More on Telehealth

COVID-19 forced psychiatric care online, and patients want it to stay

The modality has proven popular with many patients, but policy and reimbursement uncertainties remain as challenges.

Jeff Lagasse, Associate Editor

A year ago, trying to find patients who would agree to see their University of Michigan mental health provider through a video screen felt like pulling teeth. Only 26 video visits with a few early adopters had happened in nearly six months, compared with more than 30,000 in-person visits.

But Dr. Jennifer Severe, one of the three psychiatrists who helped launch a test of telehealth initiatives in U-M's outpatient psychiatry clinic, wasn't about to give up. She prepared to give a talk at the beginning of April of 2020, hoping to convince more of her colleagues to give telepsychiatry a try now that a major insurance company was paying for it. She even had examples of how clinic staff had "rescued" the care of patients who had called at the last minute to cancel an appointment for their depression or bipolar disorder, but agreed to a video therapy session instead.

Severe never got to give that talk. Instead, on March 23, all nonurgent healthcare across the state of Michigan shut down to prevent the spread of COVID-19. And video chats and phone calls became the only way for most patients to connect with their psychiatrists and psychologists from Michigan Medicine, U-M's academic medical center. For nearly all of those patients, it has stayed that way for the past nine months.

Now, a new study led by Severe suggests that more than half of those patients will want to keep going with virtual mental healthcare even after the pandemic subsides.

According to the new findings published in JMIR Formative Research, the convenience of seeing a provider without leaving home, and avoiding potential exposure to the coronavirus especially for those with other underlying health concerns, factor heavily into this preference. So does a patient's initial experience with seeing a provider virtually.


The data comes from a summer 2020 phone survey of 244 patients or parents of patients who'd had appointments scheduled with a U-M mental health provider in the first weeks of the pandemic-related shutdown. Nearly 83% decided to have their or their child's first pandemic-era appointment through a video chat instead.

But the study also suggests a need for special attention to the minority of patients who initially chose to continue psychiatric care through telephone calls.

Though this accounted for less than 14% of the study population, they were more likely to be over the age of 45. By summer, they were much less likely to want to receive mental healthcare remotely in the future.

As health insurers and government agencies make decisions about whether and how to pay mental health providers for virtual care in the short term and long term, the new data could help inform them and open up opportunities to improve continuity and access to care. Policy and reimbursement decisions will be important in that regard.

Nearly all the patients in the group who had a virtual visit by summer said it went as well as they had expected or better.

Mental health services have been one of the bigger drivers of telehealth use over the past year, being used more often for behavioral health than for medical care, according to a new RAND study.

Between mid-March and early May 2020, telehealth was used by more than 40% of patients with a chronic physical health condition and by more than 50% of those with a behavioral health condition, according to findings published in the Journal of General Internal Medicine.

In a finding with important implications for the future of telehealth, researchers also found that during the pandemic a large majority of telehealth users connected with their own doctor rather than a new or unfamiliar doctor. Prior to the pandemic, patients frequently were reluctant to use telehealth because it often meant seeing a provider other than their own physician, the study said.

The JMIR study does not cover the period after Dr. Mary Carol Blazek, the study's senior author, led the development of a program called GET Access, which helps older adults prepare for video visits with a geriatric psychiatry specialist. Michigan Medicine also now offers assistance for any patient with a scheduled appointment to help them set up their online patient portal account and test the video visit technology within it.

Parents of children receiving mental health or behavioral health care from Department of Psychiatry providers especially noted that video visits were more engaging. Phone-visit patients said it was important to have the option to talk when their Internet connection was unstable or they had trouble with the video platform. One-third said they were just more comfortable talking by phone.


Although the new paper does not examine clinic appointment cancellation and no-show rates, anecdotal evidence suggests that it has come down substantially from a one-in-four rate before the pandemic.

Whether it's the debilitating effect of their mental health condition, or their access to transportation, time off from work or childcare, many factors can get in the way of a patient making it to an in-person appointment, authors said. But virtual visits remove most of these barriers.

Cost poses another potential barrier for phone-based care. In the test-run months before COVID-19, insurers wouldn't typically cover phone calls, leaving the provider to absorb the cost or to ask patients to pay out of pocket to talk on the phone with their provider.

Insurers covered phone-based mental health care for much of 2020, but it's unknown at this point how long that will last. But Severe said that for certain patients with an established relationship with their mental health provider, phone and video appointments are equally effective and should receive similar reimbursement from insurers. Both modalities offer opportunity for a blended care model bridging in-person sessions with virtual visits as deemed appropriate.


In October 2020, a survey from leading healthcare cybersecurity firm CynergisTek revealed that nearly half of Americans, 46%, would embrace telehealth widely for mental health and therapy sessions, but still worry about their behavioral health data being exposed by hackers.

Attitudes towards telehealth, especially in mental healthcare, have shifted dramatically as Americans increasingly seek out virtual visits with behavioral health professionals. When considering telehealth use for nonurgent care, Americans would most likely consider using it for mental health sessions (46%), followed by chronic care check-ups (29%) and annual physical and children's wellness exams (27%).

When drilling down into other key groups, it was discovered that millennials, GenXers and females are more receptive than other Americans to using telehealth solutions for a mental health session (54%, 50% and 52% respectively). Baby boomers and men were less enthusiastic about using teletherapy: Only 34% of boomers and 40% of men reported they'd consider using telehealth for mental healthcare counseling.

Twitter: @JELagasse
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