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A new study suggests that telemedicine uptake has not shown a substantial increase in mental health treatment for patients in rural and low-access areas.
The findings highlight the need for policy interventions, said researchers from Mass General Brigham, Harvard Medical School and the Brown School of Public Health.
WHY IT MATTERS
Centers for Medicare and Medicaid Services Director Dr. Mehmet Oz told lawmakers this past year that telepsychiatry is vital, especially in places where Americans suffering from undiagnosed mental health illnesses lack access to mental health therapies.
New research indicates that pandemic-era extensions providing coverage may not be enough to change metrics.
"It is also possible that telemedicine has not led to mental health specialists treating more patients in rural communities," the researchers said in their study, "Mental Health Specialist Telemedicine Uptake and Patient Location," published earlier this month in JAMA Network.
They examined Medicare fee-for-service claims for 17,742 mental health specialists providing services from Jan. 1, 2018, to Dec. 31, 2023. The researchers reported finding that greater telemedicine uptake was associated "with only small increases in the share of visits to patients in rural, low-access-to-care, or distant communities."
There was "little evidence that greater telemedicine uptake among mental health specialists improved access to care for patients in rural communities or communities with specialist shortages," they said.
"Furthermore, the observed small differences were accounted for by established Medicare fee-for-service patients moving farther away from their specialists rather than strictly by specialists seeing more new patients from those communities."
The researchers had categorized specialists, including psychiatrists, psychologists, clinical psychologists, neuropsychiatrists, licensed clinical social workers and psychiatric mental health nurse practitioners, into quartiles based on their 2021 telemedicine and uptake.
Then, they performed supervised machine learning and statistical analyses of patients residing in mental health shortage areas (with the exception of services provided by federally qualified health centers), rural areas, different states and those living more than 20 miles from the practitioner.
Levels were stable before the pandemic, the researchers said.
"For example, specialists in the highest telemedicine group, compared with the lowest group, had a lower percentage of visits with patients living in mental health shortage areas (2% vs. 6%), in rural areas (7% vs. 17%), and 20 miles or more away (13% vs. 20%)."
However, those with high telemedicine adoption by the end of the study period were mostly based in urban areas and had already served fewer Medicare fee-for-service patients who had lower incomes and lived in rural areas before the COVID-19 pandemic onset.
"Compared with 2018 and specialists in the lowest telemedicine quartile, specialists with the highest telemedicine use had 0.88 percentage points more visits with rural patients in 2023," researchers said.
They observed similar changes in the fraction of visits with patients living in mental health specialist shortage areas, in a different state, and those living 20 miles or more away from their specialists.
Limited broadband and awareness of available telemedicine services may have reduced specialists' ability to reach patients in rural communities, while higher demand for mental health specialists may have reduced capacity to treat new telehealth patients in rural communities, the researchers said.
State coverage and licensure regulations could have also restricted specialists' abilities to treat patients in other states, they said.
Researchers suggested that health policy could incentivize specialists to prioritize populations with low access to care.
"Dedicated referral pathways may link healthcare practitioners who work in these communities to specialists with high telemedicine adoption outside the local area," they said. "Reforms to licensure regulation may facilitate cross-state practice. Financial incentives may also help."
Shifting provider reimbursements to patient locations and implementing higher rates for telemedicine visits with rural patients could also improve telepsychiatry for those in low-access and rural areas, the researchers also suggested.
The findings may not be generalizable to patients with commercial insurance, or to specialists who do not accept Medicare or treat few Medicare fee-for-service patients, the researchers noted.
THE LARGER TREND
Virtual care has been seen as a way to help address care gaps caused by a chronic shortage of mental healthcare providers in rural areas.
Dr. Sy Atezaz Saeed, founder and executive director of the Center for Telepsychiatry and e-Behavioral Health at East Carolina University, has been working on an approach to enhance mental healthcare access for rural children that he called "cost-effective and efficient."
The center created virtual mental healthcare access for about 1,000 rural children with clinical anxiety or depression that otherwise would not have been diagnosed, he told Healthcare IT News last month.
Screenings for anxiety and depression through the program took place during primary care visits at five or six clinics in some of the state's rural counties. Once children were diagnosed, technology was then able to enhance access to scarce mental healthcare, Saeed said.
They used telepsychiatry to provide the children with access to child psychiatrists.
"So they see patients, as well as connect with a team, and supervise the [embedded] master-level clinicians all using telepsych," he said.
They also created a virtual community house where they get peer support. Program clinicians also monitor NC Kids Get Well, built on the Roblox platform, for any emerging issues.
ON THE RECORD
"Together, our findings suggest that despite the dramatic shift from in-person care to telemedicine among mental health specialists, telemedicine uptake was not associated with a substantive change in the geographic distribution of patient panels of mental health specialists in the Medicare population."
Andrea Fox is senior editor of Healthcare IT News.
Email: afox@himss.org
Healthcare IT News is a HIMSS Media publication.
