The COVID-19 pandemic presents complex challenges for the US health care system and social safety net programs. In our latest blog post series, IMPAQ experts bring you timely updates and informed insights on the intersection of COVID-19 and pressing policy issues.
Since the start of the pandemic, mental health concerns have intensified across the country. A recent CDC study found that more than 40 percent of 5,470 respondents experienced a mental or behavioral health condition associated with the COVID-19 pandemic. The Meadows Mental Health Policy Institute estimates that the continued recession may result in the loss of 4,000 additional Americans to suicide due to unemployment. Given the considerable need to provide safe and effective mental health care to patients, more health care organizations, payers, and clinicians are turning to telemental health to address this situation.
Telemental health can act as a lifeline for communities and individuals who are struggling with the vast effects of COVID-19. Analogous to the increase of telehealth for other services as discussed in our prior blogs and issue briefs, telemental health is an important tool for providers and payers, with recent policy shifts attempting to expand access to these options for patients.
As the school year gets underway, telemental health services will be in significant demand to students, families, and staff members nationwide. K-12 students and their families who live in rural areas may not have easy access to in-person mental health care services. Out-of-state college students may be faced with a lack of access to their regular mental health care provider. With these and other ongoing circumstances in mind, it is critical to recognize the evolution of telemental health services and how the pandemic will define their role in the continuum of care going forward.
What Was the Telemental Health Landscape Before COVID-19?
The field of telemental health is uniquely positioned to expand access to the mental health services needed nationwide. Patients are able to engage in one-on-one sessions and peer support counseling options. The initial growth of telemental health was largely sequestered to the Department of Veterans Affairs (VA), given its significant role in leading telemental health innovation strategies and the incremental approaches taken by the Centers for Medicare & Medicaid Services (CMS) and private payers to offer coverage and reimbursement for services. Before the rapid deregulation of telehealth policies during the COVID-19 pandemic, some barriers prevented the widespread expansion of telemental health.
As highlighted in our earlier blog series, lack of and limited reimbursement structures have long been identified as a major factor in preventing the growth of telemental health nationwide.
- Out of the 4 million mental health and substance abuse service claims submitted from 2009-2013 to private insurers, only 13,480 were submitted for teletherapy services.
- A 2018 national survey of 164 psychologists found that less than half of respondents offered teletherapy to their clients.
- More than half of 1,330 Community Health Centers nationwide reported no use of telemental health services in 2018.
Since 2005, limited payments have resulted in a stark decrease in the number of mental health professionals who will accept all types of insurance. In 2009-2010, almost 50 percent of 1350 psychiatrists did not accept new patients with commercial fee-for-service insurance and more than 50 percent did not accept Medicare or Medicaid patients. While reimbursement rates for in-person psychiatric visits are similar to in-person medical evaluation and management visits, effective counseling and therapy can require more time and investment on the part of the mental health practitioner.
Many telepsychiatry programs previously relied on continual grant applications, which prevented long-term sustainability and extensive implementation. However, reimbursement rules continue to change as more commercial payers have begun to pay for telemental health services and state Medicaid agencies have expanded coverage options.
In addition to reimbursement concerns, a 2017 report by the Health Resources and Services Administration (HRSA) indicates a looming shortage of psychiatrists and other mental health professionals through 2025. Telepsychiatry has often been employed for younger patient populations, yet the workforce of trained child psychiatrists has remained stagnant since 1995. Educating psychiatrists on providing telemental health may offer some opportunity to reduce staffing shortages and improve access for patients who are most likely to utilize this method of delivering mental health care.
What Policy Shifts Have Influenced Telemental Health Delivery During the Pandemic?
Early actions taken by CMS expanded access to Medicare telemental health counseling services, including allowing for behavioral health and education services to be provided through audio-only communications. Many governors have removed onerous licensure requirements to allow mental health practitioners to provide telemental health care to patients who live in different states. The Health & Human Services Officer for Civil Rights waived penalties for HIPAA violations, allowing providers to utilize common communication platforms, such as FaceTime, to deliver telemental health services.
On the horizon, CMS has issued a proposed rule for policy changes to the Medicare telehealth list. In the Category 1 basis, which are services similar to existing categories, CMS has proposed two additions for telemental health services including the allowance for neurobehavioral status exams and group psychotherapy. For Category 3 services, which have the potential to benefit patients but lack sufficient evidence for permanent inclusion, CMS has proposed four codes to promote psychological and neuropsychological testing. The long-term inclusion of these telemental health services is dependent on demonstrating that these services can improve diagnoses, treatment, or functioning for patients. These recent policy changes present the opportunity to examine if there are gaps in existing telemental health research literature as well as the significant effects of expanding services during the pandemic.
How Have Recent Policy Changes Impacted Telemental Health Utilization & Delivery?
More Medicare & VA Beneficiaries Access Telemental Health
Following the recent deregulation of telehealth policies stimulated by the pandemic, 460,000 Medicare beneficiaries (60 percent) have been able to receive mental health services via telehealth. Medicare’s prior targeted approach to telemental health delivery resulted in 87,120 visits for rural patients in 2014. This staggering increase is critical to acknowledge as patients’ mental and behavioral health status shifts amid the pandemic.
Along with significant utilization by Medicare beneficiaries, the VA has also been successful in providing homebound veterans with necessary telemental health services during the pandemic. From March to July, telehealth services for the VA increased by 1,140 percent. This quick transition to virtual care delivery was possible due to changes in policy and a pre-existing infrastructure that supported these care options. The COVID-19 pandemic has demonstrated the need for a robust nationwide telehealth delivery system to support the mental, behavioral, and physical health of patients.
Schools Continue Mental Health Care Remotely
As with military veterans and elderly citizens, the coronavirus emergency has magnified the potential for technology to support a quantum leap forward in access to needed support for children and youth. Schools play a critical role in student mental health—including mental health promotion, prevention, and intervention. Dr. Nancy Lever, co-director of the National Center for School Mental Health, cites research showing approximately 75 percent of youth who receive mental health services, receive these services in schools. Passage of the CARES Act has allowed funding for school districts to furnish laptops and other mobile devices to students, incidentally fueling the growth of access to telemental health via internet-supported devices that allow for video-based clinical visits.
“Use of telemental health during the pandemic has offered a lifeline for students and families to be able to continue to receive mental health services and supports from their school-based mental health staff, and for school staff to receive mental health consultation on how to best support the well-being of students and families,” says Dr. Lever.
She also notes that relaxation of telemental health regulations has allowed for a broader array of providers (including social workers, psychologists, counselors) to deliver telemental health services from their homes to patients’ homes, and has generated more options in the platforms used to connect with students and families. The flexibility in approved platforms and technology (phone and/or video) allowed for more school-based staff and families to have the necessary technology to access care. “The use of telemental health helped to decrease barriers to care including social distancing concerns, health conditions, transportation, childcare, and the time needed to get to and from appointments, increasing family participation in clinical sessions,” concludes Dr. Lever.
What is the Future of Telemental Health?
Virtual mental health care is becoming an essential part of our health care system and the pandemic has demonstrated a need for a robust telehealth delivery system to be in place. 74 percent of large employers now offer plans with telehealth services, compared to 27 percent in 2015. Another survey found that 54 percent of 122 large employers are planning on offering zero- or low-cost virtual telemental health counseling for their employees. Expanding access to these services is essential to address projected provider shortages and can reduce the stigma associated with seeking out mental health care.
Innovative commercial payers are also recognizing the significant benefits associated with increasing access to telemental health. Blue Cross Blue Shield of Massachusetts indicated their intention to pay mental health clinicians the same rate for their telehealth visits as their in-person visits, extending this to phone visits as well. This step is critical as it recognizes that patient preferences will vary tremendously with regards to face-to-face, videoconferencing, and phone interactions. This step also promotes the equitable delivery of care given that 147,000 residents lack access to a broadband connection that would support a video visit and 43.3 percent of residents have access to a low-priced internet plan. Other health systems, such as Atrium Health, are offering real-time telemental health integration into their primary care practices for appropriate follow-up care.
Another advancement to address provider shortages and improve the future delivery of telemental health care is the development of PSYPACT, an interstate compact that allows licensed psychologists to practice telepsychology across state boundaries. States that join this compact will be well-positioned to improve the mental health of their residents by increasing access to providers and ensuring continuity of care in the case of out-of-state college students. Even a one percent increase in treatment for behavioral health can yield an annual medical cost savings of $2.4 billion nationwide.
Younger patients will continue to focus on virtual channels for the delivery of mental health care. Dr. Lever suggests that as we move forward, “it would be beneficial to continue current regulatory flexibilities, offering hybrid strategies of in-person and telemental health in an effort to improve access to and follow through with mental health services and supports for all students.”
Continue the Conversation
To learn more about using telemental health to support K-12 students and the future of telemental health care delivery, please visit the National Center for Safe and Supportive Learning Environment’s curated resources at Responding to the COVID-19 Pandemic – Resources to Support Primary and Behavioral Health Care.
Stevland Sonnier, Research Intern, IMPAQ Health
Dr. Brandon Hesgrove, Senior Research Associate, IMPAQ Health
Frank Rider, Senior Human Services Financing Specialist, American Institutes for Research
Kevin Van Dyke, Managing Director, IMPAQ Health