Behavioral Telemedicine: Past, Present, and What Lies Ahead

telehealth with virtual afro American doctor appointment and online therapy session. Black doctor online conference. High quality photo

By Steven Powell, MD

Telemedicine for behavioral healthcare has existed for nearly a decade, but utilization only began to pick up speed one or two years prior to the COVID-19 pandemic. At that time, however, there were still several roadblocks preventing widespread adoption. Ultimately, most of these challenges – including lack of insurance coverage, end-user inability to use the necessary devices, regulatory issues, insufficient patient buy-in, and lingering apprehension from many in the medical community, among others – were quickly addressed and resolved with the onset of the pandemic. The pandemic led to the explosion of telemedicine – its use increased 63-fold – as providers and patients sought a means to safely access and deliver quality care.

Barriers to telemedicine adoption

Barriers to telemedicine adoption were still in place prior to the COVID-19 pandemic for several reasons. Ultimately, many believed that telemedicine wasn’t an effective modality. Regulatory challenges were a significant factor preventing widespread telemedicine adoption, and outdated payment models and lack of reimbursement also meant that large health systems failed to provide telemedicine services – therefore preventing patients from utilizing these treatment modalities. Prior to the pandemic, apprehension from the medical community stemmed from the belief that being in the same room as the patient was critical to providing quality care. Patient buy-in was a generational challenge for telemedicine, particularly telemedicine. While there were certain patient subsegments who clearly had no issues with telemedicine, middle-aged and aging patients struggled with the concept. 

The pandemic broke down these barriers very quickly because people were falling out of care or lacking access to care. Whereas telemedicine as a care delivery option previously wasn’t even on the table for most, telemedicine was operationalized out of necessity – and the population has benefited from its use. Once telemedicine systems were established and people witnessed the simplicity and convenience of virtual care, they plugged in and are no longer waiting weeks, months, or even years for adequate care; it’s at their fingertips. In fact, Medicare fee-for-service data for 34.9 million beneficiaries in 2019 and 2020 shows that telemedicine visits increased from approximately 840,000 in 2019 to 52.7 million in 2020. All patients need is a smartphone or computer and private space to achieve access to telemedicine care, and several types of care – including behavioral health care – can be provided equally as effectively, if not more effectively, via telemedicine.

The explosion of (behavioral) telemedicine

In 2020, telemedicine experienced an unprecedented surge amid nationwide lockdowns and the fear of contracting the virus. Telemedicine use then fluctuated throughout the pandemic, rising and falling as COVID-19 case rates ebbed and flowed. Behavioral health, in particular, experienced the highest telemedicine utilization, increasing 32-fold from 2019 to 2020. Overall, visits to behavioral health specialists comprised one-third of all telemedicine visits in 2020, compared with eight percent of visits to primary care providers and three percent of visits to other specialists. The need for behavioral telemedicine has always persisted in the background, if not in the forefront. For example, years ago I trained in a hospital system that had a “cap” on the number of psychiatric patients that could be accepted for inpatient or outpatient care. As they’re turned away, these patients have had no choice but to turn elsewhere – and now, there are endless hospitals and private companies that can provide patients with the behavioral health care they need via telemedicine. 

Telemedicine visits for mental health conditions consistently outpaced visits for COVID-19-related conditions before the pandemic even ended. While variants are unpredictable and COVID-19 may not yet be entirely in the rearview mirror, COVID-19-related conditions are no longer the primary reasons behind telemedicine utilization. Why is this the case? A person’s mental health – including stress, depression, and anxiety, among other conditions – can be particularly impacted by the long, national pandemic that we have all experienced. Whereas a patient may contract COVID-19 one or two times over a two-year period, those are isolated events. Anxiety and depression, however, are not as transient. Separation and isolation, lockdowns, face masks, and fears over contracting the virus all take their toll and can be incredibly detrimental to a person’s mental health and long-term well-being. Unlike COVID-19, mental health is not a one-time doctor’s visit. The mental health implications of the COVID-19 pandemic have reached an even wider swath of patients than COVID-19 itself, and we are still experiencing the impacts of the pandemic on our collective mental health. 

What the future holds for telemedicine

I used telemedicine as early as 2010 when I worked in hospital emergency rooms and conducted patient evaluations. Back then, telemedicine was a newer concept. Often, I’d treat patients both in-person and via telemedicine, and I can attest to the fact that these were identical experiences, and that very little was lost in the virtual experience. Of course, sometimes there are complex patients and more is learned from face-to-face interactions, but for the average patient telemedicine is just as efficacious as in-person care. 

Once the technology is understood, I find that most patients – those from our aging population, in particular – prefer to receive care via telemedicine. Patients can avoid getting in their car, navigating through poor weather conditions, walking into a large medical complex, taking the elevator, and waiting 30 minutes in a doctor’s office. In-person care can be burdensome, especially for patients with limited mobility, or who live alone and have limited access to transportation. The aging population has benefited telemedicine as much, if not more, than younger populations – ironically, those who telemedicine initially targeted.

Some roadblocks to widespread telehealth adoption have unfortunately reemerged as the COVID-19 pandemic has subsided. For example, during the pandemic, providers were permitted to practice in other states regardless of the state in which they held a license. Those regulatory flexibilities have been taken away from many and will be one of the most significant challenges for behavioral telemedicine in the future. Health plan reimbursement was a significant issue pre-COVID-19 pandemic; however, most limitations were lifted during the state of emergencies. However, payers may now backtrack on pandemic policies, and it’s critical that telemedicine is billed similarly to in-person visits to prevent cost increases at the patient’s expense. However, other barriers have subsided; providers are now more open to leveraging telemedicine – or at minimum adopting a hybrid of telemedicine and in-person care – and patients’ willingness to use telemedicine is no longer a challenge. Ultimately, it’s that care delivery via telemedicine is just as efficacious as in-person care, and often much more convenient for patients – allowing many more patients suffering from mental health disorders and other conditions to engage in care.

Steven Powell, MD

Dr. Steven Powell is Chief Medical Officer for MediTelecare, on staff in the Dartmouth-Hitchcock system, a Fellow of the American Psychiatric Association, and a Fellow of the American Society of Addiction Medicine. He currently works clinically as an internist and psychiatrist with a focus on Addiction Medicine.