Telemedicine’s Tipping Point: Pandemic Exposed Longstanding Coverage Issues
By Emma Freer Texas Medicine November 2021

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For Fort Worth child and adolescent psychiatrist Debra Atkisson, MD, the shift to telemedicine during the COVID-19 pandemic was necessary but abrupt. Since then, however, she and many of her teenage patients – digital natives who grew up steeped in a media-saturated culture – are quite comfortable meeting from behind a screen. In fact, many of her young patients prefer it. 

More importantly, Dr. Atkisson found that telemedicine addressed one of the most pressing issues facing her profession: a dire shortage of psychiatrists that predates the pandemic. 

Using this new-to-her modality, Dr. Atkisson has been able to fill that gap by meeting with patients who live far away from the facility where she treats adolescents diagnosed with autism spectrum disorder, and by consulting with primary care physicians across the state, stretching the limited workforce through collaborative care. (See “Making the Right Call,” page 26.) 

The technology’s rise came at a critical time. 

“Whether people were aware of it or not, we were already at a crisis point with mental health in this country,” she said. “The pandemic was a tipping point.” 

Acute need 

For these and other reasons, mental health specialists like Dr. Atkisson want to see telemedicine long outlast the pandemic. Although recent policy changes at the state and federal level have helped carve that path, medicine continues to advocate for many of the temporary adjustments during the pandemic remaining permanent. (See “The Tele-Future is Now,” July 2020 Texas Medicine, pages 14-19, www.texmed.org/TelemedFuture.) 

And with good reason.  

Telehealth claims, which accounted for 2.1% of private insurers’ overall health claims filed in Texas in January 2020, peaked at 43% in April 2020, according to a recent analysis of insurance data conducted by the national COVID-19 Healthcare Coalition Telehealth Impact Study Work Group, of which the American Medical Association is a member (tma.tips/telehealthclaims). Although telehealth claims plateaued in the ensuing months, they continued to show significant gains on the prepandemic baseline, accounting for nearly 20% of claims filed in December.  

Among those claims, mental health disorders were the leading diagnosis both before and since the pandemic. In fact, behavioral and mental health saw more dramatic growth than other diagnoses during the pandemic, accounting for 33% of overall claims in December, compared with about 12% in January 2020, according to the analysis. (See “Measuring the Behavioral Telehealth Boom,” page 46.) 

In the early months of the pandemic, when practices closed down and trips outside the home were limited, state and federal government eased regulatory and payment barriers to delivering medical care via telemedicine. Private health plans and state agencies followed suit by allowing physicians to use audio-only telemedicine, removing site restrictions, and ensuring payment parity – if only temporarily.  

With these restrictions and financial concerns alleviated, physicians were more comfortable using telemedicine and better able to see its merits, says Austin psychiatrist and internist Thomas Kim, MD, who serves on TMA’s Committee on Health Information Technology and has testified regularly on behalf of TMA in support of telemedicine advancements. 

“Our regulators and legislators did an enormous mitzvah by effectively suspending all of these historic regulatory barriers that people like me have been running at walls beating our heads against for years,” Dr. Kim said. 

At the state level, thanks in part to Texas Medical Association advocacy, the 2017 Texas Legislature paved the way with improvements to coverage parity, meaning health plans must pay for telemedicine visits for a covered service. (See “Clearer and Simpler,” August 2017 Texas Medicine, pages 38-39, www.texmed.org/SB1107.) Although sweeping, the legislation didn’t mandate payment parity, which requires health plans to pay a physician the same for a telemedicine encounter as for a similar in-person visit. 

During the 2021 session, the House of Medicine came away with significant victories relating to telemedicine, including two pieces of TMA-backed legislation, despite falling short of payment parity. House Bill 4 by Rep. Four Price (R-Amarillo) makes permanent the pandemic-induced allowances for expanded telemedicine payment in Medicaid and the Children’s Health Insurance Program, if the state determines those services are clinically sound and cost-effective. House Bill 5 by Rep. Trent Ashby (R-Lufkin) creates a state broadband development office, which would in turn create a program to award financial incentives, including grants and loans, for broadband expansion. 

“There are Texans in more remote areas who have been able to be served because of those [state and federal] changes,” Dr. Atkisson said. However, “if reimbursement cannot occur, people won’t be served.” 

In addition to helping assuage a longstanding psychiatric shortage in Texas, telemedicine helped meet the behavioral health needs of patients during the pandemic, which continues to drive demand for care.  

Nov_21_TM_Econ_Telemed_StarkLike many of her peers, Amarillo addiction psychiatrist Amy Stark, MD, has seen an uptick in the number of patients trying to establish care – and lengthening waitlists. “The stress of the pandemic, the civil unrest we had last summer, the political discourse: There are a lot of reasons people are stressed right now,” she said.  

But this increased demand coincides with longstanding state and national psychiatric workforce supply issues. As of Sept. 30, Texas had the greatest shortage of mental health practitioners in the country, according to the U.S. Department of Health and Human Services (tma.tips/shortage). (See “Supply and Demand,” page 32.) 

And the COVID-19 pandemic “will only exacerbate existing behavioral healthcare shortages, as more Texans seek treatment and support for their mental health and wellbeing due to continued stress and social isolation,” according to a December 2020 report from the Texas Health and Human Services Commission Statewide Behavioral Health Coordinating Council (tma.tips/HHSbehavioralworkforce). 

In addition to staffing challenges, there is also a national shortage of inpatient psychiatric beds, as facilities have cut their capacity to meet social distancing requirements or repurposed psychiatric beds for COVID-19 patients (tma.tips/psychiatricbeds). 

Proof positive  

Behavioral health professionals were early adopters of telemedicine because the specialty relies less on physical exams when it comes to forming a patient-physician relationship, says Dr. Kim, one of the technology’s pioneers and champions.  

Telemedicine also offers unique benefits. 

Without telemedicine, Dr. Kim would not have been able to talk down an actively suicidal patient in a juvenile prison. The patient likely would have been hospitalized and heavily medicated for two weeks.  

Telemedicine also makes it easier for patients with mental health conditions to access care. Dr. Kim cites another one of his patients, a military veteran with post-traumatic stress disorder, who once attended an appointment from his car – while on a hunting trip in the middle of the West Texas desert.  

“Telehealth creates opportunities for care engagement and compliance that conventional models simply cannot replicate,” he said.  

Before the pandemic, physicians who used telemedicine were often marginalized, Dr. Kim says. But now many of his peers have developed a newfound appreciation for the modality, which he likes to say enables him to be in the right place at the right time with the right information.  

Dr. Kim also hopes the recent regulatory changes become permanent to preserve telemedicine’s momentum, likening them to the lifeforce of a functioning telemedicine system. “You can’t take the ‘blood’ out of a care model and say, ‘See? It doesn’t work,’” he said. 

Taking root   

Some physicians, however, fear this metaphorical bloodletting is on the horizon. 

As the pandemic languishes on, some health plans have started to revert to certain prepandemic rules, says TMA Council on Socioeconomics Chair Rodney Young, MD, citing telephone-only telemedicine appointments as an example.  

If such visits are not paid for at the same rate as an in-person visit, many physicians will stop offering them out of financial necessity, robbing patients of a newfound convenience, he says. Elderly patients, in particular, have taken a liking to telephone appointments during the pandemic because they require fewer technological investments than video.  

“It’s serious,” Dr. Young said of the potential consequences.  

A family physician in Amarillo, Dr. Young serves as the first line of defense for his patients with behavioral health issues, such as depression, insomnia, and social phobias. During the pandemic, he’s seen an uptick in the number of patients with such problems as well as the number of telemedicine visits, which are especially well suited for behavioral health care. 

“Like everything else, you do more of it during stressful life circumstances,” he said. 

Although telemedicine has helped advance access to mental health care, particularly since the onset of the pandemic, physicians are clearheaded about its limitations.  

Dr. Kim doesn’t expect behavioral health care to transition entirely to a virtual setting, like he has. “Telehealth is not a silver bullet,” he said.  

But he argues it can be a tool in physicians’ toolbox, one that can help address the psychiatric workforce shortage, as well as the high no-show rates and cancellations that are common when treating such populations.  

Dr. Stark agrees telemedicine is an important way to broaden access to specialty care in a less populated part of the state. Still, there are days when she’d prefer to see patients in person. 

As an addiction psychiatrist, Dr. Stark uses all her senses when meeting with patients. “This is going to sound weird, but I rely on my sense of smell when my patients walk in the room,” she said, explaining that she can often tell if her patient is using cannabis or not practicing good hygiene. 

With patients who are victims of domestic violence, it can be difficult to establish privacy and confidentiality during a virtual appointment, Dr. Stark adds. 

Other patients simply prefer in-person visits. “What we do is so personal, and we ask people to be so vulnerable with us and disclose information,” she said. “Patients notice the difference.”  

Despite telemedicine’s limitations, Dr. Stark hopes it remains an option for her patients, especially those who live far away or who would not otherwise seek psychiatric care because of fear of being stigmatized.  

For now, her policy is to provide telemedicine so long as patients’ health plans cover it. “I worry that it’s not going to be covered the same,” she said. “But I hope it will be.”

Tex Med. 2021;117(11):44-47
November 2021 Texas Medicine Contents
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Last Updated On

January 20, 2022

Originally Published On

October 31, 2021

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Mental Health | Telemedicine

Emma Freer

Reporter

(512) 370-1383
 

Emma Freer is a reporter for Texas Medicine. She previously worked in local news, covering city politics, economic development, and public health. A native Clevelander, she graduated from Columbia Journalism School and the University of St. Andrews.

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