/or telemedicine policies.

These results are consistent with findings from the computer and internet use in the United States: 2016 report, which demonstrated that the states with the lowest broadband internet subscription were mostly located in the southern regions.23 States that were among the bottom of the social vulnerability and telehealth rankings need improvement in broadband access and social vulnerability indicators to ensure the utilization of telehealth care, including PT/OT.

Allocating funds to promote telehealth, reevaluating restrictions on telehealth laws, and improving broadband access for all residents are methods that states with low rankings can utilize to improve patient care.15 In April 2020, Congress introduced the Coronavirus Aid, Relief, and Economic Security Act, which targeted improved accessibility to telehealth services.24 Before the pandemic, only 2% of physical therapists used telehealth, and now, this figure has increased to 48%.25 For OT, 33% of providers were using telehealth after the National Emergency (J. Furniss, personal communication, August 4, 2020). Given pre-pandemic challenges in PT/OT access due to availability and health coverage barriers, it is unclear whether the increases in PT/OT telehealth services are disproportionately benefiting populations with lower access barriers.26,27

To provide long-lasting and equitable policy implementation, programs and additional policies may need to target several aspects of telehealth accessibility. First, Medicare, Medicaid, and most private insurance companies relaxed restrictions on telehealth during the COVID-19 pandemic. However, it is unclear if these changes are permanent and whether they will have an impact in improving equity in PT/OT access.9,15 More permanent changes in policies that can be proven to improve PT/OT and telehealth access are necessary. Second, broadband offices at the state level, as well as funding programs, may help improve broadband availability, whereas municipal broadband restrictions can have the opposite effect.28

Limitations and Future Directions

The present analysis includes several limitations. First, policies are ever-changing, and therefore, the present analysis may need to be updated given policy updates. Second, selected telehealth and social vulnerability indicators may not include additional factors that need to be accounted for. Third, this analysis did not include patient-level data, and therefore, it is unclear the degree to which policies, broadband access, and other indicators are associated with telehealth access and equity in PT/OT engagement across the U.S. population. Finally, the present analysis is correlational, and causal attributions cannot be made to the findings. Further research is needed to explore the relationship between social vulnerability factors, structural barriers and facilitators, and individual person-level outcomes.

Conclusions

Despite the policies expanding PT/OT telehealth capabilities, structural barriers (e.g., broadband access) may further exacerbate inequities in care accessibility. Therefore, any future health policies focused on expanding nonpharmacological pain management access need to include designated funding to reduce structural barriers.

Acknowledgment

The authors thank Mrs. Maria DiMarzio for article formatting assistance.

Disclosure Statement

The views expressed in this manuscript are those of the authors and do not reflect the official policy of the Uniformed Services University, of the Department of Army/Navy/Air Force, Department of Defense, U.S. Government, or The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (HJF).

Funding Information

Funding for this project was provided by the Uniformed Services University through Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. under Cooperative Agreement #HU00011920042.

Supplementary Material

Supplementary Table S1

REFERENCES





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