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Psychiatrists turn to telehealth as shortages, access challenges grow

The following is the final story in a four-part series examining how the growing telehealth industry is influencing healthcare delivery. Story one is available here, story two can be read here and the third installment is here. This part focuses on how psychiatrists are using telehealth services to address the shortage of behavioral health specialists across the U.S.

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Telepsychiatry may seem detached — a doctor on a video screen asking you deeply personal questions or even raising traumatic issues — but therapists say such psychiatrist-patient distance may yield unexpected positive results.

"A child or adult with a significant amount of anxiety may feel more comfortable using this modality, as well as if there is someone who has a significant trauma history," said Shabana Khan, director of child and adolescent telepsychiatry at NYU Langone Health. "I've also seen children with autism, they may actually do better with that distance ... might actually feel more comfortable opening up."

Telepsychiatry and telebehavioral health use technology like videoconferencing, television screens attached with cameras and mobile devices to connect with patients remotely.

Khan, who has been using these services for over a decade, says technology has advanced to where high-definition cameras can pick up physical cues in patients and scan around the room, allowing her to connect with patients as if she were meeting with them in person.

Beyond treatment, telehealth technology could help combat the stigma surrounding mental illness, healthcare experts said.

Haiden Huskamp, health economist and professor of healthcare policy at Harvard Medical School, said patients may avoid in-person treatment for mental illness or substance use disorder due to the stigma attached to them.

"Even if there is a specialist in their community, they may ... feel more comfortable being engaged in treatment if they're doing some of it remotely," Huskamp said.

Telehealth services conducted from a remote site like a doctor's or dentist's office also help protect patients' privacy, particularly in smaller communities, Huskamp said.

Addressing shortage of specialists

Improving patients' access to healthcare specialists has been one of the primary promises of telehealth. As the U.S. continues to deal with a shortage of mental and behavioral health specialists, healthcare experts see telehealth services as a way to connect patients with needed treatment that would otherwise not be available to them.

A total of 6,335 mental health practitioners were needed in the U.S. to remove the federal designation of a professional shortage area as of Dec. 31, 2019, according to data from the Health Resources and Services Administration, an agency within the U.S. Department of Health and Human Services. The data shows that 6,117 total areas in the U.S. were designated to have a mental healthcare professional shortage.

Behavioral health specialists and psychiatrists are also not evenly distributed across the U.S., which is especially acute in subspecialties like child psychiatry.

A November 2019 study from the medical journal Pediatrics showed that the number of child psychiatrists grew by 21.3% from 2007 to 2016. However, about 70% of U.S. counties had no child psychiatrists in 2016, the same amount as in 2007. The study found that child psychiatrists were more likely to practice in counties whose residents had higher incomes and higher levels of post-secondary education.

Khan said in an interview that she can overcome these gaps in access and distribution with telepsychiatry.

"A lot of the counties that we provide care in don't have a single child psychiatrist, so we are definitely meeting a need," Khan said.

The barriers between a patient and psychiatrist, like hours of travel and taking time off work regularly, will cause some patients to forgo treatment completely, Khan said.

Access challenges can also put off a patient's diagnosis for years, according to Khan. "Early intervention is key for a lot of the conditions that we treat. Telemedicine allows us to do that sooner."

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Shabana Khan, director of child and adolescent telepsychiatry at NYU Langone Health, said telepsychiatry allows her to reach patients who may otherwise go without treatment because there are no psychiatrists in their area.
Source: Photo by John Karsten Moran, photo provided by NYU Langone Health

The sensitivity of certain treatment requires extra safety precautions when the psychiatrist providing treatment is not in the room. Telepsychiatry services require more coordination with other healthcare workers at the patient’s site and an understanding of emergency systems and local emergency contacts like the fire department and police department, Khan said.

This planning and coordination is needed even more so when conducting in-home visits. Khan said it may be determined that telepsychiatry is not the appropriate treatment strategy for certain patients.

These and other concerns have some healthcare experts questioning the increasing adoption of telehealth.

Ateev Mehrotra, associate professor of healthcare policy and medicine at Harvard Medical School, argued that the Centers for Medicare and Medicaid Services should open up payment policies only for certain treatments and regions of the U.S., including rural areas and some urban locations.

Krisda Chaiyachati, medical director for telemedicine at Penn Medicine, an academic medical center in Philadelphia, said in an interview that while he does support increasing patients' ability to use telehealth, including more government reimbursement and further adoption by the healthcare industry, access could get so simple it could lead to overutilization, which would ultimately drive up healthcare costs.

Khan waved off this concern. Telemedicine still comprises a very small amount of total Medicare payments, she said, and if anything, utilization has not happened fast enough.

Cowen analysts said in a Feb. 24 report that behavioral health services make up a large portion of Medicare telehealth payments. Because of this, as investors look at telehealth companies, it will be important to "assess their ability to deliver behavioral health capabilities," the analysts said.

American Well Corp., a privately held telehealth provider, acquired Aligned Telehealth Inc., a tele-behavioral health and telepsychiatry provider, for an undisclosed amount in November 2019, expanding the companies' telepsychiatry offerings.

Telepsychiatry's impact on hospitals

Jonathan Merson, medical director of a behavioral telehealth service line for New York-based hospital system Northwell Health Inc., said in an interview that a lack of access to behavioral health specialists has increasingly led patients in crisis to go to emergency rooms, which can overwhelm staff who lack specialized training.

Patients visiting emergency rooms are also often left waiting for a long time in an environment that is not designed for their type of crises, according to Merson. Telehealth can help provide patients with treatment and alleviate the pressure on emergency departments staffs, he said.

Northwell Health's telepsychiatry program is an effort to address patient wait times in its emergency care. The program allows staff to take carts with audio-visual devices to patients' bedsides to connect them via videoconferencing with behavioral specialists, according to Merson. Specialists can also access patients' electronic medical records. The hospital system's telepsychiatry team can also find beds, transfer patients and do admission work if they need inpatient psychiatric hospitalization, which just under 40% of patients require, Merson said.

The hospital's telepsychiatry program started as a small number of facilities in 2013 and has grown to 17 emergency departments, with 4,707 consultations made in 2019, according to data provided by Merson.

"We've been adding new emergency departments every year," Merson said. "It went from being better than not having anybody to a level of care that hospitals are actually signing up for because they are seeing that we are getting to patients quickly, and it's a very high-level assessment, even in the middle of the night."

Patients have responded to the treatment well, with the technology seamlessly integrated, Merson said.

Iris Berman, vice president of telehealth services for Northwell Health, said the program allows hospitals to provide a higher quality of care, operate more efficiently and maximize doctors' time, all of which "contribute to the bottom line." However, she did not comment specifically on the financial impact of Northwell's telepsychiatry program on the hospital system.

Rural vs. urban reimbursement challenges

Much like other telehealth services, telepsychiatry has had to deal with the challenges of reimbursement from private insurers and government insurance programs like Medicare and Medicaid.

Berman said that drawing a line between urban regions and rural regions is not an accurate way to determine coverage of services. Patients in urban regions experience similar access issues for behavioral health specialists and psychiatrists as those in rural areas, but the CMS has still been slow to cover providers in cities, Berman said.

The CMS recently eased certain payment policies to cover behavioral health treatments and telehealth treatments for substance use disorder.

Both Khan and Huskamp believe that as regulations open up, telepsychiatry adoption will grow even faster than it already has.

"[Telepsychiatry] is not a new idea, certainly," Huskamp said. "And we're going to see even more growth in the next few years."