Behavioral Health Faces Challenges During and After the Pandemic

Behavioral Health Faces Challenges During and After the Pandemic

Public and private insurers need to continue allowing psychiatrists and other behavioral health clinicians to see patients via telehealth even after the pandemic ends, Lori Raney, MD, said at this year’s Population Health Colloquium.

“My worry is that we’re going to go back to the Dark Ages as soon as the public health emergency is over,” said Raney, a psychiatrist and principal at Health Management Associates, a Denver healthcare consulting firm. She spoke on Tuesday at the colloquium, which was held virtually this year due to the pandemic.

“We’re already starting to see it; state Medicaid agencies that allow billing telephone visits are saying ‘We’re going to stop these.’ Major insurers are already calling companies and saying, ‘You can no longer use telehealth,'” she said.

Raney said it happened to her personally when she heard from one large, nationwide commercial insurer who told her that as of Oct. 15 it was no longer going to cover telehealth psychiatric visits. “It’s what patients want; it helps us get to them; and that really, really worries me,” she said.

Telehealth’s Challenges

Telehealth for behavioral health is easier than for any other specialty because “you don’t have to lay on hands,” said Raney. And of course it’s very convenient. “I’ve had the lowest no-show rate I’ve ever had. The patient doesn’t have to drive to see me — I can pick up the phone and call them, or FaceTime. I can reach a lot of people and have a sense of their home environment — maybe even talk to their families.”

That’s not to say that telehealth hasn’t had its challenges, she continued. The first one was with the staff: “Our staff had to learn how to do it; some love it, some hate it.”

The second challenge? “We’ve had to prepare our patients,” including explaining the right environment to be in for the appointment, Raney said. “We’ve had them in the bed, in the grocery store, in the car, in various forms of dress, with people behind them listening to our session.” In addition, in some cases, “we had to call the day before and have a navigator or someone help them download the technology so they’re ready for the appointment.”

Although telehealth participation is still high, “we’ve found a little bit of drop off in engagement. It was exciting and interesting at first, and now we’re getting more no-shows — didn’t answer the phone, didn’t answer the video, weren’t around when it was time for their appointment,” she said. “We haven’t quite figured out what to do around patient engagement.”

Showing Effectiveness

Another issue is getting in the data needed to prove to payers that telehealth is really effective. “If we want payers to pay us, we actually have to prove there’s value in it,” such as by demonstrating that a patient’s “PHQ [Patient Health Questionnaire]-9, which is a measure of depression, is coming down, whether their substance abuse is being reduced … They used to come into a primary care clinic and get a piece of paper or an iPad or go to a patient portal and fill out these tools that help us monitor their progress, so now we’re really struggling with that. I’ve been talking to clinics in the last couple of weeks about them actually not meeting some of their quality metrics,” Raney said.

Meanwhile, behavioral health practices also are dealing with patients who prefer to be in the office. “They don’t care if they have to wear masks or use hand sanitizer or get their temperature taken … We’ve actually had to knock down walls at mental health facilities because we can’t get 6 feet apart in tiny therapy offices,” she noted.

But seeing patients in person can be good because “I get a lot out of being able to see and smell for alcohol and dealing with a patient who is psychotic” and thinks telehealth is part of a government conspiracy. “I need to see if someone has had any self-harm, looking at wrists and other places” on the body.

For substance abuse patients, the pandemic has brought about several positive changes, she noted. “We’ve had a major relaxation of rules by DEA [the Drug Enforcement Administration] and other federal agencies to allow us to do home induction” so patients don’t have to come into the clinic to get their medications, but that could all go away once the pandemic is over.

Michael Consuelos, MD, MBA, senior medical advisor at NeuroFlow, an integrated behavioral health company, agreed. “We as physicians are able to get people addicted on opioids very easy, but they put a lot of barriers for helping us to treat them using medication-assisted treatment” and other therapies, he said.

Provider Concerns

Raney also expressed concern about healthcare providers abandoning the workforce due to burnout and other issues. “That’s a real issue in the next 12 to 18 months,” she said.

One problem is a lack of personal protective equipment for those who see patients in person. “We’re at the bottom of the list to get it.” In addition, she said, some behavioral health workers are “hanging on by a thread” financially. “One study found a third of two thirds didn’t have 3 months’ worth of reserves to keep going.”

And as mental health providers are in danger of burning out or being laid off due to a lack of funding, a predicted increase in the need for mental health services due to the pandemic has come to pass.

“We anticipated a spike in depression, anxiety, substance abuse, PTSD [post-traumatic stress disorder],” as well as domestic abuse, said Raney. “We predicted this in May and it’s come to fruition, unfortunately. What happens if the behavioral health workforce … is let go because there’s not the funding for it? In the next 12 to 18 months, we have to address the workforce and these new behavioral health issues that are spiking.”

One way to do that is to come up with different ways to use psychiatrists. “With a lot of adjustment disorders and common behavioral health conditions, the primary care provider can pick up the phone and call me; we can have a 6-minute conversation and I can help them through that, instead of referring patients to me and them waiting 6 months to see me,” Raney said. “In this next 12-18 months, we have got to do something different about behavioral health.”

Part of addressing mental health patients’ needs should involve considering their social determinants of health (SDOH), said Trisha Swift, DNP, RN, vice president for innovation and transformation at ZeOmega, a population health management firm in Plano, Texas.

“Patients’ ability to engage in a care plan is going to be set back” if they don’t have access to good nutrition, transportation, or social connection. But behavioral health providers can’t even begin to really determine how well they’re doing in this area “because we have yet to have a national definition of what SDOH are,” she said.

“Without a data definition, we can’t even really begin to collect it, and set standards around it,” she added. “We have to realign incentives in a way where we’re working on upstream problems, the root of issues, so the outcomes we all want to see, become reality.”

  • Joyce Frieden oversees MedPage Today‚Äôs Washington coverage, including stories about Congress, the White House, the Supreme Court, healthcare trade associations, and federal agencies. She has 35 years of experience covering health policy. Follow

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