Telehealth - One Year Later

Now that many of us have been exposed to seeing doctors and therapists on Zoom, we have to decide if this technology driven delivery of mental healthcare will continue post-pandemic. The reviews are mixed. It was necessary for a while, but most people with severe mental illness who I know can’t wait to get back into a room with someone who can help. For these people Zoom isn’t working.

But an industry has been born, and it’s unlikely we’ll be going fully back to the types of mental health visits we embraced pre-pandemic.

Orders from most state governors had us stuck inside for much of the last year and our therapists’ offices were (and in most cases still are) closed to in-person sessions.  Therapists and doctors who scrambled to set-up the technology to conduct appointments over the phone and on Zoom still struggle to make connections through technology that is cold and glitchy. 

Yet for many there’s a push to continue therapy through telehealth technology. It’s convenient and lucrative and the demand is overwhelming.

There are companies like BetterHelp and TalkSpace that have mastered this new care delivery system for the technologically adept with the ability to pay. Clinics are closed, but the internet is always open, and I fear that there are lucrative incentives for therapists to cram in appointments, reduce clients to mere thumbnails on a screen, and risk losing the personal connection that can only be gained by sitting together reading each other’s body language and sharing the pauses of reflection that can be attended to when people are together, but lead to awkward silence that must be filled when on-line. 

Even though most providers and many clients have gotten over the unfamiliarity with conducting sessions on-line, there are a slew of regulations that still make such visits difficult, or even illegal.

Typical health insurance companies outsource mental health coverage administration to large behavioral health management companies.  Anyone who’s tried to deal with one of these companies knows they are as anxiety provoking as the fear of Covid-19.

The codes your therapist and/or doctor uses for in-person visits still may lead to a rejected claim when you don’t see them in the office.  Many policies still don’t cover on-line visits at all.  A neighbor has a practice with 40 therapists.  One large administrator is being very cooperative and working hard to make sure everybody gets paid, regardless of where the visit takes place.  The other large administrator isn’t budging at all.

Therapists can only do so much pro bono work, and most clients can’t afford to pay cash for their visits. But for many services, including those provided by new entries to the telehealth and teletherapy field, no insurance is accepted.

Telehealth doctors are available for emergencies with prescriptions, but they cost an average of $49 and often don’t bill through insurance.  One large provider in my city says they are not equipped to change that, and they recommend that people who must bill to private insurance, Medicare, Medicaid, or pay in cash, visit one of their urgent care clinics instead.

Medicare and Medicaid have adjusted their policies to allow for payment to telehealth providers, but that doesn’t mean the providers have been able to fully set up the administrative functions to accept such coverage.  Many are still turning away people who seek third-party payment.

Federal and state regulators have been scrambling for a year to change policies that limit private insurance companies from covering telephone therapy sessions, but again for most practices this is all new and few are prepared, as much as they try, to make quick changes.

The therapists and their administrative staff are working from home and communication aimed at making major changes is difficult.  Plus, therapists rightly want to do therapy, not get tied up in back office tasks.

Then there’s HIPPA.  HIPPA regulations prohibit much information transmission through telephone and on-line visits because this communication is not secure.  Privacy violations are risky and possible.  However, Health and Human Services has issued an exemption from this regulation for many telehealth providers.  You can see that memo here.

It’s not entirely clear how this memo impacts psychiatrists and psychotherapists.

Finally, state licensing of therapists can be an obstacle.  Many cities are on the border between two or more states.  If you see a therapist in the state you work in, but are now working from home in a different state, it is very possible your therapist is not licensed in the state in which you reside.  If that’s the case, they can’t legally treat and bill you while you’re out of state.  Even over the phone.

As in so many industries, the technology that makes new forms of healthcare possible is way out in front of the regulations.  If there is any positive in the coronavirus pandemic, it’s that catching these regulations up with the technology available, or even easing such regulations, is happening at a quickening pace.

But at such a pace mistakes will surely be made and new holes will open up through which those with severe mental illness will fall.  As with so much else in mental healthcare these systems favor the worried well, those with the ability to pay who place little demand on healthcare infrastructure and enthusiastically fill their prescriptions. We’ll see how clinics change as they reopen, and we’ll see how those who can’t afford or operate the technology that this bifurcated system of healthcare delivery demands fare as Covid 19 fades and severe mental illness grinds on.

Men at Work and Mental Health

I wrote a post for the International Bipolar Foundation about the occurrence of mood disorders in male dominated industries. Unique patterns and challenges emerge in less diverse situations, especially when it comes to whether a worker will seek treatment or not. Please read the post here.