A qualitative RAND Corporation study finds that psychiatrists offering telemedicine for the first time during the COVID-19 pandemic have had largely positive perceptions of the transition. Many, however, say they plan to return to in-person care when possible, due to the challenges psychiatric telemedicine entail.
WHY IT MATTERS
Before the COVID-19 pandemic struck, a variety of logistical and regulatory hurdles prevented many psychiatrists from using telemedicine. Although research supported the efficacy of video telepsychiatry, the National Institute of Mental Health-funded study notes, only 5% of psychiatrists in the Medicare program had ever provided a telemedicine visit.
“While there were some pockets where psychiatrists were doing a lot of telemedicine, that wasn’t the norm in the United States,” said Lori Uscher-Pines, lead author on the report and senior policy researcher at RAND.
The research team interviewed 20 outpatient psychiatrists in regions where early flares of COVID-19 activity had triggered social distancing measures and shelter-in-place orders, such as New York, California, and Louisiana.
“Our key finding is that the rapid transition to telemedicine went fairly smoothly,” said Uscher-Pines. “Psychiatrists were pleasantly surprised about how well it was going and about patient response.”
Many respondents noted the safety advantages of avoiding in-person contact; some pointed out the benefits of seeing inside a patient’s home.
The shift to telemedicine was made simpler, researchers note, by regulatory and reimbursement changes.
“For example, the Centers for Medicare and Medicaid Services declared it would reimburse for telemedicine visits in both rural and urban communities, and services could be delivered into patients’ homes,” study authors wrote.
“In addition, the U.S. Department of Health and Human Services indicated that it would waive penalties for good faith use of non-HIPAA compliant video conferencing software during the nationwide public health emergency.”
This was particularly important, Uscher-Pines noted, as many HIPAA compliant software became overwhelmed with users. Instead, providers could use a variety of platforms, including Zoom, Doxy.me, FaceTime, Google Meet, Clocktree, and thera-LINK.
“Multiple participants mentioned technical issues with one or more of these platforms that led them to experiment with new platforms or offer phone visits,” the study notes.
More than half the psychiatrists interviewed were exclusively in private practice; the rest of the participants worked in more than two outpatient settings or for nonprofit agencies, community mental health centers, federally qualified health centers, or hospital clinics.
About a third of the interviewed psychiatrists were mostly using the telephone for sessions, Uscher-Pines said. Many said this was because their patients did not have access to devices or reliable Internet that would have allowed them to use other platforms.
Other disadvantages included less information to inform a provider’s diagnosis, increased difficulty with perceiving nonverbal cues, an inability to conduct physical exams, and patients’ struggle to find privacy in their homes.
When it comes to long-term telepsychiatry sustainability, providers in private practice expressed concerns about revenue impact. Others who served older adults and vulnerable populations worried those groups could be left out of future care because of increased technical needs. And some indicated their hesitation to evaluate new patients over the phone or on video rather than in person.
“I can sustain my practice now, but practice development [growing the practice] will be hard,” said one California psychiatrist.
THE LARGER TREND
Telemedicine technology for behavioral health use has been on the rise for a number of years, with providers pointing to its accessibility and cost-efficiency as main drivers for patient engagement.
“Increasingly, people who are suffering from behavioral health disorders are recognizing that virtual care can often be a highly effective solution,” said Dr. Lew Levy, Chief Medical Officer for telehealth vendor Teladoc, in 2018.
Telehealth has also allowed behavioral health providers to connect with patients in underserved areas.
Still, COVID-19 has pushed an unprecedented shift to telehealth across multiple specialties – and many providers and advocates say it needs continued regulatory support.
“The new realities of healthcare delivery in a post-COVID-19 world will necessitate the continued use of telehealth to support social distancing and maximize health care resources,” said Ann Mond Johnson, American Telemedicine Association CEO, in an April statement to Congress.
ON THE RECORD
“We’d heard a lot of news reports and anecdotes that providers were rapidly transitioning to telemedicine to support patients, but there hadn’t been empirical research to document their experiences,” said Uscher-Pines.
Before this study, she said, “There was nothing more formal that captured the experiences of psychiatrists in multiple states.”
“Whether psychiatrists will continue to have favorable experiences as time goes on is unclear,” said the study authors.
“The mental health needs of their patients are likely to grow given isolation, financial hardship, and widespread illness,” they continued.
“Given this massive natural experiment in rapid telemedicine deployment, it is critical to describe experiences and track them over time.”