Issue Brief October 2020 Telebehavioral Health: An Effective Alternative to In-Person Care By Brittany Lazur, MPH, Lily Sobolik, MPP, and Valerie King, MD, MPH Policy Points ABSTRACT In recent years, many states have seen an increase in the prevalence of behavioral > Telehealth is just as health diagnoses and challenges in treatment access. At the same time, the health effective as in-person care care delivery system has increasingly relied on telehealth. Given the importance of for certain behavioral behavioral health care and the desire of state policymakers to improve outcomes, health conditions leaders should consider the effectiveness of various behavioral health treatments > States can cover delivered via synchronous telehealth. telebehavioral health as as a separate benefit or as While the COVID-19 pandemic has prompted numerous, often temporary, telehealth a treatment modality, policy changes across the health care field, some states and health care organizations meaning that certain services are covered already had robust telehealth policies in place. As health care leaders and organiza- regardless of how they are tions consider extending or making these new telehealth policies permanent, they delivered should consider the lessons learned from existing programs. This brief provides summary findings from a 2019, pre-pandemic review of the evidence of telebehavioral health’s effectiveness on key clinical outcomes. It also describes the programmatic structure and relevant telebehavioral health policies of three programs: Texas Medicaid, Massachusetts Medicaid, and the Portland Veter- ans Affairs Medical Center Rural Telemental Health Program (VA RTMH). Key Evidence Findings: Key Policy Findings: • Telehealth is just as effective as • Permanent telebehavioral health in-person care for certain behavior- policies can be implemented using al health conditions; various means, including treating • Telehealth is not harmful compared telehealth as a modality or as a with in-person behavioral health separate program; and care; and, • Administrative or legislative mecha- • The cost of telebehavioral health nisms can be used to enact authori- can be lower than in-person visits, zation for such policies. provided that patients have devices they can use. BACKGROUND health may have the ability to fill at least some of these More than 50% of Americans will be diagnosed with gaps in access to care. a mental health disorder such as anxiety or depression The telehealth policy and reimbursement landscape during their lifetime, with one in five US adults experi- continue to evolve, particularly with changes occurring encing a mental illness in a given year.3-5 Approximately in the wake of the COVID-19 pandemic. Still, prior to 21 million Americans have a substance use disorder COVID-19, Medicaid fee-for-service provided reimburse- (SUD) related to alcohol, opioids, or other drugs.6 Popu- ment for some forms of live video telehealth in 49 states lation-based surveys suggest one in six US children aged and Washington, DC.11 two to eight years has a mental, behavioral, or develop- mental disorder.7 Evidence on Telebehavioral Health As Effective as In-Person Care for Common Telebehavioral health, also known as telemental Behavioral Health Conditions health, is broadly defined as any telehealth services • Studies indicate that there are largely no significant delivered by behavioral health professionals, such differences between telehealth and in-person care as psychiatrists, psychologists, and social workers.1 for adults with anxiety,12-18 depression,13-22 substance Examples of behavioral health services delivered use disorder,23 and post-traumatic stress disorder17,18 via telehealth include cognitive behavioral for the following outcomes: therapy, general psychotherapy, behavioral • Symptom improvement, activation, problem-solving therapy, medication management, and training for parents of children • Patient satisfaction, with attention-deficit hyperactivity disorder. • Quality of life, and For the purposes of this brief, telebehavioral • Medication and treatment adherence. health services are limited to live audio-video connections (synchronous) in which patients • Patients have reported that behavioral health receive health care at an originating site (e.g., treatment delivered by synchronous telehealth clinical or home setting) from providers located at was convenient and reduced barriers to accessing a distant site.2 treatment.15,23 Greater Improvements in Attention Deficit Despite the ubiquity of mental and behavioral health Hyperactivity Disorder (ADHD) Symptoms conditions, access to treatment is often out of reach, • For children with ADHD, a study showed improve- particularly for children and adolescents. Sixty-five per- ment in symptoms occurred in both synchronous cent of nonmetropolitan counties in the US do not have telehealth—in which a patient and provider are a psychiatrist, and there are often shortages of both connected in real time via teleconferencing—and nonpsychiatric and psychiatric care professionals in rural in-person treatment groups, but the improvement geographic areas.8 While primary care clinicians provide was significantly greater for those participating in substantial amounts of behavioral health care, they often the telehealth intervention.24 report difficulties obtaining specialist mental health • Telebehavioral health led to decreases in distress referrals for rural and low-income patients.9,10 Even among caregivers of children with ADHD.25 with sufficient staffing, providers may be unable to deliver the right services, such as acute and crisis care. Neither Worse Than Nor Harmful in Comparison Furthermore, only a small proportion of individuals with to In-Person Care for Many Behavioral Health SUD receive treatment, a reflection of the shortage of Conditions SUD treatment providers.6 This treatment gap is partic- • No study found behavioral health treatment ularly evident among vulnerable populations including delivered by synchronous telehealth to be worse racial and ethnic minorities, children, rural communities, than or harmful in comparison to behavioral health and individuals with special health care needs.7 Tele- treatment delivered in-person.12-36 However, no Milbank Memorial Fund • www.milbank.org 2 studies evaluated the effects of long-term There are minimal differences between in-person and telebehavioral health treatment, and there were remotely delivered services, regardless of modality or few studies in children. separate benefit designation.38,39,42 Costs Vary Greatly by Program, Depending on The Texas and Massachusetts Medicaid programs Staffing, Services, and Technology both provide: • Studies reported mixed findings pertaining to • Equal reimbursement;37,38,43,44 costs and health care utilization for participants • Identical patient eligibility requirements; in synchronous telehealth and comparison groups • Identical prior authorization requirements;37 and across all behavioral health populations stud- ied.12,13,18,26 • No start-up funding or equipment for providers or patients. • Studies of people with depression noted direct telehealth costs were lower than costs for in-person Implementation nuances remain for telebehavioral care if patients provided their own technology rather health services: than being provided with equipment by clinical pro- • Requirement of staff training programs (Mass.);38,39 viders or the government.18 • Presence of a health care professional in mental • Telebehavioral health costs less as long as patients health emergencies (Texas);45 have devices that they can use.18 • Specific eligibility exclusions including severe SUD, high risk of suicide or homicide, and dementia (VA Telebehavioral Health Policy RTMH);4*and Implementation • Special delivery and eligibility requirements for Telebehavioral Health as a Treatment Modality children (Texas).45,46 or Separate Benefit States can cover telebehavioral health as a treatment Minimal Restrictions to Allowed Services modality, meaning that they cover certain services All three programs (Texas, Mass., VA RTMH) permit a wide regardless of how they are delivered, or as a separate range of services to be delivered through telebehavioral benefit, where the state specifically defines its coverage health including:4*,38,47-50 of telehealth treatment (e.g., cover telehealth but only for • Diagnosis, evaluation, and treatment; particular conditions or under certain circumstances). • Services for new patients; and Below, we describe examples of both approaches from three states: Texas, Massachusetts, and Oregon. In all • Medication prescribing. three states, the major impetus for developing telebe- Considerations for prescribing of controlled havioral health programs was to address health profes- substances include: sional shortages and reduce treatment barriers related • Compliance with federal and state laws (Texas, to patient location.40,41 Mass., VA RTMH); 4*,38,39,49,51 While Texas and Massachusetts’s Medicaid policies • Required periodic in-person visits (Mass., VA were authorized using different mechanisms, Texas RTMH); 4*,38,39 legislatively in 200537 and Massachusetts administrative- • Particular restrictions for Schedule II controlled ly in 2019,38,39 both states treat telebehavioral health as a substances (Mass.);38,39 and treatment modality, not as a distinct, separately covered service.1*,2* In contrast, the Portland Veterans Affairs • Exclusion of chronic pain conditions (Texas).51 Medical Center (Portland VA) created its telebehavioral health program, Rural Telemental Health (RTMH), in 2009 for patients living in rural areas of Oregon as a separate specialty program.3* *1 Texas Medicaid staff, personal communication. *2 Massachusetts Medicaid staff, personal communication. *3 VA RTMH staff, personal communication. *4 VA RTMH staff, personal communication. Milbank Memorial Fund • www.milbank.org 3 Minimal Restrictions to Allowed Sites Considerations for States Thinking All three programs permitted a patient’s home to serve About Continuing New Telebehavioral as an originating site for telemedicine, ensuring patients Health Policies Established During did not have to travel to a practitioner’s office or medical COVID facility.37-39,49,50 The Texas and Massachusetts Medicaid The establishment of permanent telebehavioral health programs had very few, if any, restrictions on patient site policies, developed prior to COVID-19 by the Texas and location. Massachusetts Medicaid programs and Portland VA RTMH program, provides important lessons for states Policy considerations for allowed sites include: and health care organizations to consider when planning • Evaluating a patient’s access to emergency services for their own long-term implementation of similar poli- (VA RTMH); cies. States should consider these findings in the context • Requiring a clinical originating site for patients of their unique regulatory environments. with certain controlled substance prescriptions, like Program Reporting Suboxone (VA RTMH); and Texas and Massachusetts Medicaid staff emphasized • Contingency planning for technical issues and health that the assessment of remotely delivered services crises (Mass., VA RTMH). 4*,38,39 is critical, and both programs have a modifier code to denote remote delivery of services.38,39,49 In Texas, the Minimal Technical Specifications first external evaluation is underway and will report cost All three programs provided limited direction on savings; recommend future data collection elements; technological requirements and did not provide and develop a methodology to evaluate the cost-effec- funding for equipment or technology for patients or tiveness, clinical efficacy, and utilization of remotely providers.4*,38,39,49 delivered services. The broad guidance for providers includes:4*,38,39,49 Texas Medicaid regularly administers stakeholder surveys • Compliance with the Health Insurance Portability and and has regular, standardized legislative reporting on its Accountability Act of 1996; and remote delivery services, which includes:37 • Secure authentication. • Number and type of health care providers using remotely delivered services; The US Department of Veterans Affairs (US VA) • Provider geographic and demographic makeup; has an encrypted, web-based app, VA Video Connect, which is a web link that creates a virtual • Provider expenditures; medical room.52 Additionally, the US VA has • Common primary diagnoses for services; and recently piloted partnerships with public and • Patient utilization. private organizations, e.g., American Legion, Veterans of Foreign Wars, and Walmart, that Texas Medicaid staff noted some current data collection will provide on-site access at five to 10 locations limitations and suggested states consider the following nationally to technology and private space for program improvements: telehealth visits.53-55 • Mandating the use of modifier codes (i.e., additional information to payers related to the specific service provided) to ensure consistency and • Implementing codes for the place of treatment to track patient location. Milbank Memorial Fund • www.milbank.org 4 Oversight Requirements Among all three programs, there were no differences in audit or oversight requirements for remotely delivered and in-person services.38,39 Remotely delivered services were simply included in any regular audit activities and were not overseen separately. Staffing Requirements Staffing requirements among the three programs depended on the scope and type of service included in the telebehavioral health program. Policies that treated telebehavioral health as a delivery modality were usually implemented with existing staffing. However, separate telebehavioral health programs required dis- tinct staffing. Key Takeaways In light of the restrictions on in-person access to health care resulting from COVID-19, many states and health care organizations may consider making temporary telebehavioral health policies permanent. A pre- pandemic review of the evidence and policies from three existing programs provides key considerations for policy- makers: • Telehealth is just as effective as in-person care for certain behavioral health conditions, and • Telebehavioral health policies can be implemented permanently using different structures, including treating it as a modality or as a separate program. These findings are promising for the adoption of permanent policies. In addition to the evidence on effectiveness, policymakers should consider imple- mentation nuances and the underlying motivations and expectations behind such policies. Cost savings and increased service utilization are of particular interest, however, the evidence in these two areas is unclear and requires additional research. A large expansion of telebehavioral health services could provide the needed impetus, and volume, to properly explore their impact on costs and service utilization. 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Milbank Memorial Fund • www.milbank.org 8 43. exas Secretary of State. Texas administrative code, title 1, part 15, chapter 355, subchapter g, rule 355.7001, T Reimbursement methodology for telemedicine, telehealth, and home telemonitoring services. 2017. https://texreg. sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_rloc=196382&p_tloc=&p_ploc=1&pg=11&p_ tac=&ti=1&pt=15&ch=355&rl=7001. Accessed September 30, 2019. 44. exas Statute. Government code, title 4, subtitle i, chapter 531, subchapter a, section 531.0217, Reimbursement for T certain medical consultations, subsection 2d. 2019. https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm. Accessed September 30, 2019. 45. exas Medicaid & Healthcare Partnership. Texas Medicaid provider procedures manual October 2019: Behavioral T health and case management services handbook. 2019. http://www.tmhp.com/Manuals_PDF/TMPPM/TMPPM_Liv- ing_Manual_Current/2_Behavioral_Health.pdf. 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Accessed September 30, 2019. 50. exas Secretary of State. Texas administrative code, title 1, part 15, chapter 354, subchapter a, division 33, rule T 354.1432, Telemedicine and telehealth benefits and limitations. 2017. https://texreg.sos.state.tx.us/public/read- tac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1432. Accessed September 30, 2019. 51. exas Secretary of State. Texas administrative code, title 22, part 9, chapter 174, subchapter b, rule 174.5, Issu- T ance of prescriptions. 2017. https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=T&app=9&p_dir=N&p_ rloc=186660&p_tloc=&p_ploc=1&pg=11&p_tac=&ti=22&pt=9&ch=174&rl=1. Accessed September 30, 2019. 52. .S. Department of Veterans Affairs. VA video connect. https://mobile.va.gov/app/va-video-connect#AppDescrip- U tion. Accessed November 18, 2019. 53. lliott VL, Congressional Research Service. Department of Veterans Affairs (VA): A primer on telehealth. 2019. E https://fas.org/sgp/crs/misc/R45834.pdf. Accessed November 18, 2019. 54. .S. Department of Veterans Affairs. VA, Walmart open telehealth locations to serve veterans in rural areas. 2019. U https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5374. Accessed December 13, 2019. 55. .S. Department of Veterans Affairs. ATLAS: offering veterans VA care closer to home. https://connectedcare. U va.gov/partners/atlas. Accessed November 21, 2019. Milbank Memorial Fund • www.milbank.org 9 Interview Contacts The authors would like to acknowledge the contributions of interviewees who provided their experience and knowledge to the development of the Center for Evidence-based Policy’s report. Massachusetts Stacie Billard Senior Policy Manager, Office of Behavioral Health MassHealth Date Interviewed: November 4, 2019 Stephanie Jordan Brown Acting Chief, Office of Behavioral Health MassHealth Date Interviewed: November 4, 2019 Texas Erin McManus Senior Policy Advisor, Medicaid Texas Health and Human Services Commission Date Interviewed: October 30, 2019 Morgan Goldstein Program Specialist, Medicaid Texas Health and Human Services Commission Date Interviewed: October 30, 2019 U.S. Department of Veterans Affairs Alan Greilsamer Director, Media Relations Office of Communications, Veterans Health Administration Date Interviewed: December 18, 2019 Derek Burks Program Manager, Rural Telemental Health Program Portland Veterans Affairs Medicaid Center Date Interviewed: November 22, 2019 Milbank Memorial Fund • www.milbank.org 10 AUTHORS Brittany Lazur, MPH, is a research associate at the Center for Evidence-based Policy (Center), who writes clinical evidence and policy reports for the Medicaid Evidence-based Decisions Project (MED) and for the Drug Effectiveness Review Project collaboratives. With an academic background in epidemiology and biostatistics and a professional background in systematic review methodology, Lazur has considerable experience conducting clinical evidence research as well as systematic and rapid literature reviews to aid stakeholders in understanding complex health care topics and making evidence-based decisions. Before joining the Center, she spent four years working on systematic literature reviews at the Pacific Northwest Evidence-based Practice Center in Portland, Ore. Lazur is currently pursuing a doctoral degree in health systems and policy from Portland State University. Lily Sobolik, MPP, is a policy analyst at the Center, who has written numerous policy reports for the MED project. Sobolik is also deeply involved in the development and analysis of the Oregon Child Integrated Dataset. Prior to joining the Center, she spent three years working as a budget fellow and fiscal analyst at the Washington State House of Representatives Office of Program Research, where, among numerous responsibilities, she conducted nonpartisan policy and fiscal research and analysis of legislative and operating budget proposals related to Washington’s six public institutions of higher education, 34 community and technical colleges, and state financial aid system. Valerie King, MD, MPH, is the research director for the Center and a professor in the School of Medicine at Oregon Health & Science University (OHSU) and in the Portland State University and OHSU School of Public Health. Dr. King oversees research methods across clinical evidence and policy implementation research projects at the Center. The Center conducts systematic evidence and policy reviews, and it provides health system design services and primary research to approximately half of all state Medicaid programs. Milbank Memorial Fund • www.milbank.org 11 About the Milbank Memorial Fund The Milbank Memorial Fund is an endowed operating foundation that works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience. Founded in 1905, the Fund engages in nonpartisan analysis, collaboration, and communication on significant issues in health policy. It does this work by publishing high-quality, evidence-based reports, books, and The Milbank Quarterly, a peer-reviewed journal of population health and health policy; convening state health policy decision makers on issues they identify as important to population health; and building communities of health policymakers to enhance their effectiveness. About the Center for Evidence-based Policy The Center for Evidence-based Policy (Center) is recognized as a national leader in evidence-based decision making and policy design. The Center understands the needs of policymakers and supports public organizations by providing reliable information to guide decisions, maximize existing resources, improve health outcomes, and reduce unnecessary costs. The Center specializes in ensuring that diverse and relevant perspectives are considered and appropriate resources are leveraged to strategically address complex policy issues with high-quality evidence and collaboration. The Center is based at Oregon Health & Science University in Portland, Oregon. The Milbank Memorial Fund is an endowed operating foundation that engages in nonpartisan analysis, study, research, and communication on significant issues in health policy. In the Fund’s own publications, in reports, films, or books it publishes with other organizations, and in articles it commissions for publication by other organizations, the Fund endeavors to maintain the highest standards for accuracy and fairness. Statements by individual authors, however, do not necessarily reflect opinions or factual determinations of the Fund. © 2020 Milbank Memorial Fund. All rights reserved. This publication may be redistributed digitally for noncommercial purposes only as long as it remains wholly intact, including this copyright notice and disclaimer. Milbank Memorial Fund 645 Madison Avenue New York, NY 10022 www.milbank.org