Telehealth and In-Person Behavioral Health Services in Rural Communities Before and During the COVID-19 Pandemic: Multisite Prospective Cohort Study.

BACKGROUND: The COVID-19 pandemic triggered widespread adjustments across the US health care system. Telehealth use showed a substantial increase in mental health conditions and services due to acute public health emergency (PHE) behavioral health needs on top of long-standing gaps in access to behavioral health services. How health systems that were already providing behavioral telehealth services adjusted services and staffing during this period has not been well documented, particularly in rural areas with chronic shortages of behavioral health providers and services. OBJECTIVE: This study investigates patient and treatment characteristic changes from before the COVID-19 PHE to during the PHE within both telehealth and in-person behavioral health services provided in 95 rural communities across the United States. METHODS: We used a nonrandomized, prospective, multisite research design involving 2 active treatment groups. The telehealth cohort included all patients who initiated telehealth treatment regimens during the data collection period. A comparison group included a cohort of patients who initiated in-person treatment regimen. Patient enrollment occurred on a rolling basis, and data collection was extended for 3 months after treatment initiation for each patient. Chi-square tests compared changes from pre-PHE to PHE time periods within telehealth and in-person treatment cohorts. The dependent measures included patient diagnosis, clinicians providing treatment services, and type of treatment services provided at each encounter. The 4780 patients in the telehealth cohort and the 6457 patients in the in-person cohort had an average of 3.5 encounters during the 3-month follow-up period. RESULTS: The encounters involving anxiety, dissociative, and stress-related disorders in the telehealth cohort increased from 30% (698/2352) in the pre-PHE period to 35% (4632/12,853) in the PHE period (P<.001), and encounters involving substance use disorders in the in-person cohort increased from 11% (468/4249) in the pre-PHE period to 18% (3048/17,047) in the PHE period (P<.001). The encounters involving treatment service codes for alcohol, drug, and medication-assisted therapy in the telehealth cohort increased from 1% (22/2352) in the pre-PHE period to 11% (1470/13,387) in the PHE period (P<.001); likewise, encounters for this type of service in the in-person cohort increased from 0% (0/4249) in the pre-PHE period to 16% (2687/17,047) in the PHE period (P<.001). From the pre-PHE to the PHE period, encounters involving 60-minute psychotherapy in the telehealth cohort increased from 8% (190/2352) to 14% (1802/13,387; P<.001), while encounters involving group therapy in the in-person cohort decreased from 12% (502/4249) to 4% (739/17,047; P<.001). CONCLUSIONS: The COVID-19 pandemic challenged health service providers, and they adjusted the way both telehealth and in-person behavioral therapy services were delivered. Looking forward, future research is needed to explicate the interaction of patient, provider, setting, and intervention factors that influenced the patterns observed as a result of the COVID-19 pandemic.

Change in Drug Use Disorders Identification Test - Consumption (DUDIT-C) with Telehealth Treatment Compared to in-Person Treatment.

Background and Objectives: There is little published evidence for the effectiveness of telehealth in the treatment of substance use disorders. Methods: We analyzed Drug Use Disorders Identification Test - Consumption (DUDIT-C) scores from 360 patients who completed the measure as part of outpatient behavioral health treatment at rural clinic sites. Some patients received in-person care, while others received telehealth. Results were analyzed using multiple regression. Results: Mean DUDIT-C scores improved with treatment in both cohorts. Changes on the DUDIT-C were related to initial scores. Treatment modality (telehealth vs in-person) had no distinguishable association with outcomes. Discussion and Conclusions: Results showed no discernible difference in outcomes between telehealth and in-person cohorts. Telehealth was as effective as in-person care in the treatment of substance use disorders, and appears to be equivalent to in-person care in rural outpatient settings.

Comparison of Telehealth and In-Person Behavioral Health Services and Payment in a Large Rural Multisite Usual Care Study.

Background: Telehealth and in-person behavioral health services have previously shown equal effectiveness, but cost studies have largely been limited to travel savings for telehealth cohorts. The purpose of this analysis was to compare telehealth and in-person cohorts, who received behavioral health services in a large multisite study of usual care treatment approaches to examine relative value units (RVUs) and payment. Methods: We used current procedural terminology codes for each encounter to identify RVUs and Medicare payment rates. Mixed linear regression models compared telehealth and in-person cohorts on RVUs, per-encounter payment rates, and total-episode payment rates. Results: We found the behavioral health services provided by telehealth to have modest, but statistically significantly lower RVUs (i.e., less provider work in time spent and case complexity), per-encounter payments, and total episode payments than the in-person cohort. Despite Medicare rates discounting payments for nonphysician providers and the in-person cohort using clinical social workers more frequently, the services provided by the telehealth cohort still had lower payments. Thus, the differences observed are due to the in-person cohort receiving higher payment RVU services than the telehealth cohort, which was more likely to receive briefer therapy sessions and other less expensive services. Conclusions: Behavioral health services provided by telehealth used services with lower RVUs than behavioral health services provided in-person, on average, even after adjusting for patient demographics and diagnosis. Observed differences in Medicare payments resulted from the provider type and services used by the two cohorts; thus, costs and insurance reimbursements may vary for others.

State-Specific Variation in Medicare Telehealth Utilization During the COVID-19 Pandemic.

Introduction: A number of reports are available exploring how telehealth use grew during the COVID-19 pandemic and public health emergency. Some have reported variations in telehealth uptake by specialty, but few have explored growth in telehealth utilization by both specialty and state, arguably the most salient combination of regulatory domains. Methods: We extracted telehealth claims from Medicare public use data files in 2019 and 2020. We calculated utilization by state both as raw encounters and as encounters per 10,000 Medicare beneficiaries in each state. We categorized providers into four major groups (primary care, specialty care, nurse practitioners and physician assistants, and behavioral health) to further explore variations in uptake among these groups. We generated tables and maps to display the variations found. Results: Growth in raw telehealth encounter volume was dominated by large states. Growth in telehealth volume per 10,000 beneficiaries was dominated by states in the Northeast and showed four- to fivefold variation between the least and greatest. Growth by state and provider group varied by even wider margins, with some states showing large amounts of growth among some provider groups, but relatively little growth in others. No states showed relatively robust growth in telehealth across all provider groups. Discussion: Growth in telehealth during the public health emergency was generally robust, but varied considerably across states and provider types. Recognizing this variation is important, and further exploring potential sources of variation is an important task for future research.

Comparison of in-person vs. telebehavioral health outcomes from rural populations across America.

BACKGROUND: This study investigates outcomes from two federal grant programs: the Evidence-Based Tele-Behavioral Health Network Program (EB THNP) funded from September 2018 to August 2021 and the Substance Abuse Treatment Telehealth Network Grant Program (SAT TNGP) funded from September 2017 to August 2020. As part of the health services implementation program, the aims of this study were to evaluate outcomes in patient symptoms of depression and anxiety across the programs' 17 grantees and 95 associated sites, with each grantee having data from telehealth patients and from an in-person comparison group. METHODS: The research design is a prospective multi-site observational study. Each grantee provided data on a nonrandomized convenience sample of telehealth patients and an in-person comparison group from sites with similar rural characteristics and during the same time period. Patient characteristics were collected at treatment initiation, and clinical outcome measures were collected at baseline and monthly. The validated clinical outcome measure instruments included the Patient Health Questionnaire-9 (PHQ-9) for depression symptoms and the Generalized Anxiety Disorder-7 (GAD-7) scale for anxiety-related symptoms. Linear mixed models, with grantee as the random effect, were used to determine the association of behavioral health delivery (telehealth versus in-person) on the one-month change in PHQ-9 and GAD-7 while adjusting for covariates. RESULTS: Across a total of 1,514 patients, one-month change scores were improved indicating that PHQ-9 and GAD-7 scores decreased from baseline to the one-month follow-up at similar rates in both the in-person and telehealth groups. Reduction in scores averaged 2.8 for the telehealth treatment group and 2.9 for the in-person treatment group in the PHQ-9 subsample and 2.0 for the telehealth treatment group and 2.4 for the in-person treatment group in the GAD-7 subsample. There was no statistically significant association between the modality of care (telehealth treatment group versus in-person comparison group) and the one-month change scores for either PHQ-9 or GAD-7. Individuals with higher baseline scores demonstrated the greatest decrease in scores for both measures. Upon adjusting for baseline scores and grantee program, patient demographics were not found to be significantly associated with change in anxiety or depression symptoms. CONCLUSION: In our very large pragmatic study comparing behavioral health treatment delivered to a population of patients in rural, underserved communities, we found no clinical or statistical differences in improvements in depression or anxiety symptoms as measured by the PHQ-9 and GAD-7 between patients treated via telehealth or in-person.

Telehealth Utilization During the COVID-19 Pandemic: A Preliminary Selective Review.

Background: The COVID-19 pandemic reduced in-person visit volume and fueled a corresponding explosion in demand for telehealth services, resulting in the enactment of several temporary state and federal policies to allow greater flexibility in delivering telehealth services. This review examines patterns in telehealth utilization during the pandemic by synthesizing available findings from large-scale studies. Methods: To be included in this review, studies must be of original research, include data from 2020 or 2021, have a U.S. study population, and analyze telehealth encounter data across multiple payers and health systems. This review includes 10 studies that fully met the inclusion criteria and 29 studies that examined telehealth use during the pandemic, although not from multipayer, multihealth system data sets. All studies were identified using Ovid MEDLINE and Google Scholar. Results: At its peak, telehealth accounted for roughly 15-50% of visits across the various studied populations and data sets. The more telehealth was utilized, the smaller the decrease in overall visit volume. Audio visits tended to be used more often than video visits, and telehealth utilization varied across geographic regions and medical specialties. There were disparities in telehealth use by race, age, income, and other factors. Discussion: Most telehealth visits during the pandemic would not have been reimbursable without the telehealth policy changes that took place. The variability in telehealth utilization across geographic regions is likely attributed to state-level telehealth policies. Most studies examining disparities in telehealth utilization did not compare disparities from before and during the pandemic, and these disparities may be a characteristic of health care overall rather than of telehealth specifically.

The Impact of the Medicaid Expansion on Telemental Health Utilization in Four Midwestern States.

Introduction: Low-income populations experience many barriers to accessing affordable, high-quality mental health services. One promising approach to improving access to care may be utilizing telemedicine in combination with expanding state Medicaid programs to cover low-income childless adults. This combination has the potential to reduce the prevalence of untreated mental illness; improve low-income populations' health and well-being; and save individuals', health care centers', and federal and state governments' money. Materials and Methods: A secondary data analysis on state Medicaid claims data was performed to calculate the percent difference in telemental health claims from 2014 through 2017 between two Medicaid expansion and two nonexpansion states in the Midwest. The percent change in claims during this time period within each of the four states was also calculated. Lastly, the difference between Medicaid telemental health utilization and other types of Medicaid telemedicine utilization was examined. Results: The Medicaid expansion states (Iowa and Minnesota) had 54% more telemental health claims per 10,000 state population than nonexpansion states (Nebraska and Wisconsin) from 2014 through 2017. During this time period, Iowa, Minnesota, and Nebraska experienced 481%, 329%, and 12% increases in Medicaid telemental health claims, respectively, and Wisconsin experienced a 10% decrease. Discussion and Conclusions: Medicaid telemental health utilization has been increasing since 2014 in the two Medicaid expansion states, especially in Iowa, while utilization has remained relatively constant in the two Medicaid nonexpansion states. This has implications for informing Medicaid policies, particularly with regard to Medicaid expansion and telemedicine reimbursement.

State Policies Influence Medicare Telemedicine Utilization.

BACKGROUND: Medicare policy regarding telemedicine reimbursement has changed little since 2000. Many individual states, however, have added telemedicine reimbursement for either Medicaid and/or commercial payers over the same period. Because telemedicine programs must serve patients from all or most payers, it is likely that these state-level policy changes have significant impacts on telemedicine program viability and utilization of services from all payers, not just those services and payers affected directly by state policy. This report explores the impact of two significant state-level policy changes-one expanding Medicaid telemedicine coverage and the other introducing telemedicine parity for commercial payers-on Medicare utilization in the affected states. MATERIALS AND METHODS: Medicare claims data from 2011-2013 were examined for states in the Great Lakes region. All valid claims for live interactive telemedicine professional fees were extracted and linked to their states of origin. Allowed encounters and expenditures were calculated in total and on a per 1,000 members per year basis to standardize against changes in the Medicare population by state and year. RESULTS: Medicare telemedicine encounters and professional fee expenditures grew sharply following changes in state Medicaid and commercial payer policy in the examined states. Medicare utilization in Illinois grew by 173% in 2012 (over 2011) following Medicaid coverage expansion, and Medicare utilization in Michigan grew by 118% in 2013 (over 2012) following adoption of telemedicine parity for commercial payers. By contrast, annual Medicare telemedicine utilization growth in surrounding states (in which there were no significant policy changes during these years) varied somewhat but showed no discernible pattern. CONCLUSIONS: Although Medicare telemedicine policy has changed little since its inception, changes in state policies with regard to telemedicine reimbursement appear to have significant impacts on the practical viability of telemedicine programs that bill Medicare for telemedicine services.

Telemedicine Spending by Medicare: A Snapshot from 2012.

BACKGROUND: Medicare has been one of the principal payers for healthcare services delivered via telemedicine to rural beneficiaries since 1997. Early projections of the cost of covering telemedicine for Medicare beneficiaries made legislators cautious to take on such a large obligation, but subsequent reports showed actual expenditures to be far below early estimates. As interest in expanding Medicare's coverage for services delivered via telemedicine grows, further examination of the extent of telemedicine use within the Medicare program and the costs associated with this use is warranted. MATERIALS AND METHODS: Medicare claims data from 2012 were examined. All valid claims associated with a Current Procedural Terminology code and modifier indicative of delivery via telemedicine were extracted and linked to the state of origin using carrier codes. Claims were summarized by clinical procedure code, medical specialty, and state. Expenditures were also calculated on a per member per month basis by state to compare the relative penetration of telemedicine among states. RESULTS: Total Medicare telemedicine-related expenditures in 2012 were found to be a little over $5 million, 65.2% of the total allowed telemedicine-related charges of $7.7 million. This figure represents an expenditure of approximately $0.09 annually per Medicare enrollee, or about three-quarters of a penny per member per month. Wide variation was found among states in telemedicine use. Mental health services and service providers accounted for nearly 70% of total telemedicine-related professional fees, and originating site facility fee claims accounted for only 28% of the total number of paid claims. CONCLUSIONS: Medicare spending on telemedicine is largely for mental health services and represents only a tiny fraction of overall Medicare spending. Adoption of telehealth is driven by multiple factors beyond need and rurality.

Telemental health evaluations enhance access and efficiency in a critical access hospital emergency department.

INTRODUCTION: Mentally ill patients in crisis presenting to critical access hospital emergency rooms often face exorbitant wait times to be evaluated by a trained mental health provider. Patients may be discharged from the hospital before receiving an evaluation or boarded in a hospital bed for observation, reducing quality and increasing costs. This study examined the effectiveness of an emergency telemental health evaluation service implemented in a rural hospital emergency room. MATERIALS AND METHODS: Retrospective data collection was implemented to consider patients presenting to the emergency room for 212 days prior to telemedicine interventions and for 184 days after. The study compared measures of time to treatment, length of stay (regardless of inpatient or outpatient status), and door-to-consult time. RESULTS: There were 24 patients seen before telemedicine was implemented and 38 seen using telemedicine. All patients had a mental health evaluation ordered by a physician and completed by a mental health specialist. Significant reductions in all three time measures were observed. Mean and median times to consult were reduced from 16.2 h (standard deviation=13.2 h) and 14.2 h, respectively, to 5.4 h (standard deviation =6.4 h) and 2.6 h. Similar reductions in length of stay and door-to-consult times were observed. By t tests, use of telemedicine was associated with a statistically significant reduction in all three outcome measures. CONCLUSIONS: Telemedicine appears to be an effective intervention for mentally ill patients by providing more timely access to mental health evaluations in rural hospital emergency departments.

Walk-in telemental health clinics improve access and efficiency: a 2-year follow-up analysis.

INTRODUCTION: Telemedicine has demonstrated potential to improve access and quality of mental health services in underserved areas. Use of telemedicine to deliver health services may enable a range of synergistic innovations in care practices, but such innovations will require rigorous evaluation. MATERIALS AND METHODS: We evaluated a telemental health program designed to increase access by eliminating clinician travel time in a multisite rural community mental health center. The program included both traditionally scheduled and "open scheduled" clinics provided via telemedicine. An initial 13-month evaluation showed better access, quality, and sustainability compared with similar services delivered using traditional methods available elsewhere within the organization. A 24-month follow-up analysis was undertaken to determine if initial findings remained consistent. RESULTS: Telemedicine clinics continued to show remarkably consistent advantages in both access and quality compared with traditional services. Cost-efficiency gains were also robust, maintaining a 20-percentage-point advantage in conversion of scheduled time to billable time over traditional clinics. Much of this advantage was attributable to the 20% of clinic volume that was open-scheduled or "walk-in" in nature. CONCLUSIONS: This study confirms earlier findings that telemedicine technology can support synergistic innovations in service format (such as "open scheduling") and maintain measurable advantages in access and quality along with cost-efficiencies past the initial implementation period.

Telepsychiatry reduces geographic physician disparity in rural settings, but is it financially feasible because of reimbursement?

Telemedicine has been shown to improve rural patient outcomes in two randomized controlled trials, to increase access to many patients, to serve underserved minorities, and to train primary care providers. Yet, programs are dwindling even after successful grants due to inadequate reimbursement. Studies have been thoroughly done to gauge the payor status of potential rural telemedicine patients, as the "floodgates" are not generally open to all-including those who cannot pay-in typical grants. Or the population of one community may not be representative of others. This study is part of a grant that explored the use of telemedicine for rural service delivery, attempted to get a clear snapshot of whom would be served if all were invited (paying or not), and to understand issues with the reimbursement systems. This article (1) examines the receipts of reimbursement and insurance coverage during the 1-year grant period by determining actual versus projected reimbursements, (2) identifies what payor(s) typical patients use, and (3) identifies problems and barriers for future study. Other administrative issues pertinent to telemedicine and costs are briefly discussed (eg, no-show rates, staffing, scheduling).

A retrospective analysis of a child and adolescent eMental Health program.

OBJECTIVE: New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary care setting, particularly in rural areas of the United States and especially for children and adolescents. The aim of this study was to examine the diagnostic characteristics and outcomes for children referred for eMental Health consultations at UC Davis (videoconferencing, telephone, and secure e-mail) from 10 primary care clinics in rural northern California. METHOD: : A retrospective analysis was conducted on the diagnostic and clinical outcomes of 139 referred children who received a full psychiatric diagnostic evaluation via videoconferencing. Within the group, a convenience sample of 58 initial and 41 three-month follow-up Child Behavior Checklists (CBCLs) was collected. RESULTS: Comprehensive eMental Health programs appear to be effective for psychiatric diagnosis and assessment of children. Attention deficit (36.2%) and mood (28.1%) disorders were the most common diagnostic groupings overall. Most children were seen only once, but a statistically significant improvement between initial evaluation and 3-month follow-up in the convenience sample was seen in the Affect and Oppositional domains of the CBCL for girls and boys, respectively. CONCLUSIONS: Versatile eMental Health programs, incorporating standardized checklists, may assist in diagnosis and treatment of rural children.

The e-Mental Health Consultation Service: providing enhanced primary-care mental health services through telemedicine.

This article describes the University of California, Davis Medical Center eMental Health Consultation Service, a program designed to integrate tele-mental health clinical services, provider-to-provider consultation, and provider distance education. During the first year of operation, consultations were provided for 289 cases. The most common diagnoses among children were for attention-deficit hyperactivity disorder-spectrum problems. Among the adult patients, mood disorders were most common. A convenience sample of 33 adult patients who completed the SF-12 health status measure showed significant improvements in mental health status at 3-6 months of follow-up. This model of comprehensive rural outpatient primary mental health care delivered at a distance shows promise for wider application and deserves further study.

Use of secure e-mail and telephone: psychiatric consultations to accelerate rural health service delivery.

Telemedicine is one strategy to improve the accessibility and quality of specialty healthcare to rural settings. After nearly 10 years of video evaluation of patients in rural primary care, telephone and e-mail physician-to-physician consultations were initiated to supplement video and hasten treatment initiation. This paper proposes a model of using telephone and e-mail consultations before or in place of video consultations, because the latter are not always available or timely. Two cases are presented in depth to delineate clinical, consultation, and health services issues. Early use of telephone appears to accelerate the telepsychiatric consultation and resulted in clinical improvement for patients. Primary care providers (PCPs) appeared satisfied with the process of these consultations. The average duration of consultation was about 10 minutes for each party. Telephone and e-mail consultation appear satisfactory to providers and inexpensive, but need to be further evaluated in terms of clinical, health service, and cost outcomes.

Models of telepsychiatric consultation--liaison service to rural primary care.

New models of psychiatric intervention are needed to improve the accessibility of mental health care in the primary-care setting, particularly in rural areas of the United States. Some models of service delivery have been successful in suburban and urban settings, but they do not always apply to rural settings. "E-health" innovations like videoconferencing, telephone, secure messaging (e-mail), and the Internet are increasingly being used to provide consultation--liaison service to primary care. This article briefly reviews successful models used in primary care, their application to rural sites, new models for rural sites, and suggestions for future e-health research.