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

June 25, 2020
Susan Ladika
Susan Ladika

Volume 30, Issue 6

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.

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.

Barriers fall suddenly

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.

Pros and cons

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.”

Ahead of the game

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.

The new normal

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.

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