Editor’s Note: Massachusetts led the nation in rapidly deploying progressive new policies to temporarily expand access to telehealth across payers and providers during the COVID-19 pandemic—prompting exponential growth in the use of telehealth, including telebehavioral health—in just a few months.
In a new report prepared on behalf of the Blue Cross Blue Shield of Massachusetts Foundation, Manatt Health explores the potential for expanding access to behavioral health services in Massachusetts through telebehavioral health. The report, summarized below, proposes a framework for an optimal telebehavioral health system of care, highlights barriers to adoption experienced by providers and consumers, and identifies opportunities for promoting and expanding access to telebehavioral health, including sustaining the policy advances that have been made during the COVID-19 pandemic. It includes lessons and recommendations valuable to all states considering expanding their telebehavioral health capabilities. Click here to access a free copy of the full report.
Telebehavioral healthcare has the unique ability to improve access to behavioral health services by increasing connectivity between patients and providers of behavioral healthcare resources, decreasing wait times and eliminating logistical barriers. This is especially true for populations with particularly challenging access barriers, such as individuals who are low income or live in rural areas, children, the elderly and individuals with substance use disorders (SUDs). As adoption continues to grow, telebehavioral health is being recognized for its distinct ability to bring care closer to home and break through the financial, logistical and geographic barriers often experienced by vulnerable populations.
DEFINING TELEBEHAVIORAL HEALTH AND COMMON CARE DELIVERY APPROACHES
Manatt Health defines telebehavioral health as the use of technology to create, promote or maintain access to behavioral health services, including services to treat mental health disorders, SUDs and co-occurring disorders. Telebehavioral health interactions typically occur either between a provider and a patient or between a provider and another provider (e.g., a consult) to deliver various services across the behavioral health continuum of care.
OPTIMAL TELEBEHAVIORAL HEALTHCARE DELIVERY MODEL
After reviewing the existing literature and interviewing experts and key stakeholders from across Massachusetts, Manatt developed a framework of the key characteristics of an optimal telebehavioral healthcare delivery model. The elements of an optimal telebehavioral health delivery model are organized within two distinct categories: clinical features and operational features.
Clinical features of an optimal telebehavioral healthcare delivery model include:
- Complementary in-person care. Emerging evidence suggests that telebehavioral healthcare interventions are generally most effective when paired with in-person treatment. The convenience of telebehavioral healthcare improves treatment adherence and consistency.
- Integration or colocation with physical healthcare. The holistic or “whole person” care model, which integrates behavioral and physical care, is recognized as a more comprehensive and effective method of care delivery. The behavioral health needs of a patient often have significant implications for their physical health, and vice versa.
- Evidence-based. As with any type of clinical intervention, telebehavioral health programs should be grounded in evidence-based practices, such as those put forth by the American Telemedicine Association and the American Psychiatric Association, that have proved to be safe and effective for patients.
- Efficient clinical staffing model. Where possible, in larger group practices or organizational settings, an optimal telebehavioral healthcare program should employ an efficient resource model in which a broad spectrum of behavioral health provider types deliver care based on the acuity of the patient.
Operational features of an optimal telebehavioral healthcare delivery model include:
- Accessible and affordable. For a program to expand access to services, it must be accessible and affordable to consumers. Cost of care, site location, language accessibility, cultural considerations and hours of business should be tailored to meet the needs of the population. When clinically appropriate and allowable under payer coverage policies, telebehavioral healthcare programs should enable patients to receive services from home, thereby eliminating many privacy, cost and logistical barriers.
- Safe and private environment for patients. Access to a safe and private environment for delivery of telebehavioral health services is essential to patient privacy and comfort, and to the efficacy of the service.
- Secure and reliable HIPAA-compliant technology. As with any other healthcare program that touches protected health information, the technology used to conduct telebehavioral healthcare must be secure, reliable and compliant with the Health Insurance Portability and Accountability Act (HIPAA).
- Multimodal technology. Optimal telebehavioral health programs encourage consumer adoption and adherence by making the communication simple, easy-to-use and reflective of consumers’ multimodal communication habits. An ideal telebehavioral healthcare intervention would enable patients to consult their providers via secure message, telephone and video, depending on their specific need.
RECOMMENDATIONS TO ADDRESS BARRIERS AND PROMOTE PROVIDER AND CONSUMER ADOPTION
The following is a summary of the common barriers to enabling the delivery of and access to telebehavioral health services, along with a series of recommendations in multiple domains to address each unique barrier—coverage and reimbursement in the state’s Medicaid program (MassHealth), coverage and reimbursement for commercial plans, and provider and consumer needs and preferences to promote adoption of telebehavioral health services.
Domain 1: Coverage and reimbursement: MassHealth
Barrier: Lack of clarity that the patient home is an eligible originating site
Recommendation. Clarify MassHealth coverage of services delivered in the home. MassHealth took an important step in 2019 (through All Provider Bulletin 281 and Managed Care Entity Bulletin 10) to expand access to telebehavioral health services and to pay for behavioral health services delivered via telehealth at the same rate as in-person services. Given the confusion providers have expressed around eligible originating sites, MassHealth should explicitly state that Bulletin 281 allows patients to be seen in their homes or wherever they may be located.
Domain 2: Coverage and reimbursement: commercial payers
Barrier: Lack of clarity around private payer coverage of telehealth
Recommendation. Clarify coverage for and enable all in-network providers to deliver telebehavioral health. The state should provide clarity around the healthcare services that are required to be covered via telebehavioral healthcare, to create greater consistency across coverage policies among private payers and to promote greater opportunity for utilization of telebehavioral health services among providers. In addition, private payers should expand coverage for telebehavioral health services to include all in-network providers.
Barrier: No private payer parity law
Recommendation: Ensure a payment parity law. Reimbursement for telebehavioral health services that is on parity with reimbursement for in-person care delivery is the most critical enabler of adoption for many behavioral health providers. Many states have enacted legislation that requires commercial payers to provide payment parity for telehealth services. Both academic literature and field experts suggest payment parity legislation has the greatest potential to improve adoption rates.
Domain 3: Provider barriers to offering telebehavioral healthcare
Barrier: Provider concerns about malpractice risks.
Recommendation: Address concerns about medical malpractice liabilities. Provider organizations should address concerns about medical malpractice liabilities related to telebehavioral health by ensuring that providers have the appropriate malpractice coverage in place for providing telebehavioral health services, clarifying medical malpractice liabilities arising from practicing telehealth, and promoting best practices in reducing liability when delivering behavioral health services virtually.
Barrier: Lack of appropriate telehealth technology and equipment and familiarity with using it.
Recommendation: Broadly implement HIPAA-compliant technology and provide education and consumer support. Many inexpensive HIPAA-compliant telehealth technology options are available. Some health plans are equipping their providers with HIPAA-compliant telehealth technology free of charge as a way to address this barrier and encourage the use of telebehavioral healthcare. Provider organizations should do the same to ensure that each individual provider has the ability to deliver telebehavioral health services should they so desire.
Recommendation: Develop technical assistance programs for providers. Technical assistance programs could help providers who lack adequate funding sources acquire HIPAA-compliant technology, receive telehealth training and offer patients user support, among other activities. These programs should be funded and orchestrated at the state level to provide behavioral health providers with guidance, training and/or technology to improve their ability to care for patients via telebehavioral health.
Barrier: Resistance to change and lack of provider training on best practices for incorporating telebehavioral health into practice.
Recommendation: Explore opportunities to challenge the status quo (i.e., in-person treatment). Health system and provider group leaders should challenge the status quo, in which treatment is provided in person only, by encouraging providers within their organizations to deliver behavioral health services virtually and supporting them in doing so.
Recommendation: Expand the evidence base. While there is a growing body of evidence about the effectiveness of telebehavioral healthcare, many studies are less than a decade old, have small or unrepresentative pools of participants, and/or lack an in-person treatment control group. Large health systems and academic medical centers can play a crucial role in developing the evidence base by providing seed funding to launch evidence-based research regarding the efficacy of telebehavioral healthcare for different populations.
Barrier: Out-of-state licensure
Explore opportunities to implement cross-state provider licensure. Policymakers should take steps that would enable behavioral healthcare providers located in other states to deliver care to residents via telehealth. There are a few actions that policymakers could take to achieve this end:
- Join PSYPACT to enable psychologists from other states to facilitate telebehavioral care with patients in Massachusetts.
- Join the IMLC to accelerate the speed with which psychiatrists in other states can obtain licensure to practice in Massachusetts.
- Create special-purpose telehealth licenses that would enable behavioral healthcare providers in other states to deliver telebehavioral health services to Massachusetts residents.
Domain 4: Consumer barriers to accessing telebehavioral healthcare
Barrier: Limited access to providers who accept insurance for telebehavioral health services.
Recommendation: Address long-standing access challenges within the broader behavioral healthcare system. This set of barriers extends beyond the scope of challenges that are specific to telebehavioral healthcare. Consumers have consistently cited difficulty in finding behavioral health providers who accept insurance, and these challenges are exacerbated for consumers with public insurance. Addressing some of the more long-standing challenges in the broader behavioral health system, including having a sufficient workforce to meet demand and providers with the appropriate credentials, training, diversity and acceptance of insurance, will require a systemic approach beyond the scope of this article.
Barrier: Apprehension about the virtual care experience and lack of awareness of telebehavioral healthcare options.
Recommendation: Promote consumer awareness and utilization of telebehavioral health. There is an opportunity for a broad coalition of stakeholders to collaborate in a public effort to promote consumer awareness and adoption of telebehavioral health. Stakeholders should collaborate to develop a broad-based, multichannel consumer education campaign to increase awareness of telebehavioral healthcare options and create user support materials to educate consumers on how to access the full range of telebehavioral health services.
Recommendation: Allow for telephone-only telebehavioral health visits. In addition to continued coverage of and reimbursement for telebehavioral health services delivered via video platforms, the state should maintain temporary policies enacted during the COVID-19 pandemic allowing for coverage and reimbursement of telebehavioral health services delivered via telephone only.
Recommendation: Expand access to Internet and cellular service and technology for low‑income and rural populations. Several initiatives underway at the state and federal levels aim to address Internet and cellular service access issues. In an effort to facilitate telehealth access for low-income individuals in response to the COVID-19 pandemic, several of the major Internet providers and the four major U.S. cellular carriers are temporarily offering low- or no-cost Internet and cellular service. Additionally, in response to MassHealth member and provider concerns about limited phone and Internet access during COVID-19, MassHealth, with assistance from the Massachusetts Department of Telecommunications, developed a resource that describes the available discounted or free Internet and cell service options or devices, including many temporary offers related to COVID-19.
The telebehavioral healthcare landscape within Massachusetts and across the United States continues to develop. Massachusetts is well positioned to maintain and build upon its recent efforts to expand access to telebehavioral healthcare within the MassHealth program, and to take actions that will drive awareness and adoption of telebehavioral healthcare across all payers, providers and consumers.
As the COVID-19 crisis began, Massachusetts was a national leader in rapidly deploying progressive new policies to temporarily expand access to telehealth across payers and providers during the pandemic. We anticipate that these changes will catalyze a huge leap forward in payer coverage, provider adoption and consumer utilization of telebehavioral health across the Commonwealth.