Telepsychiatry Opens a New Window into Behavioral Healthcare

AN INDUSTRY IN NEED OF HELP

Telemedicine is coming along at just the right time for America’s mental health providers.

From 1995 to 2013, the number of psychiatrists in the United States rose 12 percent to roughly 49,000, yet the nation’s population jumped 37 percent during that span, according to the American Association of Medical Colleges.

Meanwhile, according to the physician search firm Merritt Hawkins, close to 60 percent of the nation’s psychiatrists are 55 or older and about 48 percent are 60 or older and nearing retirement, making them the fourth-oldest group of doctors practicing among 41 medical specialties. And the mean annual wage for a psychiatrist is $182,700, almost 30 percent less than that of a surgeon, a factor that may deter medical students from entering the profession.

The number of patients, on the other hand, has risen steadily. Millions of Americans have become eligible for mental health coverage as a result of the Affordable Care Act, and improvements in analysis and diagnosis mean many more children and adults are diagnosed with behavioral and mental health disorders - including and especially active and retired military members and police and fire department personnel diagnosed with stress disorders and PTSD.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), roughly 43 million adults (or 1 in every 5 adults) suffered from some mental illness in 2014, with about 10 million defined as having a serious mental illness. And according to the National Alliance on Mental Illness (NAMI), 13 percent of children between the ages of 8 and 15 experience a severe mental disorder in a given year. Among adolescents aged 13 to 18, that number is 20 percent.

All of this adds up to a growing patient base and a shrinking provider pool.

The issue is particularly acute in rural and remote regions – areas of the country where healthcare specialists like psychiatrists tend to be in even shorter supply.

Federal records indicate there are roughly 4,000 regions in the country with a ratio of one psychiatrist for every 30,000 patients. Statewide, largely urban states like Massachusetts, New York, Connecticut and Rhode Island have as many as 15 psychiatrists per 100,000 patients, while largely rural states like Montana, Wyoming, Nevada and Idaho have less than six.

All of these numbers add up to one big arrow pointed directly at telemedicine.

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COMING TO THE TELEPSYCHIATRY TIPPING POINT

“Telemental health has gone mainstream,” reads a report issued in 2016 by the national healthcare law firm Epstein Becker Green. The 602-page report analyzes each state’s telemental health capabilities, while arguing that telemedicine is the ideal platform for addressing the needs listed above.

Yet the report also notes that mental health providers – psychiatrists, psychologists, counselors and others in the field – face significant challenges in using telemedicine.

“As telemental health care gains in popularity, it gives rise to a number of significant legal and regulatory issues, including privacy and security, follow-up care, emergency care, treatment of minors, and reimbursement, among other things,” Rene Y. Quashie, who was senior counsel in the law firm’s healthcare and life sciences practice, said when the report was released.

“While some federal laws and regulations (such as HIPAA) apply, most of the issues involve state law, which has resulted in an inconsistent patchwork of laws and regulations that vary widely by state. And there are a number of states that don’t address telemental health specifically in their laws.”

In a recent interview, Quashie, now with Cozen O’Connor’s healthcare practice, said the nation “is starting to turn a corner” in understanding the value of telemental health.

“The technology has improved dramatically,” he said. Healthcare providers “are starting to realize the value of technology … in deploying the healthcare experience when and where it’s needed.”

Also last year, the American Telemedicine Association issued its first-ever state-by-state report card on telemental health. The ATA gave generally good marks for each state’s efforts, handing out eight ‘A’s and flunking just one state.

“Our analysis indicates that decades of evidence-based research highlighting patient adherence to treatment, positive clinical outcomes and increasing telehealth utilization have been met with overwhelmingly supportive scope of practice policies for psychologists,” ATA Chief Policy Officer Gary Capistrant and Latoya Thomas, director of the ATA’s State Policy Resource Center, wrote in their summary of the 50-page report.

“However, psychology boards, much like other health professional licensing boards, remain mired in a fragmented state-by-state licensure approach which stifles collaboration, service access, and availability.”

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ONE PSYCHIATRIST’S STORY

James Varrell, MD, has a two- to three-month waiting list for new patients to his Marlton, NJ psychiatry practice. But if someone wants an online appointment, he can see that person within a day or two.

“We can do it in hospitals, we can do it in homes, in institutions, in clinics,” he says. “We can do it wherever they feel comfortable. It gives us an exceptional ability to level the playing field.”

Alongside the access issue, Varrell says an online session appeals to patients who have trouble leaving their homes, because of either emotional or physical reasons.

Varrell launched his online practice in 1999. Back then the technology was complex and expensive - $20,000 for one doctor’s platform – and occasionally unreliable.

“Back then it was voodoo,” he adds. “No one thought much of it.”

But times have changed. The technology is cheaper, more efficient, and accessible not only on desktop computers but on laptops, tablets, and even smartphones. Sound and video quality are much better as well, so Varrell can not only see his patients, but see around them.

In 2008, Varrell launched Insight Telepsychiatry, and became its medical officer. In 2015, the company added a direct-to-consumer platform, called Inpathy. The company now operates in 27 states.

Varrell says psychiatrists can learn more about their patients in a video visit than they might in an office visit.

“You see them in their home environment,” he says. “You see their families and the care they’re getting” rather than having it described in an office. It helps him assess pediatric patients in their homes while giving busy parents relief from travelling costs, and it helps him reach out to elderly patients who might otherwise go without treatment.

Likewise, he says, many of his patients feel more comfortable at home, and end up telling him more than he’d get from a session on the couch.

Varrell estimates he sees about 80 percent of his patients in person, but that percentage is shifting. Payers are starting to open up to reimbursing for telepsychiatry, especially as studies tie a lack of mental health treatment to increased clinical costs, including medication use and hospitalizations.

“It not only improves access, it’s going to reduce their medical side,” he says. And as healthcare moves to value-based care and the idea of the patient-centered medical home, collaborative care models that combine clinical and behavioral health will become more popular.

Varrell sees the positive effect on his patients and on his profession. He can see a couple of patients in person, then simply open up a portal on his computer and see someone online. He can also work from home when appropriate. New psychiatrists with small families like that option, as do doctors who move away or “retire” but want to keep seeing their patients, or those on vacation who want to keep a few scheduled appointments.

“It’s coming to its fruition,” Varrell says. “It’s a whole new world for us. The in-home space is really making a difference.”

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ON-DEMAND TELEPSYCHIATRY

Solo psychiatrists and those in practices aren’t the only ones to see the value of telemedicine. Faced with a consumer market looking for on-demand healthcare, direct-to-consumer telehealth companies are also using the platform.

American Well, Teladoc, MDLive, Iris Telehealth, TruClinic, MyOnCallDoc, JSA Health, Insight Telepsychiatry and Doctor on Demand are just a few to have added behavioral health or telepsychiatry services to their menu.

“When we started [offering telehealth], it was kind of left to the side, as part of overall wellness,” says Sharp, of MDLive, which in 2016 reportedly became the first on-demand vendor to offer telepsychiatry in all 50 states. “It went kind of unrecognized for a long time.”

No longer.

“It’s the largest opportunity in telemedicine now,” says Larry Gleit, MDLive’s executive vice president and general manager for behavioral health. “With about 77 percent of the country in severe shortage [of mental health providers], this is where the need is.”

“There’s a real need for this type of service,” adds Jess-Huff, of American Well, which added psychiatry to its Online Care Platform in late 2016.

Jess-Huff notes that psychiatrists offer more extensive care – including the ability to prescribe medications, where permitted – than typical online behavioral health platforms.

“In some cases, therapy is only half the equation,” she says. “You need a full, holistic platform to meet those patients’ needs.”

Sharp says telepsychiatry platforms like that offered by MDLive seek to solve the access issue for anyone in need of telemental healthcare. An on-demand platform offers almost-immediate access to a licensed clinician, offering relief for hospital emergency departments, jails, schools, businesses and individuals in remote areas who don’t have their own psychiatrists.

“This isn’t some isolated physician trudging out to a remote place and trying to do a great job,” he says. “Now, more than ever, telemedicine providers are regular doctors, filling a need in a coordinated care environment.”

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RIGHT PLATFORM, RIGHT PATIENT

Mental health providers often mold the telemedicine platform to meet a specific population’s needs. Pediatric telemental health tends to be more hands-on, employing games and other tools that try to coax out causes and clues that can’t or aren’t easily verbalized. Telemental health services for veterans, meanwhile, often target substance abuse issues and PTSD, while services for the elderly focus on age-related depression and dementia issues.

Then there’s the college and university population – high school students taking that next step into adulthood, perhaps moving away from home for the first time, balancing studies with socializing, perhaps sampling alcohol or drugs for the first time.

That’s where TAO (Therapy Assistance Online) Connect comes into play. Launched in 2012 by Dr. Sherry Benton and targeted primarily at college-aged students, Florida-based TAO Connect combines online educational resources, including videos and interactive sessions, with short support sessions with counselors.

Benton says many of today’s consumers in need of behavioral healthcare don’t need to sit down with a psychiatrist for an hour or two each week – they need less invasive services to treat anxiety issues, which they can access on a smartphone or laptop at their convenience. And they need a platform that is engaging and realistic, keeping the user’s attention and encouraging him or her to follow through on a care plan.

“We’re delivering behavioral healthcare that doesn’t really fit anyone’s life,” Benton says. “What’s available is often expensive, inconvenient and doesn’t fit anyone’s lifestyle. There’s no comfort zone. And hiring more [doctors] won’t solve that problem.”

Benton, who’s looking to branch out from colleges and universities into other populations, says healthcare providers are starting to take notice of telehealth as a mental health and wellness tool because many chronic diseases are adversely impacted  by untreated behavioral health issues - and leaving them untreated leads to more expensive and less effective care.

“They’re beginning to screen for these things now, especially depression and anxiety,” she says.

TAO Connect is part of the next wave of telemental health platforms looking to broaden the care continuum beyond the psychologist’s couch. The company is taking advantage of the telemedicine platform to offer not only virtual visits, but also to provide access to self-help tools and resources that encourage patients to be more active in their treatment.

Some companies are even incorporating mobile health tools, such as remote patient monitoring platforms, wearables, and mHealth apps, to help providers track their patients in between visits and give those patients instant access to tools they need to cope during moments of stress or depression.

“There’s a role for ever more digital information,” says MDLive’s Sharp, who envisions telemental health providers collecting information on diet, exercise and sleep patterns – even using a GPS system in a smartphone to determine location - to better understand how, when and why a patient becomes stressed or depressed.

“This type of [platform] would be especially useful for those treating addictions,” adds Gleit. “We’re finding that even the patients will opt for this type of support.”

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EXPANDING THE PLATFORM

Like every other medical profession, psychologists must be licensed in each state in which they treat patients. Telemedicine advocates say that policy has hampered multi-state telemedicine programs, such as those run by large health systems, but also impacts solo and small practice doctors who just happen to live and work near a state line.

That issue may be easing. This year the Federation of State Medical Boards activated the Interstate Medical Licensure Compact, giving physicians in several states an expedited means of getting licenses in multiple states. The Federation of State Boards of Physical Therapy (FSBPT) has also enacted its licensure compact, and the National Council of State Boards of Nursing (NCBSN) expects to have one of its own within a year or two.

The Association of State and Provincial Psychology Boards (ASPPB) is working on a licensure compact as well. At an ATA conference in 2016, Janet P. Orwig, MBA, the ASPPB’s associate executive officer for member services, said such a compact would greatly assist psychologists, many of whom work in multiple states. She said one psychologist, who’s an expert on death penalty cases, spends $100,000 to $125,000 a year just to maintain 25 licenses.

Also on the horizon is an expected amendment of the Ryan Haight Online Pharmacy Consumer Protection Act. Passed in 2008, the act prohibits the dispensing of controlled substances via the Internet without a “valid prescription.”

Quashie says the Ryan Haight Act “really stifles the ability for telemedicine providers.” This, he said, sets telepsychologists back to a point where they’d have to first schedule an in-person session with a patient before being able to prescribe any medications.

He’s not alone.

In 2015, the ATA sent a letter to the U.S. Drug Enforcement Agency (DEA), the agency charged with applying the Ryan Haight Act in telemedicine cases, asking that the DEA ease its restrictions to allow the prescribing of controlled substances by “legitimate, licensed providers who offer needed medical services to a highly targeted group of patients.” The ATA also asked the DEA to carve out a “structured yet flexible framework for appropriate online prescribing” for physicians and psychiatrists who use telemedicine.

According to several healthcare sources, the DEA is expected to release a new rule before the end of 2017 that would enable doctors and psychiatrists to prescribe controlled substances without the need for an in-person exam. Some states, meanwhile, are amending their telemedicine laws to alllow some online prescribing of controlled substances.

With multi-state licensure and an easing of the Ryan Haight Act, telemental health should continue its upward climb, giving clinicians the ability to expand their practices and opening the door to millions of people who need help, but can’t make it to the doctor’s couch.

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