The expansion of telehealth during the COVID-19 pandemic has been lightning fast, particularly compared to its slow trajectory before the crisis. The Lancet first discussed how phone-based doctor appointments could reduce the need for in-person visits in 1879. Science and Invention foresaw video-based telehealth encounters in 1925. However, prior to COVID-19, less than 10 percent of the U.S. population used telehealth for a clinical encounter, and only 18 percent of physicians provided such services.
The slow rate of adoption is not due to a lack of evidence. On the contrary, telemental health (i.e., the provision of mental and behavioral health services via technology), in particular, has a robust evidence base. Numerous studies have demonstrated its effectiveness across a range of modalities (e.g., telephone, videoconference) and mental health concerns (e.g., depression, substance use disorders).
Virtual services are safe, effective, and comparable in outcomes to in-person services. However, prior to COVID-19, telemental health was used primarily to provide services in areas that otherwise do not have access — for instance, in rural regions. It is now used throughout the country.
Barriers to Telehealth
One of the largest barriers to widespread implementation of telemental health has been issues of parity. No federal statute requires payers to reimburse telehealth encounters at the same rate as in-person (i.e., reimbursement parity) or even to cover telehealth at all (i.e., coverage parity). State parity laws are thus essential to guarantee that providers will receive comparable payment for telehealth encounters as for in-person services. But prior to COVID-19, only five states had implemented telehealth parity laws. And while recent analyses showed that an additional 21 states expanded telehealth services through COVID-19 emergency orders, only 13 required parity. Many states have taken direct action via Medicaid policy; all but two issued specific guidance on the expansion or reimbursement of Medicaid-based telehealth services.
Why Now?
The pandemic has disrupted the delivery of mental health care. In addition, there is increasing evidence of a mounting surge in mental and behavioral health care needs because of the pandemic. While formal data are not yet available, anecdotal evidence shows an increased demand for mental health services that is overtaxing the mental health care system. Even more troubling, modeling has predicted precipitous increases in overdose and suicide. The duration of the economic recovery and protracted nature of control measures like social distancing point to a continued need for services. Because minorities and people with lower incomes are being disproportionately affected by pandemic-related job losses and social stress, we also could see heightened heath inequities. Telehealth can rapidly expand access to safe, effective treatment in a way that has also been shown to avoid stigma.
Prior to COVID-19, most payers (including federal) only covered home-based methods (e.g., direct-to-consumer and mobile applications) for limited diagnoses that frequently required physical comorbidities to be covered. For example, this could mean covering treatment for substance use disorder via telehealth only if the patient had a comorbid chronic condition like diabetes. The dramatic expansion of home delivery of telehealth for virtually all diagnoses in emergency COVID-19 guidance and payer policy has dramatically expanded access to care. In addition, the pandemic has created a fifth hybrid approach for telemental health: hub-and-spoke and integrated care providers are extending their services to be direct-to-consumer. This allows patients to access the same providers at home whom they previously saw only at clinical sites.
Guidelines and Best Practices
Historically, concerns regarding infrastructure, privacy, and crisis management have discouraged many providers from entering the telemental health space. High-quality technology is more accessible now, with even smartphones able to facilitate HIPAA-compliant encounters. While there are still concerns regarding the use of nonmedical platforms like Zoom for encounters, there are commercial and nonprofit telehealth platforms available to handle privacy problems. Telemental health also presents unique challenges regarding safety issues — for instance, what to do if a remote client is exhibiting suicide symptoms. To help address these challenges, the American Psychological Association and the American Psychiatric Association have issued formal best-practice guidelines. While concerns remain regarding accessibility, particularly across racial or ethnic groups, recent studies have shown comparable rates of smartphone ownership that suggest technology access may be improving. For people with economic need, programs like FCC-backed Lifeline provide access to phones.
Looking Forward
While it is not a panacea, telemental health offers a critical avenue to not only sustain mental and behavioral health services, but to expand them during the pandemic. Advocates have called for the expansion of telemental health for decades. Unfortunately, many of the critical orders that have allowed for the expansion of telemental health services will expire, and it is unclear how many of these expansions — if any — will be extended.
