Telehealth Treatment for Alcohol Use Disorder Associated With Patient Retention

Patients with alcohol use disorder (AUD) who receive treatment via telehealth are more likely to engage in more psychotherapy visits and have a longer duration of medication treatment compared with those who have only in-person visits, according to a study published this week in Alcohol, Clinical and Experimental Research.

“Evidence-based treatment for AUD differs from other substance use disorders in that it includes multiple psychotherapy and medication options,” wrote Ponni V. Perumalswami, M.D., of the VA Ann Arbor Healthcare System and colleagues. “Evaluating telehealth delivery of treatment to vulnerable patients, including those with AUD, is particularly important in the current context as the United States debates whether to sustain or revoke pandemic-era policies that decreased barriers to telehealth.”

Perumalswami and colleagues analyzed electronic health record data from the Veterans Health Administration (VHA) during the year following the start of the COVID-19 pandemic (between March 1, 2020, and February 28, 2021). They included 138,619 patients aged 18 or older who were diagnosed with AUD in the year prior to or during the study period and who had at least one AUD treatment visit. AUD treatment included an individual or group psychotherapy visit and/or AUD medication coverage (defined as the number of days covered by a filled prescription for AUD). The authors used VHA codes to determine whether patients received their treatments via video, telephone, or in person.

During the study period, 52.8% of participants had at least one video visit, 38.1% had at least one telephone visit but no video visits, and 9.1% had only in-person visits. Telehealth was associated with a greater number of psychotherapy visits and medication coverage days compared with in-person visits for both patients initiating and continuing treatment during the study period. Further, among those who received any treatment via telehealth, those who had video visits had a significantly greater number of psychotherapy visits compared with those who only had telephone visits.

Participants who had only in-person visits were more likely to be initiating AUD treatment and were older, male, Black, rural, homeless; they were also more likely to have an opioid and/or stimulant use disorder. Additionally, among participants who received any treatment via telehealth, those who were 45 years or older, Black, and diagnosed with a cannabis or stimulant use disorder or serious mental illness were less likely to receive video compared with telephone visits. The authors noted that this finding highlights “important disparities in AUD telehealth use.”

“Additional efforts to increase the engagement of certain VHA patient groups in telehealth use should be made, given its association with receiving more AUD treatment,” the authors concluded. “This study offers insights into patient characteristics associated with AUD treatment in an era of expanded telehealth and suggests that future policy changes in telehealth should be carefully considered given the potential to widen disparities in care.”

For related information, see the Psychiatric News article “Federal Telehealth Policy Changes After COVID-19 Public Health Emergency.”

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Strong Patient-Therapist Alliance Possible in Nontraditional Inpatient Settings, Study Finds

Individuals in nontraditional inpatient care settings such as residential care and virtual hospitalization can develop strong therapeutic alliances with their care providers, reports a study in Psychiatric Services in Advance.

“Although inpatient care is considered the standard approach for acute states, efforts have been made in recent years to develop alternatives to hospitalization,” wrote Avraham Friedlander, Ph.D., of Ariel University, Ariel, Israel, and colleagues.

“Because alternatives to psychiatric hospitalization ground their treatment approach in therapeutic principles that differ from those of traditional inpatient care, whether the alliance will develop in a similar manner remains unclear.”

Friedlander and colleagues recruited 188 patients from three treatment settings:

• A standard inpatient psychiatric ward at a medical center.
• A residential care center known as Soteria House, which has a full professional staff but aims to create “a nonhierarchical and nondiagnostic environment … with medication not considered a first-line treatment.”
• A telepsychiatry-based hospitalization in which patients recover at home but have ongoing monitoring and online access to psychiatrists, nurses, and other professionals 24/7.

Each patient and therapist (the psychologist, social worker, or psychiatric nurse who spent the most regular time with the patient) completed the Session Alliance Inventory following the first therapy session and again at discharge or treatment termination. The Session Alliance Inventory tracks how both participants in the therapeutic relationship feel on issues such as being appreciated, agreement on therapy goals, and development of a bond.

Patients in all three settings reported a strengthening of the therapeutic alliance over time, with no significant differences among the groups. Therapist responses, however, showed some differences, with therapists at the online hospital reporting a stronger therapeutic alliance at baseline compared with therapists in the other two settings. Friedlander and colleagues suggested that the novelty of online patient care and its nonstigmatizing nature may have helped therapists engage more rapidly with their patients, but more research is needed.

The Soteria therapists reported significant strengthening of bonds over time, however, and by the time of patients’ discharge, the therapist-reported therapeutic alliance at Soteria was almost as strong as for the online therapists.

“These findings suggest that alternatives to psychiatric hospitalization enable alliance to develop in a manner similar to that in traditional psychiatric hospitalization,” the researchers concluded. “To further advance research and clinical care, additional studies are needed to assess the effects of these dynamics on recovery, stigma, social inclusion, and therapeutic outcomes.”

To read more on this topic, see the Psychiatric News article “When Prescribing, Remember the Power of the Doctor-Patient Relationship.”

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Psychiatrists, Patients See Important Gains in 2024 Medicare Physician Fee Schedule

APA advocacy scored important victories for psychiatrists and patients in the 2024 Medicare Physician Fee Schedule, released by the Centers for Medicare and Medicaid Services (CMS) last week. These include policies regarding physician reimbursement, outpatient telepsychiatry, MIPS (Merit-Based Incentive Payment System) reporting, and virtual supervision of trainees. The new policies will go into effect January 1, 2024.

Importantly, CMS accepted APA’s recommendation to increase the relative value units (RVUs) for psychotherapy codes used alongside a code for an evaluation and management (E/M) services by approximately 19.1%, phased in over four years. For 2024, this will result in an increase in payment for psychotherapy visits of between $3 and $6.

Additionally, CMS approved a new E/M add-on code (G2211), which can be used in addition to codes for outpatient E/M services to recognize the resource costs associated with care of patients with chronic or complex conditions.

The 2024 fee schedule also includes good news for psychiatrist in the following areas:

• CMS extended through 2024 the current temporary policy to reimburse outpatient telepsychiatry in the patient’s home (code POS 02) at the same rate as in-person care. (The patient’s home can include temporary lodgings or other community-based settings.)
• Medicare practitioners may continue to report their practice location instead of home address when providing telehealth services from their homes.
• Payment for telehealth services delivered by Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) without a prior in-person visit will be extended through 2024.
• Through 2024, resident physicians can continue to be virtually supervised when they are delivering telehealth—an important APA advocacy priority. However, in-person care delivered by residents must still be supervised in person, and resident training sites should be prepared to provide in-person supervision beginning in January. (An exception to this is if the resident and patient are in rural areas; in which case virtual supervision is permitted.) This issue will continue to be an APA priority for the 2025 Medicare fee schedule.
• CMS will maintain the MIPS reporting threshold for neutral payment adjustments at 75% for an additional year, alleviating the pressure to increase MIPS reporting.
• CMS payment for audio-only periodic assessments in opioid treatment programs is extended through 2024.
• Services in intensive outpatient programs (IOP) will be covered when delivered by hospital outpatient departments, community mental health centers, RHCs, and FQHCs.

To learn more about what this news might mean for psychiatrists, register to attend APA’s 30-minute live discussion of 2024 Medicare Physician Fee Schedule & Telehealth Policy Updates next Thursday, November 16, starting at noon.

For more information, also see the 2024 Physician Fee Schedule fact sheet and look for additional coverage in the December issue of Psychiatric News.

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Patients Found Less Likely to Cancel Telepsychiatry Visits, Study Shows

Patients with depression who scheduled an appointment to see a psychiatrist between July 2020 and October 2022 were less likely to miss or cancel the appointment if it was virtual compared with in person, according to a report published today in Psychiatric Services.

“Appointment completion was higher for telepsychiatry than for in-person care among all patient characteristics studied,” wrote Catherine K. Ettman, Ph.D., of Johns Hopkins Bloomberg School of Public Health and colleagues. The findings “suggest that telepsychiatry is associated with improved efficiency and continuity of care.”

The researchers examined electronic health records for 12,894 patients aged 10 or older with a diagnosis of depression who scheduled 586,266 psychiatric outpatient appointments at Johns Hopkins Medicine between November 2017 and October 2022. They compared the number of in-person and telepsychiatry appointments that patients completed, cancelled, or failed to show up to before the pandemic with these outcomes of in-person and telepsychiatry appointments scheduled from July 2020 to October 2022. (The researchers did not analyze the appointment trends between March 2020 and June 2020 due to the fall in overall appointment completion rates caused by the pandemic.)

Prior to the pandemic, the number of patients who scheduled and completed in-person appointments vastly outnumbered those who scheduled and completed telepsychiatry appointments. Between July 2020 and October 2022, however, telehealth appointments outnumbered the in-person appointments. During this period, 13.3% of telepsychiatry appointments were canceled compared with 18% of in-person appointments.

Overall, telepsychiatry appointments were 1.30 times more likely to be completed than in-person appointments. Moreover, the likelihood that a telepsychiatry appointment would be completed relative to an in-person appointment increased steadily between July 2020 and October 2022. Ettman and colleagues noted that the increased likelihood of completion of telepsychiatry appointments remained regardless of the patient’s age, gender, race, insurance, or employment status.

“[H]ealth systems may wish to maintain telepsychiatry to optimize delivery of care and to improve patient outcomes,” Ettman and colleagues wrote.

However, they noted that telehealth may not be accessible to all patients and may exacerbate existing disparities. For instance, they found that patients who were younger, female, White, employed, or had higher socioeconomic status or private insurance were significantly more likely to schedule telepsychiatry appointments compared with in-person appointments after the pandemic’s onset.

“These findings merit future study,” they wrote. “Additional research on patient preferences, potential disparities in access to care, and efforts to reduce barriers to telehealth is warranted.”

For related information, see the Psychiatric News article “After the Pandemic: What Will the ‘New Normal’ Be in Psychiatry?”

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Prepare Now for End of Public Health Emergency, Telepsychiatry Experts Advise

In a webinar today, APA leaders in telepsychiatry urged psychiatrists to start working with their telepsychiatry patients now to prepare for the end of COVID-19 Public Health Emergency (PHE) on May 11.

Shaban Khan, M.D., director of child and adolescent telepsychiatry at NYU Langone and chair of the APA Committee on Telepsychiatry, and John Torous, M.D., director of the Digital Psychiatry Division at Beth Israel Deaconess Medical Center and chair of the APA Committee on Mental Health Information Technology, outlined what psychiatrists need to know about the status of telepsychiatry in terms of prescribing medications, licensing, HIPA-compliant modalities for telepsychiatry, and coverage and reimbursement.

“We know that the landscape of psychiatry has fundamentally changed with the rapid increase in telehealth modalities throughout the COVID-19 public health emergency,” said Khan. “Federal and state governments have some authority to maintain elements of these flexibilities, but cannot—or in some cases, choose not to—maintain them all. So, when the PHE ends on May 11, 2023, some flexibilities will remain on a permanent basis, some will phase out, and some remain uncertain.”

During the webinar, Khan shared one important new piece of information: The Centers for Medicare and Medicaid Services (CMS) will not reimburse for partial hospitalization services delivered in the patient’s residence beyond the PHE. Partial hospitalization services can be delivered only in hospitals and community mental health centers starting May 12.

Some PHE flexibilities were extended or made permanent under Medicare. These include the following:

• Audio-only telehealth services for mental health and substance use disorders will be reimbursed on a permanent basis.
• In-person visit requirements for mental health services have been deferred through the end of 2024.
• Restrictions on geographic originating sites (the location where a Medicare patient gets medical services through a telecommunications system) have been permanently removed, including patients’ homes.
• Psychiatrists will be reimbursed for telepsychiatry services at nonfacility rates through the end of 2023, but beginning on January 1, 2024, Medicare will revert to paying the lower facility rates.

Other Medicare policies will revert to their pre-PHE status. For instance, after May 11 psychiatrists cannot bill Medicare for services delivered in states in which they are not licensed (in fact, most states have already ended those licensure flexibilities). Additionally, psychiatrists must use HIPAA-compliant technology, although the government announced an extension on enforcing this for 90 days after the end of the PHE to August 9. “You can help your patients by starting now to adopt and teach them about HIPAA-compliant communications platforms,” Torous said.

Finally, virtual supervision of psychiatry residents treating Medicare beneficiaries is scheduled to end on May 11, though APA has asked CMS to reconsider this provision.

Still other policies, especially the details of prescribing controlled substances to telepsychiatry patients, are still to be determined. In February the Drug Enforcement Administration (DEA) proposed rules about how to maintain some telehealth prescribing flexibilities after the PHE. 

“APA submitted comments suggesting extensive revisions to these rules, but we will not know the final contents or timeline of the rules until the final rules are published in the Federal Register,” Torous said. “If not finalized, the rules will revert to pre-public health emergency rules.

“In addition, the current rules are vague on where you have to be to prescribe controlled substances, but it is safe to proceed under the assumption that you will continue to need a physical location in order to obtain a DEA registration in any given state and that you will need a DEA registration in order to prescribe in the state,” Torous said. “Like controlled substances prescribing, assume that you will need to be licensed where your patients are.”

Look to Psychiatric News for further updates and to the Telepsychiatry Toolkit, Telepsychiatry Blog, and COVID-19 and Telepsychiatry Frequently Asked Questions. Members may also register for a webinar in May titled “Telepsychiatry Reimbursement: Who Pays for What?”

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Telepsychiatry Collaborative Care Found Effective for Treatment of Complex Disorders in Rural Areas

Telepsychiatry collaborative care (TCC) can help primary care clinicians working in rural or underserved areas to identify and treat patients with posttraumatic stress disorder (PTSD) and bipolar disorder with more confidence. These were the findings of a report published today in Psychiatric Services, which describes how care managers, primary care clinicians, and telepsychiatrists work together to support these patients.

Theresa J. Hoeft, Ph.D., of the University of Washington and colleagues analyzed data from the Study to Promote Innovation in Rural Integrated Telepsychiatry trial. The trial was conducted in 24 community health centers associated with 12 Federally Qualified Health Centers (FQHCs) in underserved areas of Arkansas, Michigan, and Washington between 2016 and 2020.

As part of this trial, patients with PTSD or bipolar disorder were randomly assigned to receive TCC or referral for direct treatment by a telepsychiatrist or telepsychologist for up to 12 months. Patients in the TCC group saw a telepsychiatrist over a videoconference for an initial visit. The consulting telepsychiatrist then communicated the diagnosis and treatment plan through the electronic health record or the care manager to the primary care clinician, who oversaw the patients’ care (including prescribing medications).

Hoeft and colleagues conducted 30- to 60-minute interviews with 22 primary care clinicians who had patients assigned to the TCC group. Clinicians were asked to describe their role on the TCC team, experiences communicating and working with team members, and the extent to which TCC changed how they managed patients’ mental health care. The authors highlighted several key takeaways from these interviews:

• Primary care clinicians—especially early career clinicians—appreciated support from the telepsychiatrist consultant both in medication management and in improving their ability to recognize, diagnose, and treat PTSD and bipolar disorder.
• Primary care clinicians identified the care manager (typically a social worker or registered nurse) as key to fostering communication between clinical care team members and with each patient. The authors noted that while the clinicians could access the telepsychiatrist’s notes via the electronic health record, they had minimal real-time interaction with the telepsychiatrist and relied on care managers for this information. Similarly, these managers “ensured that information on diagnosis, medication management, and side effects was clearly communicated to the clinician and patient while also relaying treatment progress to the telepsychiatrist consultant.”
• Primary care clinicians noted TCC increased patient engagement, and collaboration with the clinical manager reduced clinicians’ administrative burden.

“Primary care clinicians in underserved areas valued TCC and offered positive feedback about their experiences treating patients with PTSD or bipolar disorder,” Hoeft and colleagues wrote. “This approach has the potential to extend the reach of specialty mental health care and to support primary care clinicians treating patients with these more complex psychiatric disorders.”

For related information, see the Psychiatric News article “Collaborative Care as a Way to Stave Off Burnout.”

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Telepsychiatry-Based Collaborative Care Approach as Effective as Traditional Referrals

A telepsychiatry-based collaborative care model (CoCM) for managing patients with posttraumatic stress disorder (PTSD) or bipolar disorder was as effective as telepsychiatry-enhanced referral at improving patient outcomes over one year, according to a study in JAMA Psychiatry.

“This study expands the evidence base for CoCM in two ways: First, it demonstrates that the CoCM can effectively manage more complex [psychiatric] disorders just as well as referring to a specialist,” lead author John C. Fortney, Ph.D., the director of the Division of Population Health and professor of psychiatry and behavioral sciences at University of Washington’s School of Medicine, told Psychiatric News. “Second, it adds to the small evidence base that CoCM can be delivered through a virtual care team using video visits. In other words, members of the CoCM team do not need to be physically located together.”

The study took place in 24 primary care clinics that had no psychiatrist or psychologist on site in rural Arkansas, Michigan, and Washington. All 1,004 participants were adults who screened positive PTSD and/or bipolar disorder during an annual wellness visit. Most were already receiving psychotropic medications prescribed by a primary care physician, but none were seeing a mental health specialist. The patients were randomized to one of the following groups:

• Telepsychiatry collaborative care: Following a diagnostic assessment from a consulting telepsychiatrist, patients were prescribed all psychotropic medications by the primary care clinician, who was supported by behavioral health care managers (for example, social workers or nurses) and off-site telepsychiatrist consultants. Behavioral health care managers, who checked in with telepsychiatrists weekly, monitored patient symptoms and provided psychoeducation, psychotherapy, and treatment engagement activities.
• Telepsychiatry/telepsychology–enhanced referral: Patients were referred for a telepsychiatry visit to confirm a diagnosis and develop a treatment plan. Afterwards, the telepsychiatrist ordered lab tests, prescribed medications, and/or referred for psychotherapy. Telepsychiatrists and telepsychologists monitored patient symptoms.

The patients were given phone or online surveys at baseline, six months, and 12 months to assess their mental health functioning using the Veterans RAND 12-item Health Survey Mental Component Summary (MCS).

The researchers found that patients in both groups experienced large, clinically meaningful improvements in MCS scores from baseline to 12 months (9-point to 10-point increase on average). Both groups also had greater perceived access to and engagement in care and experienced fewer adverse effects from psychotropic medications. However, the telepsychiatry/telepsychology–enhanced referral group had three times more encounters with telepsychiatrists (4.3 visits on average for referral group vs. 1.4 visits for collaborative care group).

“From a health care system perspective, [the] results suggest that clinical leadership should implement whichever evidence-based practice [collaborative care or referral] is most sustainable,” Fortney and colleagues wrote. “From a societal perspective, [telepsychiatry collaborative care] should be incentivized by policy makers because it leverages scarce telepsychiatrist capacity through consultation and case-review.”

For related information, see the Psychiatric News article “Collaborative Care Fits COVID-19 Workflows.”

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APA to CMS: Some Telehealth Changes Made During COVID-19 Should Become Permanent

APA CEO and Medical Director Saul Levin, M.D., M.P.A., sent a letter on Monday to Seema Varma, the administrator of the Centers for Medicare and Medicaid Services (CMS), commending the agency for the steps taken to reduce barriers to telehealth services for people with mental and substance use disorders during the COVID-19 pandemic and urging the agency to make permanent many of the regulatory changes that have helped expand telehealth services.

“The days, weeks, and months ahead are at best uncertain and for many crippling. … As some areas of the country begin to explore what the new normal will be and are lifting shelter-in-place restrictions and allowing nonessential businesses to resume in-person operations, there will continue to be an increased need for mental and behavioral health care services,” Levin wrote.

To ensure continuity of care and continued improved access to mental health and substance use care, the letter calls on the agency to make the following changes permanent:

• Remove limitations around originating site and geographical restrictions for mental health services.
• Include all services on the expanded Medicare-approved telehealth list, including group psychotherapy.
• Maintain coverage of and increased payment for telephone evaluation and management (E/M) services (99441-99443) that matches reimbursement for traditional outpatient E/M services that may be provided in person or via telehealth. Additionally, Levin requested the removal of the frequency limitations that are imposed under those codes to allow those patients who receive all their care via the telephone alone (and not in person or via telehealth) as often as is medically necessary, which could be more frequently than once every seven days.
• Allow for the use of audio-only (telephone) communications for E/M and behavioral health services, including care for opioid use disorders, when it is in the patient’s best interest. In addition, reimbursement for audio-only care should be no less than what was established during the emergency.
• Remove frequency limitations for existing telehealth services in inpatient settings and nursing facilities.
• Allow teaching physicians to provide direct supervision of medical residents remotely through telehealth.

“These changes would ensure a smooth transition to in-person care and increase access via telehealth and telephone to necessary care. It is especially important for mental health and substance use care, where the ability to establish and maintain a strong, uninterrupted therapeutic alliance with patients is crucial to effective interventions,” Levin stated.

Levin also recommended that after the COVID-19 pandemic ends, CMS should resume regulations “that require general supervision of nurse practitioners and physician assistants by a physician and implement policies to advance the use of physician-led, team-based care, such as evidence-based integrated care models and telehealth, to improve access to quality care.”

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Relaxed Telehealth Regulations Need to Continue Post Pandemic, Experts Tell Congressional Leaders

During a virtual Congressional briefing on Wednesday, APA President Jeffrey Geller, M.D., M.P.H., and members of APA’s Committee on Telepsychiatry emphasized the need for expanded access to mental health care through telehealth not only during the COVID-19 pandemic, but afterward as well.

The briefing, titled “Collective Crisis: Preparing for America’s Next Wave of Mental Health and Substance Use Disorder Needs With Telehealth,” was hosted by APA and the National Alliance on Mental Illness (NAMI). The panel included Peter Yellowlees, M.B.B.S., M.D., of UC Davis; Shabana Khan, M.D., of NYU Langone Health; and Jodi Kwarciany of NAMI. Yellowlees is the co-editor of Telepsychiatry and Health Technologies from APA Publishing.

Rep. Bill Johnson (R-Ohio) and Rep. Paul Tonko (D-New York) also made remarks during the briefing. Johnson is one of the sponsors of the CONNECT Act (HR 4932), which would expand access to telehealth services for mental health treatment. Tonko recently worked on a bipartisan letter to House and Senate leaders asking them to extend tele-mental health services beyond the COVID-19 emergency.

Geller commended Congress and the Trump administration for taking steps to reduce barriers to telepsychiatry, such as allowing Medicare beneficiaries to receive treatment in their own home and through audio-only appointments when necessary. “The evidence is clear that psychiatric care provided by telehealth is as effective as in-person psychiatric services,” he said. He urged lawmakers to make some of these changes permanent, including the following:

• Remove geographic restrictions on tele-mental health care.
• Allow patients to be receive treatment via telehealth in their homes, as the CONNECT Act does.
• Waive the Ryan Haight Act requirement that stipulates any physician issuing a controlled substance must conduct an initial, in-person medical evaluation.
• Allow audio-only telehealth care when appropriate.

Yellowlees and Khan, both members of APA’s Committee on Telepsychiatry, shared stories about how the loosening of telehealth regulations have helped them reach more patients and continue care for others during the pandemic. Yellowlees described one patient, a physician diagnosed with bipolar disorder, who has been able to avoid hospitalization thanks to being able to meet regularly with Yellowlees through telehealth.

“I hope that it’s very clear to people that the reduction of these regulations has been really very positive,” Yellowlees said. He implored all the participants in the meeting “to do their best to maintain this current situation long term.”

“What we’ve found is that individuals who have a significant amount of anxiety may actually feel more comfortable with the distance that this technology affords them,” Khan said.

Kwarciany noted that the pandemic is causing symptoms related to anxiety, depression, and substance use disorders to rise, but it has also allowed for change and innovation to connect patients with care in a very short time. “It’s really critical that we keep this momentum going, maintain a lot of these existing flexibilities, … and pressure policymakers to address these barriers across locations, populations, and forms of coverage so that everyone can receive the right care at the right time.”

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Psychiatrists Urge Field to Plan Now for Post–COVID-19 Psychiatry

The lifting of federal and state regulatory barriers to telemedicine in response to COVID-19 has led to an unprecedented revolution in telehealth. Psychiatrists, patients, and health systems have shown in recent months that they can quickly adapt to telepsychiatry, but numerous questions remain: “What happens next?” and “What happens when the COVID-19 pandemic ends?” Such questions are the subject of an article appearing in JAMA Psychiatry by psychiatrists Jay H. Shore, M.D., M.P.H., and Christopher D. Schneck, M.D., of the University of Colorado School of Medicine and Matthew C. Mishkind, Ph.D., of the Steven A. Cohen Military Family Clinic at the University of Colorado.

“When the pandemic eventually ends, psychiatry and telepsychiatry will be transformed. What the psychiatric care environment will look like is currently unpredictable,” they wrote. “The longer the pandemic and associated quarantines continue, the more likely current changes become solidified and routinized into the practice of psychiatry. Less certain are what changes will remain in effect when the pandemic is controlled, as well as what changes that will occur if the pandemic becomes episodic, resulting in a series of sporadic and regional quarantines. Will the current regulatory and structural changes stay in place, or will they also change in a parallel, sporadic, and episodic manner?”

Now is the time for psychiatric organizations and clinicians to plan for these different scenarios, they wrote, including “how, when, and to what extent they would transition back to more in-person care” and what the financial implications of such changes may be. “It is not clear how the current billing environment will affect the long-term resources and sustainability of psychiatric organizations and clinicians. To the extent that information is available, financial forecasting and planning with assumptions of both current and traditional billing environments is warranted.”

This time also presents an opportunity for the field to learn more about the interactions with patients that can and should take place in person versus those that can be done through telepsychiatry or other technologies, they continued. “How much virtual care is too much? Is there a virtual saturation point, at which the benefits of a virtual relationship decrease or patients request more in-person interactions? What data need to be captured now to better understand this and identify current lessons learned?”

They concluded, “The regulatory and system changes wrought by the COVID-19 crisis present the opportunity for the field to gather lessons learned to strategically shape the post–COVID-19 world of psychiatry and telepsychiatry. This work could usher in a golden era for technology in psychiatry in which we are able to harmonize the benefits of telepsychiatry and virtual care while maintaining the core of our treatment: that of human connectedness.”

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Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

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Psychiatrists Report Mostly Positive Transition to Telemedicine During Pandemic

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News is posting summaries of these submissions soon after acceptance.

Despite some challenges, 20 psychiatrists who completed interviews from March 31 to April 9 said that the transition to seeing patients via telemedicine due to COVID-19 has generally been a positive experience. The findings appear in an article in press at Psychiatric Services.

“The majority argued that given the unprecedented circumstances, the transition to telemedicine went more smoothly than they had expected, and they were pleasantly surprised that they could meet patients’ needs via telemedicine,” wrote Lori Uscher-Pines, Ph.D., of the RAND Corporation and colleagues.

The researchers interviewed 20 outpatient psychiatrists transitioning to telemedicine due to the COVID-19 pandemic. The researchers recruited psychiatrists for the study from a panel of 730,000 physicians who are part of an online network; psychiatrists were sent an eight-item screener survey to assess eligibility for participation. The psychiatrists were practicing in states especially hard-hit by the pandemic, including New York, California, Washington, New Jersey, and Louisiana. During 30-minute phone calls, the researchers covered topics such as practice setting, patient population, and barriers encountered during the transition to telemedicine.

While most of the psychiatrists had only limited telemedicine experience with their patients prior to the outbreak of COVID-19, by March most had transitioned to fully virtual practices through which they offered video visits and/or phone visits.

There were positive and negative impacts to working with patients via telemedicine, the psychiatrists reported. Negative impacts included their reduced ability to observe nonverbal cues of patients to support diagnosis and treatment and hear patients clearly; additionally, patients may not have had privacy and had to deal with more distractions in the home. Positive impacts included increased ease and access for some patients and the ability to see patients’ home environment. Most participants reported that patients had been responding positively to the switch, as well.

The psychiatrists expressed a strong preference to return to in-person care after the pandemic ends. “Reasons include the ritual of going to an office, the fact that the office is a private and safe space, and for some, the perceived inferior quality of physician-patient interactions via telemedicine,” the authors wrote.

The psychiatrists shared lessons they had learned during the rapid transition to telemedicine, including the following:

• Start each visit by asking patients whether they are concerned about their privacy, and if they do not have privacy, reschedule the session. One psychiatrist reported that some patients have done visits from a car outside the home.
• Reassure patients by conducting video visits from the same spot in your home or office.
• Identify patients “at risk” of having difficulty with video visits and explore if there is someone in their environment who can help them.
• Choose a platform that will ensure patients cannot see your personal phone number.

(Image: iStock/izusek)

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Now in Psychiatric News

Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

Behavioral Health Organizations Struggle Financially During Pandemic

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Survey Reveals Challenges Faced by Psychiatric Patients in China Amid COVID-19 Outbreak

The journals of APA Publishing are receiving numerous submissions on aspects of the COVID-19 pandemic. To get information about findings to the field faster, Psychiatric News is posting summaries of these submissions soon after journal submissions are accepted.

More than 20% of patients diagnosed with depression, bipolar disorder, or schizophrenia who receive care at a large Chinese medical center reported they were not able to receive their routine care due to suspended hospital visits during the COVID-19 pandemic. This was one of the findings of a survey reported in an article in press in the American Journal of Psychiatry.

Moreover, nearly all of those patients with existing diagnoses who couldn’t get care experienced a deterioration in their condition. Almost a quarter of new patients experiencing anxiety, depression, or insomnia could not get timely care, the survey found.

“[O]ur data reiterated the importance of implementing appropriate mental health measures in the face of the COVID-19 pandemic,” wrote Junying Zhou, M.D., Ph.D., of West China Hospital of Sichuan University in Chengdu, China, and colleagues.

Using the “Questionnaire Starr” survey program on WeChat, a popular Chinese smartphone application, Zhou and colleagues surveyed 2,065 outpatients seeking care in the departments of Psychiatry, Neurology, or Sleep Medicine in West China Hospital from February 25 to March 9. There were 589 new patients and 1,476 patients with existing psychiatric diagnoses. Here are the major findings:

• 25.5% of the respondents in the combined groups experienced anxiety (defined as a score of 5 or more on the Generalized Anxiety Disorder-7 scale), and 26.2% experienced insomnia (defined as a score of 8 or more on the Insomnia Severity Index). Just under 17% experienced depression (defined as a score of 5 or more the Patient Health Questionnaire-9).
• Among existing patients, 22.2% could not get their routine care, and 20.9% experienced a deterioration in symptoms. Just over 17% stopped taking their medications because of problems related to filling their prescriptions during the outbreak.
• Among new patients, 24.5% could not get “timely diagnosis and treatment” at the hospital. These included 46 patients with anxiety, 37 patients with depression, 79 patients with insomnia, and 21 patients with schizophrenia.

The researchers wrote that “transport restriction, isolation at home, and fear of cross-infection in the hospital have inevitably become the major concerns and barriers to treatment for these patients during the outbreak.”

The researchers noted that a number of hospitals in China have initiated telemedicine services for patients in need, and in January, West China Hospital opened a free online outpatient service to provide prescriptions to existing patients and consultations to new patients. Although thousands of patients have received health care through this service, only 7.4% of those with mental disorders in the survey did so. “Thus, there is a need for promoting online mental health services across China to manage mental problems during the pandemic,” they wrote.

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The commentary describing the results of the survey is in press at the American Journal of Psychiatry and can be cited as follows: Zhou J: Mental health response to COVID-19 outbreak in China. Am J Psychiatry [doi: 10.1176/appi.ajp.2020.20030304]

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APA’s COVID-19 Resource Center Keeps You Updated

APA’s COVID-19 Resource Center brings together a number of useful resources from APA and other authoritative sources to help you deal with the COVID-19.

CMS Loosens Telehealth Restrictions After COVID-19 Declared National Emergency

Medicare patients seeking certain medical services—including mental health services—can now be seen using live videoconferencing in their homes. They do not need to travel to a qualifying “originating site” for Medicare telehealth encounters, regardless of geographic location, according to a guidance issued yesterday by the Centers for Medicare and Medicaid Services (CMS).

CMS is temporarily expanding Medicare telehealth services and waiving existing restrictions on those services under authority granted to the secretary of Health and Human Services in the bipartisan Coronavirus Preparedness and Response Supplemental Appropriations Act approved by Congress and signed by President Trump on March 6. The new policy is intended to protect patient health and slow the transmission of COVID-19 by allowing patients to receive care without leaving home.

Through an emergency declaration under the Stafford Act and the National Emergencies Act, Medicare coverage will now include three types of virtual services: Medicare telehealth visits, virtual check-ins, and e-visits. The temporary rules apply to all Medicare providers.

Additionally, for the duration of the emergency, HHS will waive HIPAA penalties for using non-HIPAA compliant videoconferencing software. This will allow physicians and other health care professionals to use popular technology, such as Skype (basic) and FaceTime, to conduct telehealth sessions. The federal Office of Civil Rights has released further guidance about the waiver of HIPAA penalties.

When conducting a telemedicine encounter, health care professionals should use the same CPT codes as they use for in-person services, but with the Place of Service (POS) code 02 to indicate the care was provided via telemedicine. Psychiatrists considering transitioning patients to telepsychiatry in place of in-person appointments should consult APA’s Telepsychiatry Toolkit, which contains more than 60 pages of guidance on topics related to telepsychiatry, including clinical considerations, administrative and technical requirements for software issues, and reimbursement.

Physicians providing telepsychiatry services need a license in the state in which the patient is located at the time services are provided. However, many governors are declaring states of emergency that may alter or waive these restrictions, and the Federation of State Medical Boards lists states that have declared emergencies and have waived various licensing restrictions. APA is monitoring state-level activities and will disseminate information as soon as there is definitive guidance for members in those states.

Finally, the Drug Enforcement Administration yesterday lifted requirements that health care professionals must conduct an initial, in-person examination of a patient—thereby establishing a doctor-patient relationship—before electronically prescribing a controlled substance. For the duration of the emergency, that requirement will not apply.

Prior to passage of the bipartisan coronavirus bill, APA CEO and Medical Director Saul Levin, M.D, M.P.A., urged Congress to remove restrictions on using telehealth for mental health services. The bill granted authority to HHS Secretary Alex Azar to do so, but did not actually lift the restrictions. Yesterday’s guidance by HHS does so.

“We are in an extraordinary crisis, and the administration has done the right thing,” Levin said. “Now, Medicare beneficiaries who may be at risk of contracting COVID-19 can be seen in their homes via telepsychiatry and maintain their regular course of therapy without disruption. This will also minimize future infections.”

Additional information is posted on APA’s website. APA members with questions related to the new telehealth policy should send an email to practicemanagement@psych.org.

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APA Praises Congress for Passing Emergency COVID-19 Funding, Authorizing Lifting of Telemedicine Restrictions

APA is hailing a bipartisan $8 billion emergency spending bill approved by the Senate today to address the spread of COVID-19. The measure was passed by the House of Representatives yesterday and is expected to be signed by President Trump.

Among the bill’s provisions is one that will allow the secretary of Health and Human Services to temporarily lift restrictions on Medicare access to telehealth services, such as live videoconference consultations with physicians.

In a March 2 letter to leaders in the House and Senate, APA CEO and Medical Director Saul Levin, M.D., M.P.A., urged Congress to take this action. “We recommend that these restrictions be waived, so that Medicare beneficiaries, who appear to be at particular risk of contracting COVID-19, may be ‘seen’ in the home via telepsychiatry and maintain their regular course of therapy without disruption,” Levin wrote. “This would also minimize future infections.”

APA President Bruce Schwartz, M.D., said in a statement APA released today that removing the restrictions will be especially beneficial to populations most susceptible to infection. “Telehealth and telepsychiatry in ordinary times can help more people access services that are critical to their well-being,” Schwartz said. “But it is especially important now, given the nature of COVID-19. Particularly for some groups, like senior citizens and other vulnerable populations, access to telepsychiatry and telehealth could be vital. We thank Congress for including this important provision in the funding package.”

In the statement Levin added, “Epidemics can cause people to experience stress and anxiety. Having tools and access to solutions like telepsychiatry, as well as clear communications from the media and government, will go a long way toward mitigating that stress.”

For additional APA resources on COVID-19, see the following:

A Message From APA on COVID-19

How Psychiatrists Can Help Patients During Coronavirus Outbreak

Coronavirus and Mental Health: Taking Care of Ourselves During Infectious Disease Outbreaks

Use of Telepsychiatry Nearly Doubles From 2010 to 2017, Study Finds

Nearly twice as many mental health facilities in the United States offered telepsychiatry in 2017 than in 2010, according to a study published in Psychiatric Services. Telepsychiatry was most commonly offered by facilities in underserved and rural areas.

“Facilities with telepsychiatry offer a variety of services to a wide range of populations, and the increased use of these services among populations with greater barriers to access, such as those residing in rural and underserved areas, continues to [show] promise that such services will be made available to patients with the greatest need,” wrote Stanislav Spivak, M.D., of Johns Hopkins University School of Medicine and colleagues.

Spivak and colleagues analyzed national data from the Substance Abuse and Mental Health Services Administration’s National Mental Health Services Survey (NMHSS) collected between 2010 and 2017. The survey asked facilities that provide mental health treatment if they provided telepsychiatry—defined as “the ability for health care providers, working from a distance using telecommunications technology, to communicate with patients, diagnose conditions, provide treatment, and discuss health care issues with other providers to ensure quality health care services are provided.” The researchers compared the ownership, licensing, funding, and treatment setting of those facilities that reported offering telepsychiatry in 2017 with those that did not. They also asked state mental health agency officials whether telemedicine was reimbursed by state funds and/or Medicaid funds, and if the state had initiatives to expand the use of telemedicine.

In 2010, 15.2% (n=1,580) of the facilities surveyed reported using telepsychiatry; in 2017, that number grew to 29.2% (n=3,385) of the facilities surveyed. But the authors noted “considerable variability” among states, with less than 15% of facilities offering telepsychiatry in some states compared with over 60% in others. The increase in the proportion of facilities with telepsychiatry from 2010 to 2017 was highest in states with a rural population of 40% or more, the authors noted.

“Facilities that offered telepsychiatry had higher odds of being funded by federal and local government sources, as well as by private insurance, self-pay, and grant funding compared with facilities without telepsychiatry,” Spivak and colleagues wrote. In contrast, facilities offering telepsychiatry were less likely to be funded by Medicaid than those without telepsychiatry—a finding the authors described as “puzzling, as the federal Medicaid statute allows reimbursement of telemedicine as a regular service.” The lower odds of facilities using telepsychiatry receiving funding from Medicaid “may reflect the effect of state Medicaid regulatory hurdles,” they wrote.

State funding may also explain the variability in telepsychiatry from state to state. States that did not provide direct state funding for telemedicine had lower odds of offering telepsychiatry services (19.3% vs. 29.8%), the authors noted.

For related information, see the Psychiatric News article “Telepsychiatry: Who, What, Where, and How.”

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Erratum; New Telehealth Code Announced

A Psychiatric News Alert distributed on January 17 contained incorrect information. The item reported that APA had joined with the American Telemedicine Association in asking the Centers for Medicare and Medicaid Services (CMS) for a temporary accommodation to address problems created by the elimination of CPT code 90862. That code had been used for pharmacologic management by psychiatrists conducting telehealth rounds for hospitals that do not have a psychiatrist on staff. The report also stated that psychiatrists must use an evaluation and management (E/M) code to bill for this function and stated that E/M codes can be used for this purpose only once every three days.

In fact, at the time the Alert was published, CMS had already made a correction to eliminate this problem.  CMS created a G-code, G0459, effective January 1, that allows for  all medically necessary inpatient telehealth psychiatric pharmacologic management, including prescription, use, and review of medication with minimal medical psychotherapy. There are no restrictions on the frequency with which this code can be used; also, there are no restrictions on the frequency with which medically necessary E/M codes can be used outside of telemedicine. We apologize for the errors.

For more information, click here.

Mobile App Helps Post-Disaster Mental Health Responders

The next time disaster strikes, mental health and other response workers may find help in delivering psychological first aid (PFA) as near as their smartphones. “PFA is an evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism: to reduce initial distress and to foster short and long-term adaptive functioning,” says the Department of Veterans Affairs’ National Center for PTSD, a codeveloper of the app along with the Department of Defense’s National Center for Telehealth and Technology and the National Child Traumatic Stress Network.

Responders should learn PFA before a disaster occurs, say the developers. “This app is a supplement to other resources [that] trained individuals utilize before, during, and after a disaster response.” Armed with that knowledge, users can then read summaries of PFA actions; match interventions to specific stress reactions of survivors; evaluate survivors’ needs and track them to simplify data collection and referrals; and use self-assessments to judge their own readiness to conduct PFA. The PFA mobile app is available for Apple iPhone users; an Android version will appear in 2013.

To learn more about key factors in preparing for the mental health aftermath of disasters, see Psychiatric News here.

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Telepsychiatry Becomes More Accessible

"Since telepsychiatry was introduced decades ago, video conferencing has been an increasingly accepted way to reach patients in hospitals, prisons, veterans' health care facilities, and rural clinics," the New York Times reported on September 25.

Several innovative telepsychiatry operations have been launched during the past few years. For example, it's being used to conduct psychiatric interviews in prisons in New York State. A University of Colorado telepsychiatry program serves American Indians in several surrounding states. A private-practice psychiatrist in Missouri uses telepsychiatry to diagnose and treat patients in rural Arizona. A Mississippi psychiatrist has launched telepsychiatry in one of the poorest areas of America. And in Canada, telepsychiatry is being used to serve patients in such far-flung places as Newfoundland and the Northwest Territories.

More information about telepsychiatry programs can be found in Psychiatric News at http://pn.psychiatryonline.org/content/39/12/4.full; http://pn.psychiatryonline.org/content/43/13/4.1.full; http://pn.psychiatryonline.org/content/44/19/14.full, and http://pn.psychiatryonline.org/content/38/23/11.full.

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