November 3, 2021

The Promise and the Challenges of Tele-Behavioral Health

Mindy Klowden

Mindy Klowden

Amid the COVID-19 pandemic, state and federal lawmakers established emergency, regulatory flexibilities – including eliminating requirements that patients have an established, pre-existing relationship with a provider, reimbursing telehealth at the same rates as in-person-services, and allowing telephonic services rather than requiring video connection – to enable individuals to access telehealth. As such, telehealth utilization, especially as it relates to behavioral health, skyrocketed.

According to FAIR Health, psychotherapy was the most common telehealth procedure code billed in the United States in both January 2021 and July 2021. As telehealth utilization increased, so did investments. In fact, Rock Health’s 2021 Q3 Report found that so far this year, mental health is the leading clinical or disease focus for investors, with $3.1 billion raised so far. And, patient satisfaction remains relatively high. A recent study released by the Colorado Health Institute found nearly four in five people who used telehealth in the last year said the quality was at least as good as in-person care.

This past year, Third Horizon Strategies partnered with the United States of Care to conduct research on how virtual care is impacting behavioral health. Not surprisingly, we found that telehealth mitigated significant barriers to care, such as transportation, childcare, and stigma; extended services into communities that may lack providers; and increased clinician productivity. Yet, our research also found that telehealth is not a panacea for addressing the myriad of barriers to behavioral health and, in fact, has its own set of challenges.

First, the “digital divide.” Lack of access to devices that can support virtual visits and access to high-speed internet can create new disparities in access to care, particularly for people of color, economically challenged communities, older adults, and rural communities.

Second, patient safety and clinical appropriateness. People who lack privacy in their home or have cognitive challenges that impede their use of technology may not thrive via telehealth. Many primary care practices and community behavioral health providers that we interviewed are attempting to offer hybrid services, with care provided in traditional office settings and telehealth available for those who want or need them. These providers also play a critical role in supporting transitions of care that help reduce unnecessary emergency department utilization or hospital admissions/readmissions. However, telehealth-only companies may not have the ability to connect patients to local services, leaving vulnerable patients without appropriate higher levels of care.

Third, social isolation or loneliness. Loneliness can lead to or exacerbate various psychiatric disorders like depression, substance use disorders, child abuse, sleep problems, and personality disorders. Historically, community behavioral health providers have used interventions such as peer supports, clubhouse models, or rehabilitative social activities to mitigate isolation and loneliness. However, digital-only behavioral health services may not be well suited to replace these face-to-face services for all populations.

Fourth, clinical outcomes. Most providers and payers have not yet begun to segment data to compare outcomes for clients receiving care via telehealth versus in person, much less breakdown the data by diagnosis, race and ethnicity, payer source, and/or other key demographics. Thus, data around tele-behavioral health outcomes seem to be quite limited.

Fifth, workforce recruitment and retention. As discussed in my previous blog, behavioral health workforce recruitment and retention is a national issue. One attempt to address provider shortages that builds on telehealth care is the development of PSYPACT, an interstate compact that allows licensed psychologists to practice telepsychology across state boundaries. The 26 states that joined this compact aim to increase access to providers and ensure continuity of care. Although virtual care expands access to behavioral health services in communities lacking providers, it does not increase the size of the provider workforce. Unless the behavioral health provider pipeline is addressed, virtual care is a temporary solution that shifts resources and stretches existing provider capacity.

So, what should the tele-behavioral health landscape look like moving forward? I would suggest the following four considerations.

First, public policy needs to address poor access to broadband, smart devices, and data plans to support telehealth access in both rural and urban, underserved communities. Digital literacy training would also be a wise investment for both patients and providers. Last month, the American Telemedicine Association released a framework for eliminating health disparities. The report states, “Notably, while broadband and connectivity are the focus of a vital investment in our nation’s infrastructure, the Advisory Group believes the broad availability and integration of telehealth can drive the changes needed to order to achieve the nation’s goals for health and well-being.”

Second, we need a thoughtful approach to utilizing telehealth as means to increase access to care and serve as one of many tools in the clinical toolbox. Behavioral health providers should be able to direct patients to the service modalities best suited to meet their clinical needs, as well as their preferences. Services that support recovery, improve quality of life and address loneliness must continue to be available in communities.

Third, we need to better define the role of telehealth in value-based care and gauge its impact on behavioral health outcomes. This may require new investment in data collection and segmentation at the provider level.

Lastly, strategic policy initiatives must mitigate systemic barriers to behavioral health that are not addressed by telehealth, such as poor reimbursement rates, limited opportunities to participate in alternative payment methodologies, and workforce shortages.

Telehealth seems to be here to stay and offers new ways to increase access to much needed mental health and substance use disorder treatment services. Yet telehealth should augment, not replace more traditional community-based services. The policy context will be critical to sustaining services in a thoughtful way.