In November 2021, the Centers for Medicare and Medicaid Services (CMS) announced a series of new policies aimed at enabling access to behavioral health services via telehealth. The announcement comes as utilization of behavioral health services via telehealth has been on the rise, which is attributable to a couple of factors:
- New flexibilities to use telehealth for both providers and patients to support access to health care throughout the COVID-19 pandemic; and
- Increased behavioral health needs resulting from social isolation, economic challenges, grief, and other challenges spurred by the pandemic.
With increased access to, demand for, and utilization of behavioral health via telehealth, states are grappling with a number of challenges to ensure adequate yet quality access to remote behavioral services.
With Patient-Centered Outcomes Research Institute (PCORI) support, NASHP convened a call series with state health officials representing diverse agencies and programs, including Medicaid/CHIP, State Employee Health Plans (SEHPs), State-Based Exchanges, and Departments of Insurance, to discuss telehealth. Throughout these conversations, behavioral health emerged as a persistent theme and area of focus, as states seek to maintain robust yet appropriate access to these critical services.
Rapid state actions bolstered remote behavioral health access
Toward the beginning of the COVID-19 pandemic, state and federal officials worked quickly to enable the utilization of telemedicine across healthcare services. Some of these changes were untested, such as allowing a telehealth visit to prescribe medication and induction of controlled substances, as well as delivery of healthcare services over non-HIPAA compliant platforms such as Google Hangouts or Zoom. States also worked to support infrastructure needs, enabling some providers, including behavioral health practitioners, to practice remotely for the first time. Significant investments in broadband extended access to remote behavioral health services to communities that may not have an adequate network of local in-person providers.
States also worked to bolster their workforce, taking action to waive in-state licensure requirements or by joining interstate licensure compacts such as PSYPACT which allows for out-of-state providers and those with lapsed or in-progress licenses to provide behavioral health services. To entice providers to deliver remote care, states mandated or encouraged parity in reimbursement and/or cost-sharing between in-person and telehealth services. States also allowed for more flexibility in health plans network definitions so that more provider types, including behavioral health professionals, could engage in telehealth delivery when clinically appropriate.
These changes incentivized the use of telemedicine services, with state coverage officials reporting that behavioral health service use via telehealth remains high, even as more patients are seeking in-person medical care again. A recent Commonwealth Fund analysis found that at the end of 2020, over half of all behavioral health visits nationally were being conducted via telehealth. Another analysis of behavioral claims data noted that over 60% of behavioral health patients now use virtual services, and 97% of the people that accessed behavioral health services between March and May 2020 did not have a behavioral telehealth claim before March 2020 when COVID-19 required closures. State officials speculate that the increased demand for behavioral health services could be indicative of both previously unmet needs and needs exacerbated by the effects of the COVID-19 pandemic.
Looking ahead, state officials balance practical concerns with emerging needs in behavioral health
As reported in a prior blog, policymakers are now grappling with many questions as they look to the future of telehealth. States seek to balance appropriate access to and coverage of both in-person and remote behavioral health services, accounting for changes in behavioral health use observed during the pandemic. States are also being funded to build out mental health and SUD service capacity and in so doing are considering the role of telehealth to support the behavioral health needs of their populations.
Policymakers flagged a few emerging issues as they consider decisions over telehealth delivery of behavioral health services.
Assessing appropriate modalities of care delivery
While flexible telehealth policies increased access to remote care and new modalities of service delivery, policymakers must consider whether these modalities are appropriate and safe to use in all circumstances. Patient needs could differ based upon specific circumstances or diagnoses that should perhaps be weighed in determining whether telehealth services will lead to optimal health outcomes. For instance, given the particularly sensitive nature of many behavioral health concerns, policymakers want to ensure appropriate measures are in place across all allowed technologies to ensure that privacy concerns are met.
In some cases, more flexible use of technology and increased capacity to receive care in an at-home environment, may help enable access for some, including for those with complex needs. However, certain technologies can also be prohibitive for some, especially if patients lack technological literacy, cognitive functionality, or adaptive or other resources to use them effectively. More information is needed to understand where technologies are, at minimum, adequately serving patients, and where continued flexibility does succeed at (or potentially inhibit) delivery of optimal care.
Ensuring equity in behavioral health accessed via telehealth
Despite increased investment in technological infrastructure by both states and the federal government, access to broadband remains an issue across many communities. In addition, the adoption of new technologies is limited for patients by both economic disparities, as well as disparities in tech literacy. In particular, communities of color, and low-income populations present lower rates of technology literacy. In tandem, these populations experience worse mental health outcommes, which may be further exacerbated if states shift to advance telehealth delivery without coordinated efforts to also address technological disparities across their populations.
Addressing behavioral health stigma while not fostering isolation
Some patients may have different comfort levels with receiving behavioral health services in person. This is driven in part by stigmatization around behavioral health that prevents some patients from seeking care at all. Individuals discussing sensitive or stigmatized topics such as substance use disorder or mental illness may feel more comfortable disclosing information in the privacy and comfort of their own homes. Additionally, Black and Hispanic communities experience higher levels of mistrust in health institutions and may feel less comfortable interacting with practitioners in their offices versus in a familiar space. Officials speculated that access to care from a safe, at-home environment, may be fueling some of the increased utilization of behavioral health services. However, others expressed concerns over the importance of community and relationship building to treating many behavioral health concerns and uncertainty over whether that could not be replicated in a virtual space.
State officials have many issues still to consider as they continue to debate the future of telehealth policy. Stay tuned for more NASHP resources to support states interested in exploring emerging telehealth and behavioral health policies.
