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The Top 10 Barriers to Wider Adoption of Telepsychiatry

teletherapy senior woman tablet computer

Although telepsychiatry has received a lot of attention in the last few years, this modality has been around for more than 60 years.  As early as 1959, the Nebraska Psychiatric Institute was using early videoconferencing to provide group therapy, long-term therapy, consultation-liaison psychiatry, and medical student training at the Nebraska state hospital in Norfolk (APA).

Like innovators in other industries, early adopters of telepsychiatry operated without the benefit of clear legislation for many decades.  Providers have had to operate in murky waters and at the mercy of multiple jurisdictions such as local, federal, and state government.  The widespread adoption of telepsychiatry has been hindered by fear and uncertainty around a variety of factors involved in seeing patients via this modality.  These are the top ten barriers to widespread adoption of telehealth:

  1. Interstate Licensing Laws- Unlike a driver’s license, having a medical license does not allow you to practice in any state. If you have a patient that you have been treating for a while but moved to another state, it makes no sense that simply due to the patient moving location, they are deprived of healthcare that has worked for them.  It unnecessarily disrupts the continuity of care and makes the healthcare system much less efficient. The Interstate Medical Licensure Compact and the FCVS have helped facilitate licensure, however, the better solution would be to have a national medical license.  Perhaps in the meantime, established patients should be allowed to keep their doctor, even if they travel across state lines.   Restrictions on practicing medicine across state lines is the single biggest barrier to the widespread adoption of telemedicine today.
  1. Stigma Against Virtual Mental Health Treatment- Sadly, there are still people who believe that virtual mental health treatment is somehow ineffective or inferior to in-person care. The truth is that telepsychiatry is highly effective and life changing for the people who receive it.  Furthermore, virtual care should not be compared to in-person care, because in many cases in-person care is not available.  Telemental health ought to be evaluated on its own merits as a progressive way of providing access to care to people who otherwise would not receive any care.
  1. Laws About Establishing a Patient-Provider Relationship via Telehealth- Although all 50 states allow a physician to establish a relationship with a new patient via telemedicine, some states include caveats such as restricting the setting (e.g. to medical site), or narrow the modality that can be used (e.g. telephone vs videoconferencing technology) (AMA Survey). We anticipate that one day all states will allow providers to establish a treating relationship with patients based on their own clinical discretion.
  1. Telepsychiatry Reimbursement- In the last several years, many individual states have passed parity laws.  While some states require that insurance companies reimburse for telehealth services, not all of those states mandate that the reimbursement should be on par with the same services provided onsite.  Fortunately, private payers are increasingly accepting telepsychiatry as a service worthy of reimbursement.  With time, our hope is that all states will pass legislation that requires insurance companies to reimburse telepsychiatry on the same level of onsite care.
  1. Online prescribing/Controlled Substances- The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was originally intended to prevent “pill mills”- online pharmacies that dispense medication without a valid prescription. Although the intent of Ryan Haight was noble, an unintended consequence was to make it much more difficult to prescribe controlled substances via telehealth.  Although there are 7 exceptions to the in-person rule, the exceptions are narrow and the DEA has not yet developed a Special Registration process for telemedicine as mandated by Congress.  Our hope is that the DEA will finally release the special registration process in the near future.
  1. Consent Requirements- According to the American Medical Association, the process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention (AMA Consent). States have approached consent for telemedicine in a variety of ways: Some states require a written consent delineating the risks and benefits of this service. Other states require verbal consent only.  The notion of consenting specifically for telemedicine to receive care is debatable.  Some would argue that since telehealth is a modality of delivering treatment, not a treatment in itself.  States that require patients to complete a separate written consent for telemedicine as a mode of treatment are adding an unnecessary barrier to care.
  1. Eligible Providers- Per CMS, only certain classifications are permitted to provide telehealth treatment. These include physicians, nurse practitioners, clinical psychologists, clinical social workers, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists, and registered dieticians or nutrition professionals.  It is our hope that CMS will one day also allow marriage and family therapists to also conduct visits remotely.
  1. Eligible Services- Medicare reimburses only for specific services when they are delivered via live video. Store-and-forward delivered services are prohibited, except for CMS demonstration programs in Alaska and Hawaii (CCHP). In recent years, more telehealth codes have been approved by the US Department of Health and Human Services.  However, it is our hope that almost any mental health service code will one day have a corresponding telehealth code.
  1. Originating Site Requirements- Unfortunately, CMS requires that originating sites (the location of the patient) are in rural or health professional shortage areas and within eligible facilities or offices. Due to the public health emergency declaration in response to the COVID-19 pandemic, CMS has, for the most part, waived these requirements temporarily.  It is our wish that CMS considers eliminating these geographic requirements.  This will set the tone for a broader adoption of telehealth.
  1. HIPAA (software encryption)- In today’s high-tech world, keeping information private and secure can be challenging, but remains an important aspect of a provider-patient relationship.  Most reputable telehealth platforms currently use a 256-bit encryption, which seems to be a reasonable bar.  As time goes on and hackers become more sophisticated, our hope is that the technology will continue to improve to ensure that patient information is kept private and secure.

The COVID-19 pandemic has forced regulatory bodies and healthcare organizations to rethink the role of telehealth in the overall healthcare system.  It is our hope that there will be a permanent lifting of many of the barriers to the practice of telehealth, while maintaining reasonable and appropriate standards for quality and safety.

SOURCES:

https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/history-of-telepsychiatry (APA)

https://www.cchpca.org/telehealth-policy/telehealth-and-medicare (CCHP)

https://www.ama-assn.org/delivering-care/ethics/informed-consent (AMA Consent)

https://www.ama-assn.org/system/files/2018-10/ama-chart-telemedicine-patient-physician-relationship.pdf (AMA Survey)

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