Highlighting the Strengths of Telemental Health Services for Patients and Clinicians

In part two of this Q&A, Victor JA Buwalda, MD, PhD, William E. Narrow, MD, MPH, Eve K. Mościcki, ScD, MPH, Renée Cookson, CTRS, and Rogena Abdelraham, BS discuss  their recent virtual APA session “Zooming Through COVID-19: Achievements and Challenges in Telemental Health Services and Patient-Centered Treatment” including the strengths of telehealth services, practical implications for clinicians, and the future of telehealth.  

In the previous Part one, researchers discussed the main takeaways from their presentation. 

Q: What other practical implications are there for clinicians?

A: The massive, rapid uptake of telehealth technology and services shortly after the start of the COVID-19 pandemic was facilitated by several changes in laws and regulations that had previously been seen as barriers to widespread adoption. First, certain HIPAA regulations were relaxed, allowing the use of non-compliant video conferencing platforms and telephone for routine visits, with the patient’s informed consent. Anticipating continued use of telehealth and eventual reapplication of HIPAA standards, many video platform companies have added security features to conform to HIPAA standards.

Billing requirements were also relaxed during the pandemic. For example, the requirement for the patient to be located in a clinic or other institution during the provision of telehealth was scuttled by the vast majority of Federal, State, and private payors. This allowed patients to remain at home for services, avoiding the risk of COVID-19 exposure by not venturing into the community. The continuation of these relaxed requirements is uncertain, although there are indications from the Federal government and some states that at least some of them will be maintained post-pandemic.

Third, licensing rules were often relaxed, allowing easier provision of services across state lines. This was particularly important for small states, and areas near state borders. In many states, licensure in the patient’s service location was not required for interstate practice, as was the previous standard. Streamlined registration procedures were established in place of the formal application process for many states. These procedures often differed by profession, and sometimes limits were put on the type of service that could be offered across state lines. For example, states may have allowed services to be provided for existing patients during the pandemic, but not for new patients. Some states have already gone back to their previous licensing standards, posing difficulties for patients who may still not feel comfortable returning to in-person visits in their clinicians’ state of licensure.

In May 2020, the multi-site, multi-stakeholder group of employers, payors, health systems, and providers called The Path Forward for Mental Health and Substance Use published “Tele-Behavioral Health for Employees: Pre-COVID Practices and Recommendations for a Post COVID Path Forward” (Powell, Bowman, and Harbin). This report outlined several key aspects of mental health services provision that should be employed in the post-COVID United States:

• Offer patients choice in the modalities through which they interact with providers, be it through telephonic, audiovisual, or in-person communication
• Pay behavioral health providers equivalently for all appropriate modalities so that they offer patients choice
• Ensure and certify that health plans comply with applicable state telemedicine parity laws, which may require payers to reimburse telemedicine in the same manner as in-person care.
• Ensure and certify that health plans offer parity in access to telehealth for physical and mental illness and are compliant with the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA).
• Health plans should cover the same TBH CPT codes as Medicare.
• Ensure that both telephonic and audiovisual care are delivered in a HIPAA-compliant manner.
• Ensure that Measurement-Based Care is implemented by providers as a component of TBH offerings as applicable.

It is encouraging that a telehealth bill passed by the Maryland legislature and signed by Governor Larry Hogan in 2021, contains several of these key recommendations and will be put into effect for patients insured by Maryland Medicaid plans.

Q: Briefly, what are the key strengths of telemental health services? What are the key weaknesses?

A: At the end of the day, this all ties into understanding that one size does not fit all. Telemental health services shift the capacity for expanding treatment options demographically and geographically. According to the Kaiser Family Foundation, as of September 2020 there were about 120 million individuals without proper access to mental health services in the United States. Telemental health enables clinicians to reach patients regardless of age, race, cultural background, location, socioeconomic status, and so much more. Treatment can become increasingly patient driven. Individuals are afforded the opportunity to choose the modality that works best for their situation.

On the flip side, some challenges do arise. Insurance dictates what patients can have access to. Licensure also becomes an unfortunate hiccup. It is not always possible to practice across state lines. Both weaknesses can lead to a patient losing their clinician due to lack of access. Whether the patient had to change insurance or move geographically, it can be a traumatizing experience for them to lose the provider they became accustomed to. Cybersecurity is an additional concern. It is necessary to have secure and HIPAA complaint platforms. One size truly doesn’t fit all. Whether it is technologically or emotionally, this modality is not for everyone.

Q: How do you see telehealth moving forward as the COVID-19 pandemic restrictions are being lifted in parts of the US?

A: Telehealth will continue to become a viable and prevalent modality. The traditional “in office” visits will no longer be the only option. Treatment will become increasingly personalized. Patients will choose where and how they want to access care based on their preferences. This can include in-office, virtual, community based, or a hybrid! Possibilities are endless as we navigate this rapidly changing technological era. There are a lot of unknowns about the future, we don’t truly know the full capacity of options that may arise.

Q: Any final thoughts?

A: Telemental health is an important tool that will remain in clinical practice in the post-covid era. Moving forward, telemental health must be maximized to reach populations and communities in greatest need, including people living in poverty and rural populations. Reimbursement issues need to be addressed. We need to explore how telemental health services might be fully incorporated into existing collaborative care or medical home models. And finally, we must recognize the importance of culture, race, and ethnicity in achieving partnership between patients and clinicians who are from different backgrounds.

Victor JA Buwalda, MD, PhD, is Chief Medical Officer and Training and Research Director at CDC Amsterdam, Netherlands. He is also the President of the American Association for Psychiatric Administration and Leadership (AAPAL).

William E. Narrow, MD, MPH, is an associate professor in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, Baltimore, Maryland. He is also the Medical Director for Behavioral Health at Johns Hopkins Medicine Alliance for Patients.

Eve K. Mościcki, ScD, MPH, is a Psychiatric Epidemiologist and research consultant based in Washington, DC.

Renée Cookson, CTRS, is the director of the Community Development Department at NAMI San Diego, California.

Rogena Abdelraham, B.S. is the Technology Community Development Specialist at NAMI San Diego, California.