Telehealth Use in Medicaid: Implications for Quality Care for Individuals With ADHD and Tourette Syndrome

Abstract

The expansion of telehealth during the COVID-19 pandemic transformed behavioral health care delivery, including for individuals with attention-deficit/hyperactivity disorder (ADHD) and Tourette syndrome (TS), conditions that require ongoing treatment and monitoring. We explored the implications of telehealth on the quality of care for Medicaid beneficiaries with ADHD and TS, highlighting the benefits, challenges, and policy considerations. Telehealth has increased access to behavioral health services, including for ADHD and TS, by reducing geographic and financial barriers to care. The expanded use of telehealth has allowed patients to more easily interact with health care providers, and it particularly benefits those with limited access to specialized care. However, challenges remain, such as concerns about stimulant misuse in online ADHD treatments and the limited privacy offered in home telehealth settings. Furthermore, disparities in broadband access may exacerbate existing inequalities in care. Despite telehealth’s potential to increase access to specialized care, the quality of telehealth provided is not guaranteed. Current quality measures for Medicaid telehealth services, especially for ADHD and TS, are insufficient. While some Medicaid programs have integrated telehealth into quality reporting, a need exists for more tailored measures that assess the unique needs of people with ADHD and TS. We recommend the development of quality measures for ADHD and TS, performance improvement projects for these conditions, better alignment of Medicaid managed care oversight, and research into the long-term outcomes of telehealth for care of people with ADHD and TS. Such efforts would support continued Medicaid telehealth expansion while ensuring high-quality care.

Attention-deficit/hyperactivity disorder (ADHD) affects approximately 11% of children and 5% of adults in the United States and is among the most common neurodevelopmental disorders.^{1 -4} Estimates for Tourette syndrome (TS) are harder to calculate; it is estimated that about half of children with TS are not diagnosed. However, the Centers for Disease Control and Prevention (CDC) estimates 1.4 million people have persistent tic disorders, including TS, in the United States. ⁵ As chronic conditions that usually manifest in childhood, ADHD and TS require ongoing monitoring and treatment (medication and/or behavior therapy), and the morbidity and economic effects are costly to individuals and society.^{6 -12} While symptoms may evolve, individuals with ADHD may struggle to complete tasks or follow instructions and/or have impulsivities that lead to accidental injuries. ¹³ Similarly, for more than one-third of individuals with TS, obsessive-compulsive disorder and its association with learning challenges, mood disorders, anxiety, and depression present challenges in diagnosis and treatment. ¹⁴ Because ADHD and TS may manifest differently in affected individuals and because no imaging or laboratory tests are available to confirm diagnosis, some health care providers (hereinafter, providers), including primary care practitioners, may be unfamiliar with or misdiagnose the conditions.^15,16 Being unfamiliar with or misdiagnosing the conditions is especially common for the diagnosis of ADHD in adults.^17,18

Before the COVID-19 pandemic, the use of telehealth for behavioral health needs was limited.^{2 -22} Only 7% of psychological visits were performed virtually before the pandemic.^20,21 By April 2020, more than half of behavioral health diagnoses were made via telehealth. ²³ Although use has declined since the height of the pandemic, dropping from 37% of all adults in 2021 to 30.1% in 2022, telehealth is an important modality for accessing care, particularly for individuals who have Medicaid or Medicare, who are Black, and/or who have low income levels.^24,25

In the 2 years since the end of the COVID-19 public health emergency on May 11, 2023, telehealth for behavioral health has remained a critical modality for health care. ²⁶ In 2023, 89% of psychologists provided services via telehealth. ²⁷ A survey of mental health facilities conducted from December 2022 through March 2023 found that of the 1221 facilities accepting new patients, approximately 80% offered telehealth services. ²⁸ Notably, approximately half of ADHD adult care was delivered via telehealth in 2021, although recent indictments for potentially inappropriate prescribing have brought into question the quality and oversight of some ADHD telehealth organizations.^29,30 Specifically, in June 2024, the US Department of Justice charged executives of an ADHD telehealth company for prescribing stimulants, including Adderall, for individuals who did not have ADHD. ³¹ Another company paid $3.6 million in fines in November 2024 for similarly incentivizing providers to prescribe ADHD medications to individuals who did not medically need them. ³²

This review draws on work conducted at The George Washington University School of Public Health, in collaboration with ChangeLab Solutions and CDC. Based on existing literature, a review of state and federal telehealth policies enacted since COVID-19, and interviews with subject matter experts, we highlight the value of attention to the quality of telehealth care for individuals with ADHD/TS. We first describe recent policy changes that affected the extent to which ADHD/TS-related care is provided via telehealth. We then discuss existing research on the effect of telehealth on people with ADHD/TS. We continue by describing existing ADHD/TS quality measures and how broader measures, particularly those in Medicaid, are beginning to address telehealth. We conclude with opportunities for promoting the effective monitoring of quality care for individuals with ADHD/TS.

Background

Federal and state policy changes during the COVID-19 public health emergency promoted the use and adoption of telehealth by both providers and patients.^33,34 Before the COVID-19 pandemic, telehealth reimbursement policies were limited: Medicare covered telehealth for certain services and for beneficiaries in rural settings. ³⁵ Because of the pandemic, the Centers for Medicare & Medicaid Services (CMS) broadened the telehealth reimbursement policy for Medicare beneficiaries to permit use in any location, accept audio-only technology, and expand the list of eligible services. ³⁶ States’ Medicaid programs largely followed suit with changes to their telehealth policies, including covering multiple modalities (synchronous, asynchronous, remote patient monitoring, and audio-only) and, in some cases, permitting patients to use telehealth to see out-of-state providers.^37,38

Since the end of the COVID-19 public health emergency, some states have codified expansive telehealth policies, although some policies have been pared back or allowed to expire. ³⁹ Differences in state policies resulted in an increasingly complex service landscape. For example:

• As of September 2024, 31 state Medicaid programs reimbursed for synchronous, asynchronous, remote patient monitoring, and audio-only telehealth modalities. ⁴⁰

• As of January 2025, 22 states had implemented some form of payment parity for commercial and/or Medicaid plans, requiring that telehealth visits are reimbursed at the same rate as in-person visits. ⁴¹

• All 50 states and the District of Columbia still cover live video telehealth services, although what services and what providers are covered vary. ⁴²

As of February 2025, several trends emerged in state telehealth policies. States are increasingly developing regulations to allow nonphysician providers to provide telehealth, are joining interstate compacts and allowing the cross-state practice of telehealth, and are revising professional licensure requirements for the provision of telehealth. ⁴³ On March 15, 2025, Congress extended several Medicare-related telehealth flexibilities through September 30, 2025, including a waiver of geographic site restrictions for patients and waiving the requirement that behavioral health patients see their provider in-person within 6 months of their initial telehealth appointment. ⁴⁴

Finally, the suspension of the federal Ryan Haight Act, which regulates the prescribing of controlled substances online and requires in-person medical evaluation before prescribing, may have increased access to ADHD diagnosis and prescription of psychostimulants in 2020-2021.^{45 -47} The suspension, which was renewed again by the US Drug Enforcement Agency most recently on November 19, 2024, is currently set to expire on December 31, 2025, pending additional action. ⁴⁸

Telehealth Expands Access to ADHD and TS Services, But Challenges Remain

Overall, expansions in telehealth flexibility increase access to care for individuals with behavioral health needs, including ADHD and TS.^{49 -55} Clinicians report that telehealth benefits them by seeing patients’ home environments, allowing for tailored care, reducing patient travel time and costs for appointments, and increasing patient satisfaction. ⁴⁹ Audio-only care expands access to individuals with poor broadband connectivity and technological proficiency. ⁵⁰ With as many as 26% of adult TS patients finding it challenging to identify a provider knowledgeable about treating TS, access to telehealth has expanded the provider pool for many patients.^56,57 Because many states and Medicaid programs allow various providers to practice across state lines, TS patients may have increased access to providers offering Comprehensive Behavioral Intervention for Tics, and ADHD/TS patients may have increased access to other behavioral therapies.^42,58,59 Both the Tourette Association of America and Children and Adults with Attention-Deficit/Hyperactivity Disorder, patient-advocacy organizations for these conditions, recognize the importance of telehealth.^{60 -64}

Despite telehealth’s benefits, limitations exist. Recent indictments of telehealth ADHD providers and an expert consensus statement on telehealth for ADHD raise concerns about online prescribing being vulnerable to misuse, abuse, and diversion of stimulants.^30,59 Additionally, telehealth provided in a home environment cannot guarantee a person’s privacy, whereas in-person care may reasonably guarantee a private setting. Furthermore, people in rural areas or with low incomes may struggle to access broadband internet or have limited technological capabilities for video telehealth appointments. Some interviewees noted that while telehealth can expand access to health care, many providers prefer in-person visits for diagnosing ADHD. ⁵⁹

Telehealth offset the declines in in-person use of health care services during the pandemic for children with commercial health insurance, as mental health service use for children increased overall by 21.7% from January 2019 to August 2022. ⁶⁵ The same cannot be said for children in racial and ethnic minority groups with Medicaid and the Children’s Health Insurance Program, who saw overall declines in mental health service use: 11% for Black children and 5% for Hispanic children, compared with 1% for White children from 2019 to 2020, despite widespread adoption of telehealth for mental health among all populations. ⁶⁶ Moreover, Black and Hispanic patients (vs White patients) who were seeking care for mental health and Medicaid patients (vs patients with other types of health insurance) had higher odds of missing appointments from 2021 to 2022, even when using telehealth, highlighting that barriers such as technological capabilities remain for some populations. ⁶⁷

Finally, monitoring the quality of care delivered via telehealth has a promising but inadequate current set of measures to assess whether ADHD and TS patients receive quality care using this modality. In the behavioral health context, this gap is exacerbated by the fact that many behavioral health providers do not participate in health insurance. ⁶⁸ In the United States, health insurance participation and requirements can serve as quality measurement infrastructure; therefore, as several interviewees noted, providers who require self-payment may lack the required oversight to ensure high-quality care. Indeed, only 43% of psychiatrists accept Medicaid, and only 19% of nonphysician mental health care providers participate in any health insurance network.^68,69

Some direct-to-consumer behavioral telehealth companies focus on diagnosing and treating ADHD but do not take health insurance. A scoping review of direct-to-consumer health care identified concerns about unproven efficacy; safety issues; lack of regulation and oversight; targeting of vulnerable populations, including children and those with mental health issues; and more. ⁷⁰ Despite arguments that these services expand access to care, numerous articles from the scoping review highlighted existing ethical concerns, including that many direct-to-consumer telehealth services are not covered by health insurance and lead to out-of-pocket costs that could otherwise be covered. ⁷⁰ Measurement development and research are needed to accurately assess the quality of telehealth care for individuals with ADHD and TS.

Efforts to Address Quality of Care Delivered Via Telehealth Exist but Are Limited

Improving Measures of Quality of Care Using Telehealth

Despite policy changes supporting the expansion of telehealth for behavioral health in state Medicaid programs, few measures assess the quality of care delivered via telehealth, in Medicaid or in general. ⁷¹ CMS does not require reporting on the quality effects of care received via telehealth for Medicaid beneficiaries, and voluntary state activities are limited. ⁷² A US Government Accountability Office report notes that 10 state Medicaid directors had concerns about the quality of behavioral telehealth services. ⁷²

A number of organizations developed principles that could help measure the quality of telehealth care delivered, including the American College of Surgeons, the American Telemedicine Association, the American Heart Association, the American Nurses Association, the National Quality Forum, and others.^{73 -78} Efforts to accredit or certify telehealth programs are also under development. For example:

• The Joint Commission developed a telehealth accreditation program for health care organizations that provide care via telehealth. ⁷⁹

• The National Committee for Quality Assurance (NCQA) Virtual Care Accreditation Pilot program will engage 18 entities, including virtual-only providers, health plans, federally qualified health centers, and other provider organizations, to highlight gaps in care and report and track outcomes provided by virtual care. ⁸⁰

• The Utilization Review Accreditation Commission accredits providers, health plans, and others offering high-performing telehealth services.^81,82

These developments are encouraging and point to an increased focus on ensuring quality of telehealth but are not tailored to the needs of patients with ADHD or TS.

Existing Quality Measures for ADHD and TS

Two national, validated quality measures relevant to ADHD and TS could serve as useful starting points for assessing the quality of care delivered to these patients by telehealth.

The Healthcare Effectiveness Data and Information Set (HEDIS) measures developed by the NCQA include the following:

1. Follow-up care for children prescribed ADHD medication (ADD-E)—initiation phase and continuation and maintenance phase; and

2. Use of first-line psychosocial care for children and adolescents on antipsychotics (APP).^83,84

The ADD-E measure promotes proper medication management for children diagnosed and prescribed medication for ADHD through follow-up visits. ⁸³ The APP measure is designed to promote safer, underused psychosocial interventions for individuals with nonpsychotic conditions for which antipsychotic medications are effective. Antipsychotics are approved by the US Food and Drug Administration for TS treatment. ⁸⁴

HEDIS measures are used by more than 90% of health plans, including commercial, Medicare Advantage, and Medicaid managed care organizations (MCOs). NCQA updated these and other measures to allow telehealth visits to count toward a plan’s overall measurement for services. ⁸⁵ However, this step does not directly compare the quality of telehealth care with in-person care.

Existing Efforts to Measure Quality in Medicaid

Medicaid, which uses HEDIS measures including those discussed previously, could be an important lens through which to assess the quality of telehealth for individuals with ADHD and TS. Until recently, the system largely relied on voluntary reporting by states, which inconsistently measured quality as it pertains to both telehealth and in-person behavioral health services.^86,87 For example, of the 43 states that delivered behavioral health benefits through managed care in 2022, MCOs reported 119 distinct behavioral health measures to their respective states, only 15 of which were reported by more than 1 state. ⁸⁸

However, starting in 2024, CMS required all state Medicaid programs to report on all measures included in the Child Core Set, which includes the 2 relevant pediatric HEDIS measures discussed previously and all behavioral health measures in the Adult Core Set. This requirement may offer a rich source of information on the extent to which telehealth care for individuals with ADHD and TS is provided through Medicaid and may open doors to research that can further assess comparative quality. ⁸⁹

While not specific to ADHD or TS, as of fiscal year 2024, 35 of the 40 states with Medicaid managed care that responded to the Kaiser Family Foundation’s annual survey of state Medicaid programs noted that they had at least 1 requirement for MCOs related to reducing health disparities. ⁹⁰ Regarding quality, 13 states with Medicaid managed care had at least 1 financial incentive tied to reducing health disparities, such as linking incentive payments to quality measures. ⁹¹ For example, Louisiana withholds one-quarter of an MCO’s capitation rate as part of a quality measure performance improvement effort designed to reduce disparities in maternal, child, preventive, and behavioral health. ⁹⁰

Potential Next Steps

As organizations continue to improve efforts to measure the quality of telehealth care, several potential opportunities exist to assess the quality of telehealth for individuals with ADHD or TS.

Additional Development of Measures for Populations With ADHD and TS

Researchers identified “the Adult ADHD Quality Measures Initiative,” which published their initial efforts to create quality measures for adults with ADHD in 2019, ⁶ as the only recent effort to develop additional measures for the population with ADHD. However, researchers noted a lack of progress by this initiative in getting measures validated and adopted by a measure steward—an organization such as CMS, the Agency for Healthcare Research and Quality, the National Quality Forum, or NCQA, which owns and maintains individual measures—as well as a lack of incorporation of a telehealth measure into Medicaid quality improvement initiatives. ⁶ A renewed focus to develop additional quality measures for both children and adults with ADHD and TS may help ensure greater oversight of the quality of both in-person and telehealth care. Additional quality measures may also better identify existing health disparities related to ADHD and TS care and identify opportunities for improvement.

CMS leaders described the current operation of more than 20 quality programs across CMS, explaining that current practice has created “confusion, increased reporting burden, and misalignment of approaches for common clinical scenarios.” ⁹² In a reimagined model called the Universal Foundation, the Center for Medicare & Medicaid Innovation works to align foundational measures across quality programs, including those in Medicaid. ⁹³ Partners could work from recently developed guidelines and other professional organizations to create measures that would assess care delivered via telehealth for individuals with ADHD or TS.^9,10,59

Medicaid Managed Care Plan Performance Improvement Opportunities

External quality reviews (EQRs), which highlight MCO annual performance on state-mandated quality measures, also provide opportunities to understand other initiatives to improve the quality of care for Medicaid beneficiaries. Medicaid managed care plans can also participate in performance improvement projects on their own initiative or as required by states, to improve the quality of care for beneficiaries. ⁹⁴

To date, no state has reported behavioral health measures focused on telehealth or implemented performance improvement projects for individuals with ADHD or TS, although at least one example exists of a state using telehealth to promote better performance on the ADD measure. In general, states and Medicaid plans have sought to improve the quality of behavioral health care through various measures, including performance improvement projects (Box).^{95 -99}

Box.

Examples of state Medicaid quality improvement activities with implications for behavioral health care, including for attention-deficit/hyperactivity disorder (ADHD) and Tourette syndrome or telehealth, United States, 2023-2024 Centers for Medicare & Medicaid Services external quality review reporting cycle.

● Twenty-one states required their managed care organizations (MCOs) to use and report the National Committee for Quality Assurance’s attention deficit disorder (ADD-E) measure, and 16 states required their MCOs to use and report the national committee’s use of first-line psychosocial care for children and adolescents on antipsychotics (APP) measure. 95 ● Seventeen of the 21 states reporting the follow-up care for children prescribed ADHD medication (ADD-E) measure, and 12 of the 16 states reporting the APP measure include comparisons to National Healthcare Effectiveness Data and Information Set (HEDIS) Medicaid rates. 95 ● There were 20 ADHD-related performance improvement projects across 4 states for the 2022-2023 reporting cycle and no Tourette syndrome–related performance improvement projects. 95 Additional behavioral health performance improvement projects may not be directly tied to ADHD or Tourette syndrome but could affect care for these patients. For example:  ○ Washington’s UnitedHealthcare MCO has a performance improvement project designed to increase the performance of the ADD-E measure. 96 The plan informs members that they need a 30-day follow-up visit for their newly prescribed ADHD medication and provides parents with education and support concerning the importance of following up with their child’s health care provider. The plan also works with health care providers to discuss best practices regarding the HEDIS measure and the importance of ensuring follow-up appointments with patients. However, the external quality review notes that UnitedHealthcare did not meet the state’s 2022 value-based payment performance targets. 96  ○ While not explicitly framed as a telehealth performance improvement project, MCOs in Texas have promoted and used telehealth and multimodal interactive technologies to improve the ADD-E measure for several years. 97 ● There are 52 telehealth-focused performance improvement projects across 17 states related to behavioral health, and at least a few such activities have relevance to ADHD or Tourette syndrome. 95 For example:  ○ Oregon MCOs have, since 2021 and through 2024, participated in a performance improvement project ensuring access to behavioral health services. 98 MCOs as part of this project have directly contracted with behavioral health telehealth companies and providers. 98  ○ Coordinated Care of Washington launched a performance improvement project focused on improving the continuity of cognitive behavioral therapy services for members aged 18 to 64 years. Through this effort, the MCO is promoting the use of telehealth for cognitive behavioral therapy to help improve the plan’s HEDIS measurement performance for follow-up after hospitalization for mental illness.96,99 This effort could be leveraged to improve care of people with Tourette syndrome and ADHD.

New CMS regulations promote more transparent and meaningful data from the annual state EQR process. ¹⁰⁰ Beginning in July 2024, CMS required that states report EQR activities on a consistent annual basis and include additional data on outcomes, align Medicaid managed care quality reporting with other existing CMS quality measurement initiatives, and create a publicly available quality rating system to allow beneficiaries greater insight into managed care quality metrics. ¹⁰¹ Notably, as part of this quality rating system, CMS requires mandatory reporting of specific measures, including the APP measure.^100,102

Certified Community Behavioral Health Clinics

There are more than 540 certified community behavioral health clinics (CCBHCs) in 46 states. ¹⁰³ CCBHCs provide comprehensive behavioral health services to all individuals, regardless of health insurance status. ¹⁰⁴ Although CCBHCs vary in quality reporting requirements, depending on whether they are in the Section 223 Medicaid Demonstration program, a subset of CCBHCs already report the ADD-E HEDIS measure. Additionally, a subset of CCBHCs uses a prospective payment system that offers clinics quality bonus payments based on performance on these quality measures as they relate to care for Medicaid beneficiaries.^{105 -107} CCBHCs are encouraged to use telehealth as much as possible and have reported overcoming staffing challenges by using telehealth. ¹⁰⁸ CCBHCs could be an effective venue to test measures of quality care delivered through telehealth. CMS and the Substance Abuse and Mental Health Services Administration added 10 new states to the CCBHC Medicaid Demonstration Program in June 2024. ¹⁰⁹

Conclusion

Despite evidence that telehealth has improved access to behavioral health care and resulted in quality care, the absence of measures to assess the quality of behavioral health care provided via telehealth to individuals with ADHD or TS enrolled in Medicaid is a concern. ¹¹⁰ Given the rapid growth and implementation of telehealth care during the COVID-19 pandemic, additional data on the quality of telehealth services and more effective quality measures of care for individuals with ADHD or TS can help inform permanent expansions of Medicaid telehealth coverage while promoting increased access to optimal care and improved patient outcomes. ⁸²