Expansion of Telehealth Availability for Mental Health Care After State-Level Policy Changes From 2019 to 2022.

Importance: Although telehealth services expanded rapidly during the COVID-19 pandemic, the association between state policies and telehealth availability has been insufficiently characterized. Objective: To investigate the associations between 4 state policies and telehealth availability at outpatient mental health treatment facilities throughout the US. Design, Setting, and Participants: This cohort study measured whether mental health treatment facilities offered telehealth services each quarter from April 2019 through September 2022. The sample comprised facilities with outpatient services that were not part of the US Department of Veterans Affairs system. Four state policies were identified from 4 different sources. Data were analyzed in January 2023. Exposures: For each quarter, implementation of the following policies was indexed by state: (1) payment parity for telehealth services among private insurers; (2) authorization of audio-only telehealth services for Medicaid and Children's Health Insurance Program (CHIP) beneficiaries; (3) participation in the Interstate Medical Licensure Compact (IMLC), permitting psychiatrists to provide telehealth services across state lines; and (4) participation in the Psychology Interjurisdictional Compact (PSYPACT), permitting clinical psychologists to provide telehealth services across state lines. Main Outcome and Measures: The primary outcome was the probability of a mental health treatment facility offering telehealth services in each quarter for each study year (2019-2022). Information on the facilities was obtained from the Mental Health and Addiction Treatment Tracking Repository based on the Substance Abuse and Mental Health Services Administration Behavioral Health Treatment Service Locator. Separate multivariable fixed-effects regression models were used to estimate the difference in the probability of offering telehealth services after vs before policy implementation, adjusting for characteristics of the facility and county in which the facility was located. Results: A total of 12 828 mental health treatment facilities were included. Overall, 88.1% of facilities offered telehealth services in September 2022 compared with 39.4% of facilities in April 2019. All 4 policies were associated with increased odds of telehealth availability: payment parity for telehealth services (adjusted odds ratio [AOR], 1.11; 95% CI, 1.03-1.19), reimbursement for audio-only telehealth services (AOR, 1.73; 95% CI, 1.64-1.81), IMLC participation (AOR, 1.40, 95% CI, 1.24-1.59), and PSYPACT participation (AOR, 1.21, 95% CI, 1.12-1.31). Facilities that accepted Medicaid as a form of payment had lower odds of offering telehealth services (AOR, 0.75; 95% CI, 0.65-0.86) over the study period, as did facilities in counties with a higher proportion (>20%) of Black residents (AOR, 0.58; 95% CI, 0.50-0.68). Facilities in rural counties had higher odds of offering telehealth services (AOR, 1.67; 95% CI, 1.48-1.88). Conclusion and Relevance: Results of this study suggest that 4 state policies that were introduced during the COVID-19 pandemic were associated with marked expansion of telehealth availability for mental health care at mental health treatment facilities throughout the US. Despite these policies, telehealth services were less likely to be offered in counties with a greater proportion of Black residents and in facilities that accepted Medicaid and CHIP.

Trends in Methadone Dispensing for Opioid Use Disorder After Medicare Payment Policy Changes.

Importance: A significant proportion of Medicare beneficiaries have a diagnosed opioid use disorder (OUD). Methadone and buprenorphine are both effective medications for the treatment of OUD (MOUDs); however, Medicare did not cover methadone until 2020. Objective: To examine trends in methadone and buprenorphine dispensing among Medicare Advantage (MA) enrollees after 2 policy changes in 2020 related to methadone access. Design, Setting, and Participants: This cross-sectional analysis of temporal trends in methadone and buprenorphine treatment dispensing assessed MA beneficiary claims from January 1, 2019, through March 31, 2022, captured by Optum's Clinformatics Data Mart. Of 9 870 791 MA enrollees included in the database, 39 252 had at least 1 claim for methadone, buprenorphine, or both during the study period. All available MA enrollees were included. Subanalyses by age and dual eligibility for Medicare and Medicaid status were conducted. Exposures: Study exposures were (1) the Centers for Medicare & Medicaid Services (CMS) Medicare bundled payment reimbursement policy for OUD treatment and (2) the Substance Abuse and Mental Health Administration and CMS Medicare policies designed to facilitate access to treatment for OUD, specifically during the COVID-19 pandemic. Main Outcomes and Measures: Study outcomes were trends in methadone and buprenorphine dispensing by beneficiary characteristics. National methadone and buprenorphine dispensing rates were calculated as claims-based dispensing rates per 1000 MA enrollees. Results: Among the 39 252 MA enrollees with at least 1 MOUD dispensing claim (mean age, 58.6 [95% CI, 58.57-58.62] years; 45.9% female), 195 196 methadone claims and 540 564 buprenorphine pharmacy claims were identified, for a total of 735 760 dispensing claims. The methadone dispensing rate for MA enrollees was 0 in 2019 because the policy did not allow any payment until 2020. Claims rates per 1000 MA enrollees were low initially, increasing from 0.98 in the first quarter of 2020 to 4.71 in the first quarter of 2022. Increases were primarily associated with dually eligible beneficiaries and beneficiaries younger than 65 years. National buprenorphine dispensing rates were 4.64 per 1000 enrollees in quarter 1 of 2019, increasing to 7.45 per 1000 enrollees in quarter 1 of 2022. Conclusions and Relevance: This cross-sectional study found that methadone dispensing increased among Medicare beneficiaries after the policy changes. Rates of buprenorphine dispensing did not provide evidence that beneficiaries substituted buprenorphine for methadone. The 2 new CMS policies represent an important first step in increasing access to MOUD treatment for Medicare beneficiaries.

Availability and Accessibility of Mental Health Services in New York City.

Mental health services are critical components of public health infrastructure that provide essential supports to people living with psychiatric disorders. In a typical year, about 20 percent of people will have a psychiatric disorder, and about 5 percent will experience serious psychological distress, indicating a potentially serious mental illness. Nationally, the use of mental health services is low, and the use of care is not equitably distributed. In the United States as a whole and in New York City (NYC), non-Hispanic white individuals are more likely to use mental health services than non-Hispanic black individuals or Hispanic individuals. The challenges of ensuring the availability of mental health services for all groups in NYC are particularly acute, given the size of the population and its diversity in income, culture, ethnicity, and language. Adding to these underlying challenges, the coronavirus disease 2019 (COVID-19) pandemic has disrupted established patterns of care. To advance policy strategy for addressing gaps in the mental health services system, RAND researchers investigate the availability and accessibility of mental health services in NYC. The RAND team used two complementary approaches to address these issues. First, the team conducted interviews with a broad group of professionals and patients in the mental health system to identify barriers to care and potential strategies for improving access and availability. Second, the team investigated geographic variations in the availability of mental health services by compiling and mapping data on the locations and service characteristics of mental health treatment facilities in NYC.

The Impact of the COVID-19 Pandemic and Policy Responses on Excess Mortality

As a way of slowing COVID-19 transmission, many countries and U.S. states implemented shelter-in-place (SIP) policies. However, the effects of SIP policies on public health are a priori ambiguous as they might have unintended adverse effects on health. The effect of SIP policies on COVID-19 transmission and physical mobility is mixed. To understand the net effects of SIP policies, we measure the change in excess deaths following the implementation of SIP policies in 43 countries and all U.S. states. We use an event study framework to quantify changes in the number of excess deaths after the implementation of a SIP policy. We find that following the implementation of SIP policies, excess mortality increases. The increase in excess mortality is statistically significant in the immediate weeks following SIP implementation for the international comparison only and occurs despite the fact that there was a decline in the number of excess deaths prior to the implementation of the policy. At the U.S. state-level, excess mortality increases in the immediate weeks following SIP introduction and then trends below zero following 20 weeks of SIP implementation. We failed to find that countries or U.S. states that implemented SIP policies earlier, and in which SIP policies had longer to operate, had lower excess deaths than countries/U.S. states that were slower to implement SIP policies. We also failed to observe differences in excess death trends before and after the implementation of SIP policies based on pre-SIP COVID-19 death rates.

The Impact of the COVID-19 Pandemic and Policy Response on Health Care Utilization: Evidence from County-level Medical Claims and Cellphone data

The COVID-19 pandemic has forced federal, state and local policymakers to respond by legislating, enacting, and enforcing social distancing policies. However, the impact of these policies on healthcare utilization in the United States has been largely unexplored. We examine the impact of county-level shelter in place ordinances on healthcare utilization using two unique datasets—employer-sponsored insurance for over 6 million people in the US and cell phone location data. We find that introduction of these policies was associated with reductions in the use of preventive care, elective care, and the number of weekly visits to physician offices and hospitals. However, controlling for county-level exposure to the COVID-19 pandemic reduces the impact of these policies. Our results imply that while social distancing policies do lead to reductions in healthcare utilization, much of these reductions would have occurred even in the absence of these policies.

Back to School: The Effect of School Visits During COVID-19 on COVID-19 Transmission

Schools across the United States and the world have been closed in an effort to mitigate the spread of COVID-19. However, the effect of school closure on COVID-19 transmission remains unclear. We estimate the causal effect of changes in the number of weekly visits to schools on COVID-19 transmission using a triple difference approach. In particular, we measure the effect of changes in county-level visits to schools on changes in COVID-19 diagnoses for households with school-age children relative to changes in COVID-19 diagnoses for households without school-age children. We use a data set from the first 46 weeks of 2020 with 130 million household-week level observations that includes COVID-19 diagnoses merged to school visit tracking data from millions of mobile phones. We find that increases in county-level in-person visits to schools lead to an increase in COVID-19 diagnoses among households with children relative to households without school-age children. However, the effects are small in magnitude. A move from the 25th to the 75th percentile of county-level school visits translates to a 0.3 per 10,000 household increase in COVID-19 diagnoses. This change translates to a 3.2 percent relative increase. We find larger differences in low-income counties, in counties with higher COVID-19 prevalence, and at later stages of the COVID-19 pandemic.

Who Is (and Is Not) Receiving Telemedicine Care During the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic has forced telehealth to be the primary means through which patients interact with their providers. There is a concern that the pandemic will exacerbate the existing disparities in overall healthcare utilization and telehealth utilization. Few national studies have examined the changes in telehealth use during the COVID-19 pandemic. METHODS: Data on 6.8 and 6.4 million employer-based health plan beneficiaries in 2020 and 2019, respectively, were collected in 2020. Unadjusted rates were compared both before and after the week of the declaration of the COVID-19 pandemic as a national emergency. Trends in weekly utilization were also examined using a difference-in-differences regression framework to quantify the changes in telemedicine and office-based care utilization while controlling for the patient's demographic and county-level sociodemographic measures. All analyses were conducted in 2020. RESULTS: More than a 20-fold increase in the incidence of telemedicine utilization after March 13, 2020 was observed. Conversely, the incidence of office-based encounters declined by almost 50% and was not fully offset by the increase in telemedicine. The increase in telemedicine was greatest among patients in counties with low poverty levels (ß=31.70, 95% CI=15.17, 48.23), among patients in metropolitan areas (ß=40.60, 95% CI=30.86, 50.34), and among adults than among children aged 0-12 years (ß=57.91, 95% CI=50.32, 65.49). CONCLUSIONS: The COVID-19 pandemic has affected telehealth utilization disproportionately on the basis of patient age and both the county-level poverty rate and urbanicity.

Availability of Outpatient Telemental Health Services in the United States at the Outset of the COVID-19 Pandemic.

BACKGROUND: Since coronavirus disease 2019 (COVID-19) has caused dramatic changes in everyday life, a major concern is whether patients have adequate access to mental health care despite shelter-in-place ordinances, school closures, and social distancing practices. OBJECTIVES: The aim was to examine the availability of telehealth services at outpatient mental health treatment facilities in the United States at the outset of the COVID-19 pandemic, and to identify facility-level characteristics and state-level policies associated with the availability. RESEARCH DESIGN: Observational cross-sectional study. SUBJECTS: All outpatient mental health treatment facilities (N=8860) listed in the Behavioral Health Treatment Services Locator of the Substance Abuse and Mental Health Services Administration on April 16, 2020. MEASURES: Primary outcome is whether an outpatient mental health treatment facility reported offering telehealth services. RESULTS: Approximately 43% of outpatient mental health facilities in the United States reported telehealth availability at the outset of the pandemic. Facilities located in the United States South and nonmetropolitan counties were more likely to offer services, as were facilities with public sector ownership, those providing care for both children and adults, and those accepting Medicaid as a form of payment. Outpatient mental health treatment facilities located in states with state-wide shelter-in-place laws were less likely to offer telehealth, as well as facilities in counties with more COVID-19 cases per 10,000 population. CONCLUSIONS: At the onset of the COVID-19 pandemic, fewer than half of outpatient mental health treatment facilities were providing telehealth services. Our results suggest that additional policies to promote telehealth may be warranted to increase availability over the course of the COVID-19 pandemic.