COVID-19 pandemic and telemental health policy reforms

Abstract

Many patients with mental disorders lack access to care mainly due to provider shortages. Coronavirus disease 2019 (COVID-19) pandemic significantly raised the prevalence of anxiety, depression, substance use disorder and suicidal thoughts among people. Mandated social distancing, and higher incidence of mental disorders increased the demand for Telemental Health (TMH). TMH expands access to care and can be an effective alternative to the costly conventional mental health care. However, there are barriers to the adoption of TMH such as reimbursement challenges, and licensure restrictions. During the COVID-19 pandemic, some policies and regulations changed to address the increase in TMH demand. The federal government increased funding for the new telehealth initiatives and more states legalized the interstate practice for psychologists. Medicare waived telehealth co-payments, reimbursed audio-only visits, and required payment parities between virtual and in-person visits. Nevertheless, Medicare maintained in-person visit prerequisite within the six months prior to the first time only for mental health treatments which can act as a hindrance. Additionally, four more states required telehealth coverage, 33 states required Medicaid plans, and 21 states required private insurers to cover TMH services. Ten states mandated payment parity for private insurers, and four states eliminated cost-sharing for telehealth services. Currently, 21 states are implementing payment parity on a permanent basis. During the pandemic, 78% of Mental health providers integrated TMH services into their practice. Despite the decline in use of telehealth for other health conditions after the pandemic peak, TMH use has remained strong representing 36% of outpatient visits. TMH is beneficial to patients in terms of cost and time saving; thus, the beneficiary regulatory changes should be sustained. Further well-designed studies are needed on the cost-effectiveness of telehealth interventions, and policymakers need to collect more data to decide whether and how to keep these changes permanently for TMH.

Keywords:

• Telemental health
• COVID-19 pandemic
• policy reforms
• mental health disorders

In 2018, one in five adults in the United States (US) suffered from mental disorders while less than half received treatment¹. Despite the increase in demand for mental health services, many of these patients are still unable to receive the care they need, given that more than 60% of the US counties lack psychiatrists².

Coronavirus disease 2019 (COVID-19) pandemic raised the prevalence of depression, anxiety and substance use disorders³. The number of adults with elevated depressive symptoms increased from 8.5% before the pandemic to 32.8% in 2021⁴. Thirteen percent of adults reported new or increased substance use, and 11% of adults reported suicidal thoughts in June 2020. Lockdown, mandated social distancing and higher incidence of mental disorders increased the demand for TMH services during the pandemic⁵. Odds of telehealth utilization were three times greater in patients diagnosed with anxiety and/or depression than in those with no diagnosis⁶. TMH is a growing field that expands access to care and diminish the long waiting time to see a provider (on average, 25 days) for patients with mental disorders⁷.

It can offer an effective solution to healthcare where access and costs are prohibitive^8–10.

Barriers to adoption of TMH

States laws vary greatly in coverage and reimbursement. Reimbursement challenges can be a significant factor in slow uptake of TMH. Prior to COVID-19 pandemic, only 11 states mandated telehealth full coverage and payment parity^11,12.

Licensure laws can further inhibit the adoption of TMH by restricting patients’ access to providers. Also, requirements such as preexisting relationships between patient and provider create an unnecessary barrier to adoption of TMH¹³.

Policy and regulation changes during the COVID-19 pandemic

To address the increase in TMH demand, some policies and regulations changed during the pandemic. The federal government and some states removed licensure restrictions and recognized out-of-state licenses for telehealth services. Traditionally, licensing laws for mental health providers have been defined and regulated by the authority of individual states. However, recent changes like the creation of Psychology Interjurisdictional Compact (PSYPACT) have eased interstate practices. Currently, 33 states have enacted PSYPACT and it is effective in 28 states^14,15. With PSYPACT, mental health professionals will be more accessible. Nevertheless, it is important for providers to fully understand and comply with regulations of both states if their patient resides in a different state than where their practice is physically located. Additionally, the federal government increased funding for the new telehealth initiatives. In March 2020, congress allocated $200 million to establish the COVID-19 Telehealth Program, which was extended into 2021 with an additional $249.95 million in federal funding¹⁶. Medicare revised regulations included payment parities between virtual and in-person visits, waived telehealth co-payments, and boosted payment for services delivered via audio-only. Almost every state implemented new policies that mirrored what was done by Medicare to increase access to telehealth services by state-regulated insurers or Medicaid programs¹⁷. Four states that did not previously require telehealth coverage changed their policies and brought the total number of states currently require coverage to 40¹⁸. Thirty-three states required Medicaid plans, and 21 states required private insurers to cover TMH services¹⁹. At least 30 health plans added mental health visits into their allowable telehealth services, and 15 health plans expanded access to TMH. For instance, Blue Cross and Blue Shield of Massachusetts added more than 400 mental health clinicians to their network to meet the increase in demand for mental health services²⁰.

Payment parity is a complex issue involving patient related as well as payor requirements. Some states mandates apply to provider reimbursements, some others apply to patient cost sharing and deductibles, and many states apply to both. During the pandemic, 10 states required insurers to pay providers the same for telehealth and in-person visits¹⁸. For example, under Medicare it accounts for “practice expenses” which means the cost of providing the service. While the work for both in-person and telehealth visit may be the same, it remains a question whether the overhead expense to the medical practice is the same. Likewise, four states eliminated cost sharing for telehealth services and three states required that cost sharing for telehealth services not exceed charges for identical in-person service. Some other states prohibited cost sharing only for services related to COVID-19¹⁸. Making telehealth services more affordable to patients was essential to encourage patients to access care remotely during the pandemic.

Although Medicare expanded coverage made telehealth services available to both new and established patients, there was an in-person visit prerequisite within the six months before the first time that only applies to mental health treatment while other Medicare beneficiaries who seek medical services via telehealth are not subject to this requirement²¹. This requirement is a hindrance to establishing mental health parity.

The next chapter of TMH

TMH uptake has traditionally been slow but steady, with a 14% increase from 2010 to 2017²².

Before the pandemic, telehealth represented less than 1% of outpatient care for mental health and substance use disorders which increased to 40% during the pandemic peak. Despite a decline in other outpatient care visits after the pandemic peak, telehealth use remined strong for mental health and substance use treatment, still representing 36% of outpatient visits. During March–August 2021, 1 in 3 outpatient visits were delivered by telehealth for mental health needs²³.

It is believed that telehealth has saved patients time and money. Analysis of FAIR health data demonstrated that patients who used telehealth spent dramatically less on healthcare services; 61% decline in average telehealth user’s monthly health care expenses from $1099 to $425 between January 2020 and February 2021²⁴. Telehealth has saved UC Davis patients nearly nine years of travel time and about $3 million in travel costs over the past 18 years²⁵. Additionally, a literature review indicated that implementation of a telepsychiatric consultation in emergency departments resulted in a decrease of the length of stay from 1.35 to 0.43 days, and a drop in admissions from 22 to 11%²⁶.

With the policy changes and restrictions removed during the COVID-19 pandemic, 78% of mental health providers have integrated TMH services into their practice compared to 30% of mental health facilities with TMH services in 2017^27,28. With increase in incidences of depression, anxiety, substance use disorder and suicidal thoughts, population mental health worsened markedly during pandemic³. Results of one study indicated that 71% of participants with baseline mental health conditions reported worsened mental health as an impact of COVID-19 pandemic²⁸.

Indeed, this impact may continue long after the pandemic itself is over. A scoping review on the use of TMH during the pandemic suggested that TMH is safe and effective and will remain in use for the foreseeable future³. Nevertheless, it is unclear whether these policy changes that eased the uptake of TMH will remain in place after the pandemic is over. Many health insurers started to roll back coverage for telehealth²⁹. However, 21 states are implementing payment parity laws on a permanent basis, and five states have payment parity in place with caveats as of May 2022. For instance, Massachusetts and Nebraska payment parity laws only apply to mental health services, and certain mental health and substance use disorders, respectively³⁰. To ensure that the increased adoption of TMH is not dissipated, lessons from deregulations need to be thoughtfully extracted and implemented. There is no clinical evidence for Medicare statutory in-person requirement since TMH services can be as effective as in-person visits and the provider-patient relationship can be established via a telehealth visit; thus, this requirement should be repealed^8,31. Additionally, while most legislations have targeted Medicare or Medicaid and fewer addressed private payers, advocates should continue to ask states requiring all private payers to expand coverage for TMH, and allow the interstate practice. Other modifications such as payment parity should be considered but need more examination. The main concern with payment parity laws is that they can contradict telehealth’s cost-saving. Indeed, the convenience of telehealth services may cause seeking unnecessary care and the high cost of healthcare in the US can be exacerbated by payment parity laws. Private insurers have experienced an increase of over 4000% with telehealth claims over the past year²⁹. These laws may also have unintended consequences for patients by preventing any cost savings that could be passed along to patients in the form of lower premiums or deductibles. Also, providers may tweak TMH services and shift too much of their schedule to these services, making it difficult to make an appointment for patients who prefer in-person visits or that TMH is not feasible.

Conclusion

The beneficial regulatory changes should be sustained since they can address projected provider shortages (a quarter of a million by 2030)³². In many settings, TMH is comparable to in-person care in terms of effectiveness and clinical outcomes^8,31. Additionally, TMH can increase access to care and lead long term cost-savings³³. Telehealth cost-effectiveness is not fully demonstrated in the literature and well-designed further studies are needed to assess the cost-effectiveness of TMH. Policymakers need to collect more data to guide their policy decisions on whether and how to keep changes permanently for TMH.

Transparency

Declaration of funding

This paper was not funded.

Declaration of financial/other relationships

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgements

None.