A telemedicine consultation

Accessing mental health services can be difficult. For example, in 2019, a middle-aged mother with a history of trauma and alcohol use missed three appointments in a row with her psychiatrist.  She was nearly discharged from treatment for “lack of interest.” What happened?

Steven Madonick, MD

In fact, she could not travel to her appointments because she could not afford to repair her car and her trauma symptoms prevented her from getting on a bus or using a ride service. She was ashamed to share these reasons. However, when COVID-19 hit and telehealth first became widely available and reimbursed in Connecticut as part of the emergency measures, she was able to see her psychiatrist without leaving her home. After that, she attended every appointment.

An older man with psychotic symptoms lived apart from his ex-wife in a single room occupancy hotel. He had no access to a computer, a smartphone, or broadband and so could not get treatment by telehealth. Without treatment, he would likely require hospitalization in facilities overwhelmed by COVID-19. Fortunately, he did have a state-issued cellular telephone. The pandemic emergency measures permitted full reimbursement for telephonic appointments. He was able to continue treatment by telephone and has remained stable during the pandemic. (Batterson et al).

We face a critical challenge during Connecticut’s 2021 legislative session. At some point this year, authorities will lift the COVID-19 emergency measures that authorize and fairly reimburse telehealth and telephonic care. Our state senators and representatives need to preserve access to these critically necessary services for people with mental health and substance use challenges.

States like California, Georgia, Colorado and Massachusetts have already passed legislation to compel private insurers to reimburse telehealth and audio only services with parity (State Telehealth Laws & Reimbursement Policies). Additionally, the American Psychiatric Association has developed model legislation for implementing these services at the state level (APA model legislation).

As the President of the Connecticut Psychiatric Society (CPS), I have witnessed the benefits of telehealth, which have greatly exceeded expectations. At Community Health Resources, where I serve as medical director, the switch to telehealth has decreased no show rates to between 5 and 10%. This contrasts with outpatient clinics serving patients in person which often have no-show rates of up to 30%.  Additionally, patient satisfaction with telehealth has been very high (Medalia et al, Yellowlees et al, Uscher-Pines et al). We must not exclude patients from receiving necessary care because they lack reliable transportation, broadband, computers, or smart phones. With telehealth and telephonic care, more patients are getting the treatment they need.

There are also advantages of telehealth for providers. The reduced no-show rate boosts revenue for chronically underfunded not-for-profit organizations that often treat our patients. These non-profits may also be able to reduce expenses for office space as practitioners increasingly use telehealth and work from home. The efficiency and cost of providing mental health treatment may be improved by telehealth and telephonic services.

To be sure, the long-term benefits and limitations of telehealth need further study. Fully compensating telehealth and telephonic care will increase costs to Medicaid and private insurers. Nevertheless, if telehealth allows us to reach the nearly 30% of patients who currently do not consistently attend in-person appointments, the gains will be substantial. Improvements in recovery from mental illness and substance use diagnoses will give patients greater independence and improve their health and dignity. These have been goals of mental health providers and advocates for decades.

The year 2020 proved to be unique and vexing. We were confronted with the pandemic, an economic crisis, and renewed evidence that inequality, discrimination, and racism persist in our country. The implementation of telehealth and telephonic care, which may significantly improve healthcare access, engagement, and outcomes has been a rare source of good news. Telehealth will help expand access to mental health and substance use services, which we will need to care for the increased number of people likely to seek mental health and substance use treatment as a result of the pandemic.

Telehealth may lead to positive, even transformational changes in psychiatric care, and Connecticut needs to keep it after the pandemic. Connecticut needs to pass the necessary laws to continue telehealth and telephonic care.

Steven Madonick, MD, is President of the Connecticut Psychiatric Society.

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