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In recent years, many states have seen an increase in the prevalence of behavioral health diagnoses and challenges in treatment access. At the same time, the health care delivery system has increasingly relied on telehealth. Given the importance of behavioral health care and the desire of state policymakers to improve outcomes, leaders should consider the effectiveness of various behavioral health treatments delivered via synchronous telehealth.
While the COVID-19 pandemic has prompted numerous, often temporary, telehealth policy changes across the health care field, some states and health care organizations already had robust telehealth policies in place. As health care leaders and organizations consider extending or making these new telehealth policies permanent, they should consider the lessons learned from existing programs.
This brief provides summary findings from a 2019, pre-pandemic review of the evidence of telebehavioral health’s effectiveness on key clinical outcomes. It also describes the programmatic structure and relevant telebehavioral health policies of three programs: Texas Medicaid, Massachusetts Medicaid, and the Portland Veterans Affairs Medical Center Rural Telemental Health Program (VA RTMH).
More than 50% of Americans will be diagnosed with a mental health disorder such as anxiety or depression during their lifetime, with one in five US adults experiencing a mental illness in a given year.3-5 Approximately 21 million Americans have a substance use disorder (SUD) related to alcohol, opioids, or other drugs.6 Population-based surveys suggest one in six US children aged two to eight years has a mental, behavioral, or developmental disorder.7
Despite the ubiquity of mental and behavioral health conditions, access to treatment is often out of reach, particularly for children and adolescents. Sixty-five percent of nonmetropolitan counties in the US do not have a psychiatrist, and there are often shortages of both nonpsychiatric and psychiatric care professionals in rural geographic areas.8 While primary care clinicians provide substantial amounts of behavioral health care, they often report difficulties obtaining specialist mental health referrals for rural and low-income patients.9,10 Even with sufficient staffing, providers may be unable to deliver the right services, such as acute and crisis care. Furthermore, only a small proportion of individuals with SUD receive treatment, a reflection of the shortage of SUD treatment providers.6 This treatment gap is particularly evident among vulnerable populations including racial and ethnic minorities, children, rural communities, and individuals with special health care needs.7 Telehealth may have the ability to fill at least some of these gaps in access to care.
The telehealth policy and reimbursement landscape continue to evolve, particularly with changes occurring in the wake of the COVID-19 pandemic. Still, prior to COVID-19, Medicaid fee-for-service provided reimbursement for some forms of live video telehealth in 49 states and Washington, DC.11
No study found behavioral health treatment delivered by synchronous telehealth to be worse than or harmful in comparison to behavioral health treatment delivered in-person.12-36 However, no studies evaluated the effects of long-term telebehavioral health treatment, and there were few studies in children.
States can cover telebehavioral health as a treatment modality, meaning that they cover certain services regardless of how they are delivered, or as a separate benefit, where the state specifically defines its coverage of telehealth treatment (e.g., cover telehealth but only for particular conditions or under certain circumstances). Below, we describe examples of both approaches from three states: Texas, Massachusetts, and Oregon. In all three states, the major impetus for developing telebehavioral health programs was to address health professional shortages and reduce treatment barriers related to patient location.40,41
While Texas and Massachusetts’s Medicaid policies were authorized using different mechanisms, Texas legislatively in 200537 and Massachusetts administratively in 2019,38,39 both states treat telebehavioral health as a treatment modality, not as a distinct, separately covered service.1*,2* In contrast, the Portland Veterans Affairs Medical Center (Portland VA) created its telebehavioral health program, Rural Telemental Health (RTMH), in 2009 for patients living in rural areas of Oregon as a separate specialty program.3*
There are minimal differences between in-person and remotely delivered services, regardless of modality or separate benefit designation.38,39,42
The Texas and Massachusetts Medicaid programs both provide:
Implementation nuances remain for telebehavioral health services:
All three programs (Texas, Mass., VA RTMH) permit a wide range of services to be delivered through telebehavioral health including:4*,38,47-50
Considerations for prescribing of controlled substances include:
All three programs permitted a patient’s home to serve as an originating site for telemedicine, ensuring patients did not have to travel to a practitioner’s office or medical facility.37-39,49,50 The Texas and Massachusetts Medicaid programs had very few, if any, restrictions on patient site location.
Policy considerations for allowed sites include:
All three programs provided limited direction on technological requirements and did not provide funding for equipment or technology for patients or providers. 4*,38,39,49
The broad guidance for providers includes: 4*,38,39,49
The establishment of permanent telebehavioral health policies, developed prior to COVID-19 by the Texas and Massachusetts Medicaid programs and Portland VA RTMH program, provides important lessons for states and health care organizations to consider when planning for their own long-term implementation of similar policies. States should consider these findings in the context of their unique regulatory environments.
Texas and Massachusetts Medicaid staff emphasized that the assessment of remotely delivered services is critical and both programs have a modifier code to denote remote delivery of services.38,39,49 In Texas, the first external evaluation is underway and will report cost savings; recommend future data collection elements; and develop a methodology to evaluate the cost-effectiveness, clinical efficacy, and utilization of remotely delivered services.
Texas Medicaid regularly administers stakeholder surveys and has regular, standardized legislative reporting on its remote delivery services, which includes:37
Texas Medicaid staff noted some current data collection limitations and suggested states consider the following program improvements:
Among all three programs, there were no differences in audit or oversight requirements for remotely delivered and in-person services.38,39 Remotely delivered services were simply included in any regular audit activities and were not overseen separately.
Staffing requirements among the three programs depended on the scope and type of service included in the telebehavioral health program. Policies that treated telebehavioral health as a delivery modality were usually implemented with existing staffing. However, separate telebehavioral health programs required distinct staffing.
In light of the restrictions on in-person access to health care resulting from COVID-19, many states and health care organizations may consider making temporary telebehavioral health policies permanent. A pre-pandemic review of the evidence and policies from three existing programs provides key considerations for policymakers:
These findings are promising for the adoption of permanent policies. In addition to the evidence on effectiveness, policymakers should consider implementation nuances and the underlying motivations and expectations behind such policies. Cost savings and increased service utilization are of particular interest, however, the evidence in these two areas is unclear and requires additional research. A large expansion of telebehavioral health services could provide the needed impetus, and volume, to properly explore their impact on costs and service utilization.
1* Texas Medicaid staff, personal communication 2* Massachusetts Medicaid staff, personal communication 3* VA RTMH staff, personal communication 4* VA RTMH staff, personal communication
1Uscher-Pines L, Bouskill KE, Sousa J, Shen M, Fischer SH, RAND Corporation. Experiences of Medicaid programs and health centers in implementing telehealth. 2019. https://www.rand.org/pubs/research_reports/RR2564.html. Accessed November 18, 2019. 2Bennett A, Lazur B, King V. Telehealth in the home: evidence, policy, and practice Portland, OR: Oregon Health & Science University; 2018. 3Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007; 6(3): 168-176. 4Centers for Disease Control and Prevention. Learn about mental health. https://www.cdc.gov/mentalhealth/learn/index.htm. Accessed January 28, 2020. 5Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2015 national survey on drug use and health. 2015. https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.htm. Accessed January 28, 2020. 6Huskamp HA, Busch AB, Souza J, et al. How is telemedicine being used In opioid and other substance use disorder treatment? Health Aff (Millwood). 2018; 37(12): 1940- 1947. doi: https://dx.doi.org/10.1377/hlthaff.2018.05134. 7So M, McCord RF, Kaminski JW. Policy levers to promote access to and utilization of children’s mental health ser-vices: a systematic review. Adm Policy Ment Health. 2019; 46(3): 334-351. doi: https://dx.doi.org/10.1007/s10488-018-00916-9. 8Andrilla CHA, Patterson DG, Garberson LA, Coulthard C, Larson EH. Geographic variation in the supply of selected behavioral health providers. Am J Prev Med. 2018; 54(6 suppl 3): S199-S207. doi: 10.1016/j.amepre.2018.01.004. 9Cook NL, Hicks LS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access to specialty care and medical services in community health centers. Health Aff (Millwood). 2007; 26(5): 1459-1468. doi: 10.1377/hlthaff.26.5.1459. 10Rust G, Daniels E, Satcher D, Bacon J, Strothers H, Bornemann T. Ability of community health centers to obtain mental health services for uninsured patients. JAMA. 2005; 293(5): 554- 556. doi: 10.1001/jama.293.5.554-c. 11Center for Connected Health Policy. State telehealth laws and reimbursement policies. 2019. https://www.cchpca. org/sites/default/files/2019-10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20 Report%20Fall%202019%20FINAL.pdf?utm_source=Telehealth+Enthusiasts&utm_campaign=1c42d90c8e-EMAIL_ CAMPAIGN_2019_10_21_11_19&utm_medium=email&utm_term=0_ae00b0e89a-1c42d90c8e-353242231. Accessed October 25, 2019. 12Morriss R, Patel S, Malins S, et al. Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial. BMC Med. 2019; 17(1): 16. doi: 10.1186/s12916-019-1253-5. 13Pande RL, Morris M, Peters A, Spettell CM, Feifer R, Gillis W. Leveraging remote behavioral health interventions to improve medical outcomes and reduce costs. Am J Manag Care. 2015; 21(2): e141- 151. 14Khatri N, Marziali E, Tchernikov I, Shepherd N. Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: a pilot study. Clin Interv Aging. 2014; 9: 765- 770. doi: 10.2147/CIA.S57832. 15Crowe T, Jani S, Jani S, Jani N, Jani R. A pilot program in rural telepsychiatry for deaf and hard of hearing populations. Heliyon. 2016; 2(3): e00077. doi: 10.1016/j.heliyon.2016.e00077. 16Berryhill MB, Culmer N, Williams N, et al. 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Telemed J E Health. 2013; 19(3): 192- 199. doi: 10.1089/tmj.2012.0108. 36Yeung A, Martinson MA, Baer L, et al. The effectiveness of telepsychiatry-based culturally sensitive collaborative treatment for depressed Chinese American immigrants: a randomized controlled trial. J Clin Psychiatry. 2016; 77(8): e996- e1002. doi: 10.4088/JCP.15m09952. 37Texas Health and Human Services Commission. Telemedicine, telehealth, and home telemonitoring services in Texas Medicaid. 2018. https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presenta-tions/2018/sb-789-telemedicine-telehealth-hts-medicaid-dec-2018.pdf. Accessed September 30, 2019. 38Tsai D. MassHealth all provider bulletin 281: Access to behavioral health services through use of telehealth options. 2019. https://www.mass.gov/files/documents/2019/01/23/all-provider-bulletin-281.pdf. Accessed October 29, 2019. 39Tsai D. MassHealth managed care entity bulletin 10: Access to behavioral health services through use of telehealth options. 2019. https://www.mass.gov/files/documents/2019/01/23/managed-care-entity-10.pdf. Accessed October 29, 2019. 40MassHealth-executive office of health and human services. MassHealth expands access to behavioral health care for members through telehealth. 2019. https://www.mass.gov/news/masshealth-expands-access-to-behavioral-health-care-for-members-through-telehealth. Accessed October 29, 2019. 41Rural Health Information Hub. Rural telemental health (RTMH) program. 2018. https://www.ruralhealthinfo.org/proj-ect-examples/916. Accessed November 25, 2019. 42Texas Legislature Online. Senate bill 1107, Relating to telemedicine and telehealth services. 2017. https://capitol. texas.gov/tlodocs/85R/billtext/pdf/SB01107F.pdf#navpanes=0. Accessed September 30, 2019. 43Texas Secretary of State. Texas administrative code, title 1, part 15, chapter 355, subchapter g, rule 355.7001, Reimbursement methodology for telemedicine, telehealth, and home telemonitoring services. 2017. https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=196382&p_tloc=&p_ploc=1&pg=11&p_ tac=&ti=1&pt=15&ch=355&rl=7001. Accessed September 30, 2019. 44Texas Statute. Government code, title 4, subtitle i, chapter 531, subchapter a, section 531.0217, Reimbursement for certain medical consultations, subsection 2d. 2019. https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm. Accessed September 30, 2019. 45Texas Medicaid & Healthcare Partnership. Texas Medicaid provider procedures manual October 2019: Behavioral health and case management services handbook. 2019. http://www.tmhp.com/Manuals_PDF/TMPPM/TMPPM_Liv-ing_Manual_Current/2_Behavioral_Health.pdf. Accessed September 30, 2019. 46Texas Legislature Online. 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