A spotlight has been shone on mental health services during the past year, and with good reason: With the COVID-19 pandemic creating an isolating effect for millions of Americans, people need it.
Telehealth has helped to connect people to qualified clinicians, but now the question remains how to retain and expand access to care for those seeking behavioral healthcare.
It's a pressing issue, with a recent study showing that mental health services were the most common use of telehealth during the early days of the pandemic. In the midst of skyrocketing depression rates, the findings show that more patients used telehealth for behavioral rather than physical conditions.
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This shift to telehealth, particularly video, was enabled by time-limited, regulatory changes related to reimbursement, privacy standards for telehealth technology, and licensure. Lessons from utilization during this period can inform policy for the post-COVID-19 era.
Importantly, measures will be needed to ensure equity of access, particularly for behavioral healthcare as education, age and gender were all associated with use. Lack of health insurance may also affect telehealth use.
Dr. Benjamin Miller of Well Being Trust is a nationally-recognized mental health expert who has not only served as an advisor to presidential campaigns, states and health systems, but has also worked as a primary care psychologist and an adjunct professor at Stanford School of Medicine. Miller has extolled the virtues of behavioral care, highlighting evidence that it gives people the tools to cope with life's problems.
Yet he acknowledges one of the issues inherent in seeking such care through telehealth: Access is uneven.
"We do run the risk of further enhancing or increasing disparities through certain technologies," said Miller. "Not every community has broadband. Not all communities will have the capacity to call in and have a safe environment where they can talk to a clinician."
A CHANGE IN POLICY
Compounding the issue is that the healthcare system is often cumbersome for patients – with insurance, transportation and food security all factoring into the issue of access. In Miller's mind, there's been an error in policy whereby the current thinking is that the best way to expand access is by having more clinicians. Not so, he said. There are more structural problems that people face that hinder access in the first place.
"The best way to expand access is to make sure that care is where people show up with need," he said. "If you think about those places where people show up, it's home, school, the criminal justice system. Why would we not think about diverting them from that system? We have to think about bringing those mental health clinicians to where people are. And then there's employers, where we go to work. Employers have a major role in making sure employees have access to mental healthcare."
There need to be clear pathways for people to access the system, and telehealth has played an important role in that. Apps, phone calls and even using a dedicated mental health platform are all contributing to a slowly improving access picture.
But much of what has allowed telehealth to flourish is based in temporary allowances. The Centers for Medicare and Medicaid Services, for example, has allowed telehealth to be reimbursed at the same rate as in-person visits and has allowed clinicians to practice outside of their normal networks, spreading their research into communities that may have previously been cut off from these services.
These are all temporary solutions set to expire at the end of the public health emergency, meaning more permanent change needs to take place before true parity is achieved.
"It needs to come from policy," said Miller. "If we just put more money into the system, we're only going to have what we've got. Industry is responsive to policy. It helps change those things so we're moving in a different direction. It helps us to regulate, which I actually think is not a bad idea. It gives us standards so we know what to expect."
Mental health parity isn't a new idea. It's been on the books for about a decade and requires insurers to treat behavioral health as primary care, but it's often not enforced properly. It could be strengthened mightily and have a huge impact.
How care is paid for is another factor. Paying for care, said Miller, is the most substantial barrier for why certain clinicians don't do things for certain patients, while reform in this regard could free them up to do things more creatively and in more of a team-based fashion.
"I think there's a huge role for policymakers at every level to step up and offer a new vision for what excellence around mental health should be," said Miller. "Now, it's not working properly and we're suffering because of it."
What the Biden Administration could do now, he said, is to use an executive order to make permanent some of the temporary allowances in regards to telehealth, and he fully expects the White House to do so.
The loosening of restrictions around who can see which provider and when has been a boon not just for the business of behavioral health, but also for behavioral healthcare patients themselves.
"Literally overnight, we decided we wanted to embrace this, and now it's here," said Miller. "I think that's a positive trend, instead of what we had for decades, which is asking people in their most difficult time of need to go through multiple hoops of fire. We're making it easier."