Before COVID-19, the question of whether digital consultations would ever supplant in-person sessions as the industry norm would have been difficult to imagine. However, when faced with the choice of either shuttering their doors against the virus or migrating onto digital platforms, mental health professionals have overwhelmingly selected the latter.
In June, the American Psychological Association (APA) reported that three-quarters (76 percent) of over 2,000 polled mental health clinicians were exclusively providing services remotely via phone, telehealth interface, or videoconference app. A further 16 percent said that they were offering remote services in addition to seeing some of their patients in person.
There’s no doubt that telepsychiatry is a core part of the mental healthcare sector’s adaption to COVID-19. However, there is some uncertainty around whether digitally-facilitated services will retain their importance after the pandemic or fade when in-person visits can be held without undue risk of contagion.
There are a few compelling reasons to believe that telepsychiatry use will continue after the pandemic. Research indicates that digital services facilitate a standard of care on par with conventional in-person sessions, as well as increased convenience and flexibility to patients and healthcare professionals alike. Some proponents even argue that virtual services are more insightful than those provided in-office because clinicians can get a glimpse into a patient’s home environment.
“Teletherapy offers a much deeper level of knowing the [patient], and understanding what their world might really be like,” Lisa Dion, president of the Synergetic Play Therapy Institute in Colorado, shared of her experience using the technology in pediatric cases.
That said, the transition into virtual care hasn’t been seamless. A recent APA survey reported that 76 percent of clinicians find remote treatment more challenging to facilitate than in-person visits. Providers may struggle to handle technology problems, Internet connectivity, reimbursement uncertainty, and patients who are uncomfortable with virtual visits. APA researchers further noted that clinicians are often forced to be more vigilant about picking up nonverbal cues, as such indicators may not come across on a screen as clearly as they might in person.
Concerns like these will undoubtedly draw some physicians — and patients — back to the office when the pandemic subsides. Some may simply prefer the in-office experience. As psychologist Lori Gottlieb recently told reporters for Time, “There’s the ritual of coming in every week, sitting in that room on the same spot on the same couch in the same office. It feels incredibly comforting and safe. I think the environment part of it is very important for people.”
It seems entirely reasonable to project that a post-pandemic mental health sector will support a consumer-friendly mix of virtual and in-person services for some. But to gauge the continued value of telepsychiatry solely on whether consumers prefer it would be to overlook a vital aspect of the situation at hand — i.e., what such services can do to bolster mental healthcare access.
For patients in metropolitan areas, digital mental health services may only be a stopgap measure until the pandemic ends, and a return to in-office care is possible. But for others, the sudden push towards telehealth could be the key to providing patients who never even had the option of visiting a mental health professional before the pandemic.
While the prevalence of mental illness is not limited by geographical boundaries, mental health providers are constrained by their location. Most providers don’t live in rural areas, and few have the resources to regularly travel out to isolated communities. This lack means that where a patient lives can determine whether they have ready access to mental healthcare. More than 90 percent of all psychologists and psychiatrists, and 80 percent of professionals with MSWs, practice exclusively in metropolitan regions. Nearly three-quarters of rural counties lack a psychiatrist, and 95 percent lack a child psychiatrist.
Without local services, patients are forced to travel significant distances or forego care entirely. A literature review published in the Journal of General Internal Medicine found that between 10 and 51 percent of studied rural patients felt that transportation posed a barrier to healthcare access, especially when combined with factors such as functional impairment, travel cost, and work or family obligations. One 2018 study noted that while most rural communities no longer struggle with stigma, patients who cannot transport themselves to care may forego it out of a fear of not being self-sufficient.
Telepsychiatry services provided a clear answer to at least a portion of rural regions’ accessibility concerns. Demand for rural telemedicine connectivity has skyrocketed in recent years, as local care providers realized the value that digital healthcare could offer their patients and began to advocate for telehealth connectivity. For illustration: in the summer of 2019, the Federal Communications Commission (FCC) increased funding for the Rural Health Care Program — an initiative that helps fund broadband and telecommunication services for rural healthcare providers — for the first time since the program launched in 1997, citing overwhelming demand.
Herein lies the problem rural telehealth proponents faced before COVID-19. Many simply do not have the funding necessary to establish or maintain virtual care services. Earlier this year, the House Ways and Means Committee’s Rural and Urban Underserved Task Force found that surveyed rural health centers are not using telehealth because they lack reimbursement (36 percent), lack funding for the equipment (23 percent), and lack training for providing telehealth (21 percent).
Another factor to consider is licensing. Before this year, the vast majority of states required telehealth physicians to be licensed in the state where their patients receive care; only nine offered special licenses that allowed for cross-state practicing. Those who practiced telemedicine also often received a fraction of the reimbursement that they would have received from an in-person appointment. These factors made it challenging for physicians to practice, even when they had virtual care infrastructure in place.
But in the wake of COVID-19, many of those problems have been at least partly alleviated. The Centers for Medicare & Medicaid Services (CMS) greatly expanded its list of reimbursable telehealth services and loosened restrictions on where and how patients could receive digitally-facilitated care. In June, the FCC added $198 million in funding to the Rural Healthcare Program to help healthcare providers establish the infrastructure they need to start offering telehealth services.
The healthcare sector has spent months debating how much clinicians should rely on digital services, with almost every argument assuming that in-person care would be available as an alternative. But in this assumption, we have overlooked one of COVID-19’s most crucial silver linings — that the pandemic has compelled us to dedicate our attention and resources towards building the foundational infrastructure that rural areas need to access telepsychiatry services. Our COVID-prompted investments in virtual care will help rural healthcare providers overcome the initial challenges of instituting telehealth services and give clinicians the tools they need to support isolated patients for years to come.
