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When mental healthcare providers mentioned using telehealth to deliver care, the thought-bubble emoticon of Chaynee Rummel stroked its chin and cocked its eyebrow. “Before, I was very skeptical about telehealth,” says Rummel, a licensed clinical professional counselor and certified alcohol and drug counselor who provides individual and group counseling for adolescents at Northwestern Medicine Central DuPage Hospital in Chicago’s western suburbs. But when Rummel began providing individual and group therapy virtually due to COVID-19, she became a believer. “I think we can gain a lot more from it than I previously thought.”

COVID-19 has pushed telehealth of all shapes and sizes to the forefront, including “telemental” care — which just might prove to have more staying power than other forms of telehealth. In March 2020, Forrester Research released its report, “Healthcare 2020: The State of the Doctor-Patient Relationship in the U.S.,” which predicted 36 million virtual visits across all specialties by the end of the year. This prediction came three days before President Donald Trump declared COVID-19 a national emergency. On April 2, Forrester published new estimates, projecting more than 1 billion virtual visits this year, with 80 million related to mental healthcare.

Any number of reasons explain the rapid adoption of using telehealth for behavioral health services. It’s not necessary to be in the same room with someone when you talk to them, and talk remains a primary mode of behavioral treatment. Payment and privacy laws rules have been relaxed. And while COVID-19 itself is not a mental health disorder, the stress of a pandemic, including social distancing and stay-at-home orders, have stirred up stress and anxiety in general and that people with existing mental health problems may feel more acutely.

The quick pivot to telehealth for behavioral health has even taken some experts by surprise. Robert L. Caudill, M.D., director of the telemedicine and information technology programs at the University of Louisville School of Medicine and a member of the American Psychiatric Association’s Committee on Telepsychiatry, took part in a congressional briefing in February that identified what seemed to be an obstacle course of barriers to increased adoption of telehealth.

Within about a 48-hour period in mid-March, more than half of those barriers had been removed, even if temporarily, says Caudill. “We had expected slow and incremental change over time. What we got was this game-changing opportunity to redefine what is possible.”

Before the pandemic, the CMS only paid providers for telehealth care that was delivered to certain geographically isolated areas, notes Caudill, who has worked to develop telepsychiatry programs for rural parts of Kentucky for more than a decade. But starting on March 6 — and as long as an official public health emergency stays in effect — CMS waived important restrictions on telehealth for Medicare patients, and commercial payers followed suit. Patients can now receive services in their homes. Visits can be held through applications like Skype instead of through HIPAA-compliant portals. And patients don’t need an existing relationship with the clinicians. CMS also began compensating providers at the same rate for virtual care as in-person care. Prior to the pandemic, several states required commercial payers to reimburse providers equally for in-person and virtual care. Now, however, a few have ordered reimbursement at rates “not lower than” in-person care, and several major insurers have followed suit.

Rummel, who had been concerned she’d miss out on seeing her young patients’ body language via telehealth, has found that, “you see it all through the camera.” Telehealth is also providing new information about patients because she’s seeing them in their homes. “I think it’s kind of neat, seeing them in their own space,” she says, adding that one of her patients used part of the virtual visit to show off their pet snake. For adolescents in particular, a virtual visit “is no big deal. They’re so used to FaceTime and Snapchat,” Rummel says. The novelty of being introduced to a pet snake aside, Rummel notes one drawback to telehealth: Patients can get distracted by their pets or family members, in contrast to an in-person visit, behind a closed door.

Peggy Vogt, a licensed clinical social worker with Philadelphia Consultation Center, which specializes in psychoanalysis, has also begun conducting virtual visits since the pandemic, and insurance is now reimbursing for it. Vogt has found that telehealth helps some patients get care when they might have otherwise just skipped it. Some of her patients used to have “horrible attendance” at their scheduled, in-person sessions, she notes. Physical limitations or financial issues were hurdles. With COVID-19 ushering in telehealth, the couch or chair in the clinician’s office has been replaced by home furnishings. Vogt says she has even conducted sessions with patients propped up in bed — who probably would not have come to an in-person session. In some instances, Vogt says, “it opens things up clinically” when the session is conducted remotely and the patient is in familiar surroundings. The possible drawback, says Vogt, is for some people — patients who are anxious in social situations, for example — getting out of the house for an appointment is “clinically useful.”

It seems like the rest of the world is finally catching up with Carly McCord, a psychologist and the director of telebehavioral health at Texas A&M University. McCord has used telehealth for a decade. When she was a doctoral student, McCord began providing telehealth care to patients in rural areas of Texas that lack behavioral healthcare providers. In areas where broadband connectivity is an issue, telehealth access points have been created at primary care resource centers in a seven-county region. Her experience and her research have shown that in many cases, “delivering behavioral health services via video doesn’t change (patient) outcomes,” McCord says.

She has seen the same “comforts of home” effect on therapy that Vogt described, recounting the story of one of her students who was working with a patient coping with trauma. When the patient began doing virtual visits from a cozy corner of their home with candles burning and their dog nearby, “the therapy (took) on (a) whole new depth,” McCord says. In another instance, a trauma survivor who took part in a virtual visit by phone, with no video, made great strides. “The eye contact was gone. The shame was gone,” McCord says. A subset of patients “actually do better” with virtual consultations, she says.

OhioHealth, a not-for-profit healthcare system based in Columbus, rolled out telehealth behavioral care in 2015 as a way to improve emergency department safety and provide consultations with psychiatrists and psychiatric social workers, says Megan Schabbing, M.D., medical director of psychiatric emergency services. The healthcare system also has integrated behavioral health into its outpatient primary care practices, and mental healthcare providers use telehealth to help manage patients, she says. Having access to telehealth consultations “provides a higher level of care throughout the system” and also helps address the severe shortage of psychiatrists, Schabbing says. By 2025, the U.S. is expected to have a shortage of between 6,100 and 15,600 psychiatrists, according to a report by the National Council for Behavioral Health. Even when reimbursement for virtual care wasn’t possible, OhioHealth provided telehealth consultations because “it was the right thing for the patient,” Schabbing says. Now, with COVID-19, Schabbing is finding that some patients requesting behavioral healthcare don’t have a history of mental illness. “They are so stressed out about the crisis,” she says.

Many believe telehealth is a COVID-19 genie that can’t be put back into the bottle. Of course, nothing happens in American healthcare unless it gets paid for. While Vogt is satisfied with her experience doing telehealth consultations, “what I’ll do — or not do — in the future is largely insurance driven,” she says.

One wild card is whether the CMS will continue its policy of relaxing its telehealth rules. It’s hard to imagine that it won’t, especially with little, if any, evidence of harm. Relaxing regulations has “greatly expanded access at a time when it is exactly what is needed,” says Caudill. “We are not in a perfect environment even now, but it is far improved from what it was just a month ago.”

“I think telemedicine is going to be part of the new normal,” says Obinna Moneme, M.D., OhioHealth’s service line chief for virtual health, although he expects tweaks to how virtual care is delivered. “It will be interesting to see what stays and what restrictions get put back after the crisis.”

Susan Ladika is an independent business and healthcare journalist in Tampa, Florida.

Articles

COVID-19 forced a shift to virtual behavioral health therapy. Some once-skeptical providers, however, are finding telehealth beneficial. Reimbursement and continued relaxation of regulations will determine whether it’s here to stay. 

Telehealth and Therapy: On the Couch. But Now It’s Your Own Sofa.

It took American Family Care, an urgent care and primary care company headquartered in Birmingham, Alabama, just 36 hours to roll out its telemedicine service, AFC TeleCare, after the COVID-19 outbreak struck. “We had been thinking about it and deciding when we wanted to venture into it (telemedicine)” prior to the pandemic, says Benjamin Barlow, M.D., the company’s chief medical officer (CMO). “We met on a Monday, and the next day it was a go.” Since AFC TeleCare’s launch in March, many of the calls the company has received involve medication management for established patients, Barlow says.

If American healthcare does wind up getting divided into pre- and post-COVID-19 eras, the migration from in-person visits to telehealth ones will likely be one of the biggest developments on the right-hand side of the inflection. Population health experts and advocates have been eyeing telehealth for some time as a way to monitor patients, encourage healthy behaviors and increase adherence to medications.

“It’s recognized as an effective and often more efficient means to connect with patients to provide healthcare and chronic disease management,” says Mitchell Kaminski, M.D., MBA, a family physician and program director of population health at Jefferson College of Population in Philadelphia. The COVID-19 outbreak moved thought, research and pilot projects into full-on implementation mode.

“We’ve gone from incremental change in 10 years to very rapid, transformative change” because of COVID-19, Kaminski says, as virtual care gives providers the opportunity to offer much needed care during the pandemic while keeping patients safe by not making them come in person and wait in a doctor’s office.

As a family physician and leader in population health, Kaminski says he had long thought that he should provide virtual care for his own patients, but it languished on the to-do list. He envisioned a steep learning curve. And like many physicians, especially those who deliver primary care, he assumed that telehealth visits couldn’t measure up to the in-person ones in establishing a strong doctor-
	patient relationship. 

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But he has been pleasantly surprised. “I have been amazed at the connection I feel, even with patients I’ve never met before,” says Kaminski, who has been seeing patients remotely through JeffConnect, an app set up by the Thomas Jefferson University Hospitals system, as well as having telehealth visits with his own patients.

Before the COVID-19 outbreak, telehealth had been edging its way into American healthcare delivery. The convenience of being able to receive immediate care online via a mobile device has undeniable appeal for patients, especially compared with having to wait days, even weeks, to be seen. In many cases, the virtual visits had a lower copay. In some cases, the services were provided by hospital and healthcare systems. In others, they were the reason to be for so-called direct-to-consumer companies such as Teladoc Health and were offered as an add-on benefit to employer-based health insurance. 

A 2019 J.D. Power survey found about 10% of respondents had used telemedicine in the previous 12 months. Two years ago, Michael Barnett, M.D., an assistant professor at the Harvard T.H. Chan School of Public Health, and his colleagues reported the results of a study of telehealth usage in an unnamed health plan in 

(Although the plan is not named, the de-identified claims that Barnett and his co-authors used came from OptumLabs.) 

From 2005 to 2017, those health plan members made almost 385,000 virtual visits, and usage climbed from 0.02 visits per 1,000 members in 2005 to 6.57 visits per 1,000 members in 2017. More than half the visits were for mental healthcare, and almost 40% were for primary care. Barnett’s report shows a steep increase in telehealth use starting in 2015. 

Teladoc, which stakes a claim to being the country’s most experienced and largest telehealth provider, reported that its number of virtual visits reached 4.1 million in 2019, a 57% increase over the previous year. On March 13 of this year the company reported that virtual visits had increased by 50% in the previous seven days compared with the week before. Teladoc provided about 100,000 virtual visits during that time. Its stock price shot up from $128 per share on March 13 to $167 on March 23.

Maven Clinic, a digital health startup that focuses on women’s health, saw a 500% spike in virtual mental healthcare mid-March when pandemic hit the United States, says CEO Katherine Ryder. Virtual care is “dramatically reshaping” healthcare delivery, she says. [After that initial spike, Maven subsequently saw a 300% increase in virtual mental health visits over the past two and a half months, a company representative said at the end of May.]

Kaminski says that Jefferson emergency department physicians set up the JeffConnect app about three years ago. Patients were charged a relatively small copay. “They were providing about 50 telemedicine visits per day until the pandemic hit, and suddenly they found themselves dealing with over 3,000 visits a day, a 60-fold increase.”

“The slow adoption of telemedicine tools really has been reflective of the lack of payment or limited payment for visits,” notes Kaminski. Prior to COVID-19, CMS had been slowly relaxing restrictions on the telehealth services that Medicare would pay for. For example, starting this year, Medicare Advantage plans were allowed to offer telehealth as a basic benefit. Last year, Medicare started paying for brief virtual check-ins with patients with whom a physician has an established relationship. But in March, CMS swept away many restrictions and agreed to pay for telehealth visits at the same rate as in-person visits. Rules that had required in-person visits with nursing home residents and hospice and end-stage renal disease patients have been waived.

For commercial payers, a 2019 report by the law firm Foley & Lardner LLP found only 10 states had payment parity laws requiring equal reimbursement for virtual visits and in-person care. But amid the COVID-19 outbreak, some states have ordered private insurers to reimburse providers for telehealth services at rates no lower than what they pay for in-person care. Some insurers have waived cost sharing for telehealth visits, and a few - Aetna, most prominently - are matching the CMS policy of paying for telehealth visits at the same rate as in-person visits.

Prior to the reimbursement changes, “it just wasn’t worth it” to have American Family Care doctors offer telemedicine services, says Barlow, the CMO. “You lost money.” But that has changed now that some insurers “are recognizing the value and need for this and are paying us for it,” he adds.

CMS could relax its telehealth rules because COVID-19 was declared a public health emergency. Once that the emergency is over, legally, the rules will go back into effect. There’s also a chance that the current appetite for telehealth is particular to the COVID-19 outbreak and to the social distancing designed to mitigate its worst effects. Kaminski says a large percentage of his telehealth visits have been about easing people’s COVID-19 fears. Still, he doesn’t see a return to the pre-COVID-19 era of telehealth when it was largely on the margins of American healthcare.

“I think of it as opening Pandora’s box. We see all the benefits of this technology patients are experiencing: greater access and convenience for care. And we’re finding that it’s effective for their care.

“When the pandemic is over,” Kaminski continued, “I don’t think anyone can predict what is going to happen. But it’s hard to imagine that we can put Pandora back into the box and say, ‘Let’s go back to this less efficient, more costly, fee-for-service-based, RVU (relative value unit) system that we
	had before.’”

There is a question, though, about who will be providing telehealth. Part of the appeal of the direct-to-consumer providers is that they make their service available around the clock. Many traditional, office-based providers will presumably add telehealth visits as a service, but it is hard to imagine their having 24/7 coverage. 

Another question centers on what exactly post-COVID-19 telehealth will be used for. Amid the outbreak, it helps people stay home. But what happens afterward? Population health experts like Kaminski worry about weakening the already tenuous continuity of American healthcare if people depend too heavily on the direct-to-consumer providers. Kaminski is also concerned about loss of data.

“When a patient has a visit with a nonaffiliated service or provider, whether it’s at a drugstore or through a virtual telemedicine visit, does that information get back to that patient’s primary medical record? It will matter if it affects the medications they take for their illnesses. So where there’s concern about the continuity with providers, you also have to think about continuity of data,” he says. 

The digital divide between low- and middle-income Americans and the affluent may be a fault line in the future of telehealth. Enthusiasts for online endeavors of all kinds sometimes gloss over the fact that reliable, high-speed internet access is not available to everyone for economic, geographic and
	other reasons.

Some observers also see a generational split. Baby boomers may still be attached to the in-person visit, partly because they are aging and will therefore tend to have more complex medical problems. In a webinar in March sponsored by Brookings Institution and the Leonard D. Schaeffer Center for Health Policy & Economics at the University of Southern California, Deutsche Bank analyst George Hill said he expects demand for telehealth care to continue, particularly among younger patients, who are “provider agnostic.” Instead, in this convenience-driven society, they want “a doctor serving you on your terms, when you’re ready,” he said. 

Susan Ladika is a health and business writer in Tampa, Florida.

If American healthcare does wind up getting divided into pre- and post-COVID-19 eras, the migration from in-person visits to telehealth ones will likely be one of the biggest developments on the right-hand side of the inflection.

Author | Susan Ladika

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