Telemental health services on rise, but barriers remain

May 26, 2016   Meg Bryant

As published by Meg Bryant in Healthcare Dive

Telemental health services on rise, but barriers remain

Telemental health services

Millions of Americans suffer from mental health conditions each year, ranging from anxiety and depression to schizophrenia and post-traumatic stress disorder. Many of those go untreated due to missed diagnosis, lack of access and other issues.

But new smart technologies and changes in state laws are making it easier for many patients to get mental health services, a recent survey by Epstein, Becker Green shows.

The survey looks at laws and regulations for telemental health in all 50 states and the District of Columbia and how they apply to 12 types of providers. It also looks at how each state defines “telehealth” and “telemedicine,” licensing requirements, coverage issues, and how they establish the provider-patient relationship.

While the survey details a rapid rise in telemental health, barriers to providing those services remain.

“The real issue comes when you’ve got providers who want to provide services in more than one state,” says René Quashie, senior counsel in EBG’s Health Care and Life Sciences practice and the report’s author.

For example, some states require very detailed informed consent for telemental health, while others are not as prescriptive. Some states regulate it with laws and regulations and some do it through their licensing boards. There are also variations by provider types — e.g., psychiatrist, psychologist, social worker, marriage and family therapist.

For instance, in New York, psychologists can use telehealth if they obtain the patient’s consent and do an initial assessment to ensure that remote counseling is appropriate. Delaware requires clinicians to conduct a risk-benefit analysis and, based on that, determine whether the patient understands the technology and will benefit from it.

In Maryland, psychiatrists practicing telehealth must protect unauthorized access to patient data through password protection, encryption and other means and develop a policy on how quickly patients will get a response to requests.

A big-ticket issue

Mental health is currently a huge problem in this country. In any given year, about 25% of the population has a diagnosable disorder—about two-thirds of which go untreated.

Among people with behavioral health issues (mental health plus substance abuse), about nine-tenths go untreated, data from the Substance Abuse and Mental Health Services Administration shows.

In addition, roughly a third of people with one of the four leading chronic illness — cardiovascular problems, cancer, chronic obstructive pulmonary disorder, or diabetes — also have a co-occurring behavioral health disorder, says Marlene Maheu, executive director of the TeleMental Health Institute, which offers consultations and professional training.

The impact on costs is jarring. According to a study in the June issue of Health Affairs, mental disorders consume more healthcare dollars than any other condition in the U.S., totaling $201 billion in 2013.

To increase access, a number of federally subsidized programs now allow for telehealth services. Medicaid is also taking advantage of the flexibility involved, with 49 state agencies (all but Rhode Island) now covering its use, says Latoya Thomas, director of the State Policy Research Center at the American Telemedicine Association.

Beyond Medicaid, there is enhanced coverage with private insurers, Thomas notes. Currently, 30 states and D.C. have some kind of private insurance coverage parity for telemedicine. The latest law, in Alaska, specifically covers mental and behavioral health, she says.

A wealth of technologies

Telemental health is more than videoconferencing and phone counseling. “If you think about the Fitbits and Jawbones, those types of devices that measure steps and activity level, the next generation will include sensors that measure emotions,” says Maheu.

Other technologies are on the horizon, too, such as affective computing and artificial intelligence.

“There’s a lot that we will be learning about how we interact with machines that can reflect what’s going on inside of us," she says, adding that avatar therapists could be used to treat some disorders in the future.

“We’re talking about a constellation of technologies that revolve around collecting the data, whether it be from devices or video consultations, to the way we aggregate and shape that data, to the technology that provides the security for this type of population health ecosystem, so that all of this valuable PHI is protected and safe,” Jacob Levenson, CEO at MAP Health Management, said in an email.

He believes the more basic telehealth consultation technology is becoming “commoditized. It’s not that innovative; it’s mostly video technology.”

By contrast, MAP’s technology uses sophisticated risk-assessment algorithms to tell providers which patients need engagement and why. And it allows for large sets of patient data to be aggregated, analyzed and reported so that clinicians and payers can see which treatment modalities work for which demographics. It also aids in value-based contracting by showing which providers are performing to acceptable levels, Levenson says.

Overcoming barriers

To expand access to telemental health services and facilitate multi-state practices, Quasie says states need to harmonize their laws and regulations. This is beginning to happen in some areas — for example, the Federation of State Medical Boards has an interstate licensure compact that makes it easier for physicians (psychiatrists) to get licensed in multiple states.

Sixteen states are currently members of the compact. Other groups are working on similar compacts.

But beyond that, there are a number of scope of practice issues — informed consent, modality, can you do it over the phone, do you have to have a video — and not much harmonization is happening in that area, Quasie says. And since regulation of health professionals has generally been the province of the states, he doesn’t envision a federal solution problem. “The states are going to have to figure this out.”

That means updating antiquated laws and policies that refer to in-person or face-to-face encounters to accommodate more contemporary modes of care delivery, Thomas says.

The ATA recently spearheaded a grassroots campaign that helped to kill a Texas proposal that would have required physicians to do in-person exams or face-to-face visits — effectively muting any kind of telehealth. “In a state where two-thirds of the counties have a shortage in access to mental health providers, that certainly wouldn’t have bode well for folks looking for access to therapy,” she says.

People like Maheu see behavioral health as the next big boom area for healthcare, and telemedicine as a leading way forward. “It represents a very big hole in the bottom of the boat, and it’s costing the government a lot of money,” she says. “Because technology can deal with these issues, it’s so available and it’s so inexpensive, it only makes sense to use it.”

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