Telemedicine has been a widely used resource during the pandemic, but as providers and policymakers consider its future, some continue to weigh the pros and cons of treating certain conditions from a distance – particularly mental illness and substance use.
“Patients have tended to be OK with teletherapy, but a lot of therapists feel something is lost relative to in-person therapy,” said Dr. John Markowitz, professor of clinical psychiatry at Columbia University and a research psychiatrist for the New York State Psychiatric Institute.
“The major advantage of teletherapy is that it maintains some access to treatment for many, but not all, patients. Exactly how good the quality of that treatment is is controversial,” Markowitz said, adding that research comparing telehealth with in-person therapy is sparse.
In an article published in the American Journal of Psychiatry six months into the pandemic, Markowitz and his colleagues explored the benefits and disadvantages of virtual therapy. Those negatives include maintaining a consistent intimate focus and balancing distractions but also inequities with internet access or inability to pay for a smartphone.
“Insurance plans, when they have reimbursed remote therapy at all, have arbitrarily tended to pay only for synchronous videotherapy” and not telephone therapy, the research found.
The pandemic pushed telehealth into the mainstream for all kinds of conditions, as stay-at-home restrictions forced some medical facilities to close and new COVID-19 variants kept patients at home.
For many Americans, mental health deteriorated, substance use increased and overdose deaths hit new highs over the past two years. People of color were hit especially hard, research shows.
Black and Hispanic adults have been more likely than white adults to report symptoms of anxiety or depression during the pandemic, according to the Kaiser Family Foundation. And Native Americans, who have faced the highest rates of COVID-19 deaths in the nation, have long experienced disproportionate rates of suicide.
These communities also struggle to access and pay for behavioral health care.
The $2 trillion CARES Act helped expand mental health and substance use services, as well as telehealth, during the pandemic. Federal research shows the percentage of mental health facilities using telemedicine increased to almost 70% in 2020 from 38% in 2019, while the percentage of substance use treatment clinics using telehealth jumped to 58.6% from 27.5%.
The Substance Abuse and Mental Health Services Administration is prioritizing expanding telehealth access for mental health and substance use disorders.
In a recent report, the agency noted that telehealth can increase treatment in medically underserved communities or those lacking providers. But the report also noted drawbacks. For example, seniors, people living in poverty and people of color report lower rates of smartphone ownership and broadband access.
From March 2020 to March 2021, 22 states implemented policies that would provide better insurance coverage for telemedicine, according to a report by The Commonwealth Fund.
In May, Arizona Gov. Doug Ducey signed legislation to expand access to telemedicine for patients, ensure doctors receive equal compensation from insurance companies for telemedicine, and allow out-of-state health care professionals to provide telemedicine in Arizona.
“Telehealth expands access to medical services for low-income families and those living in rural areas, protects vulnerable populations, and allows snowbirds visiting our state to receive telemedicine from their home state,” Ducey said.
Removing obstacles to care is especially important in Arizona, which ranks 46th in the nation for access to insurance, treatment and providers for mental health conditions, according to the national nonprofit Mental Health America.
Although many providers applaud the changes, some remain wary.
Vanessa Andersen is a registry nurse for Copa Health, a nonprofit that cares for patients living with developmental, intellectual or behavioral challenges across the Phoenix area. The center accepts in-person visits only under specific requirements, and all therapeutic appointments are done on Zoom.
For Andersen, in-person visits are limited to those who require risk assessments, medications, prescription pickup and court-ordered treatments. She worries that conditions she’d easily spot during face-to-face visits could be missed over video calls.
“A patient can say ‘I’m fine’ over the phone but cry,” Andersen said. “A patient may say they are eating and sleeping well but physically are not well. Patients that are not seen can have signs of abuse, whether it be physical, mental or emotional.”
Many of Andersen’s patients are dealing with poverty, homelessness or substance use, making access to technology that much more challenging.
“Phones and tablets are a last priority considering some don’t know where the next meal is coming from or where they’re going to sleep for the night,” she said. “Not all but many patients are homeless and need housing. There are so many guidelines and criteria that they need to meet to even qualify for housing. At times there is a waitlist for years for some assistance.”
For those who do have a phone or computer, accessibility or other technical issues can still get in the way of making appointments, Andersen said.
Although telemedicine can help increase access, Markowitz said, he agreed that it’s not a perfect solution.
Beyond that, Markowitz said, some patients simply can’t afford to burn minutes on their phones.
“This is the technological equivalent of more widespread economic unfairness in access to health care,” he said. “If you have good insurance, you can afford good treatment; otherwise, you may be out of luck. It’s a disgrace that our rich country has insurance companies with profit motives rather than trying to help its entire citizenry.”
Telemedicine story by Jenna Sauter, Cronkite News