There have been few more stressful times than these, in light of what has quickly become merely the first phase of a global pandemic. Health care systems are saturated; children, college students, workers and travelers are being sent home; and our social infrastructure has been frozen, leaving millions stressed not only physically, but emotionally. For those currently involved in mental health treatment, now is potentially the worst time to lose access to the services upon which they rely.
During the COVID-19 crisis, and beyond, however, access to care is indeed endangered. Many mental health professionals have curtailed their in-office practices following CDC and other recommendations, and many patients are reluctant to travel to those offices that remain open, leaving the most emotionally vulnerable among us in crisis. Such crises can often be averted, however, if patients can continue psychological treatment with their established providers virtually -- by phone or video.
Yet while some insurance companies are supporting this option by waiving some restrictions on telementalhealth during this state of emergency, reimbursement for distance therapy is far from universal and far from equitable. Even when telementalhealth is included among covered services, reimbursement rates are often significantly lower than those for in-office visits for the same services. Meanwhile, many patients have seen their incomes evaporate. In short, without adequate reimbursement for telementalhealth by public and private insurers, few could afford to continue to access it, and few practitioners could afford to provide it.
Many of those insurers that say they are offering telementalhealth coverage are unclear as to what they will reimburse, leaving practitioners with no choices other than to defy quarantine restrictions and sit with patients, endangering both parties and the community at large, or to speak with them via whatever means are at their disposal and as their clinical judgment dictates, and bill as if therapist and patient were sitting together, putting themselves at risk for charges of fraud in order to serve the best interest of those they are attempting to help.
Further, many insurers have presented more subtle obstacles to allowing for tele-treatment -- and these have been especially disruptive in this time -- even when they publicly state that they intend to cover it. Some insurers refuse to reimburse for telephone or video meetings unless practitioners use their affiliated tele-health provider networks, many of which demand exorbitant fees and require procedures that are not conducive to optimal care. And, many such networks are currently closed to mental health professionals who attempt to enroll in them. Other insurers will reimburse for shorter sessions but not the longer ones that are preferred and are more often used because they better serve patients and also pay a more reasonable reimbursement to practitioners.
Indeed, the intensified examination of telementalhealth that the situation demands has thrown a light on the flaws in insurer's overarching policies regarding distance treatment. Because of the novelty of the resources available, telementalhealth has been the "wild west" of insurance coverage thus far, and insurers have taken advantage of the changes in opportunity to the detriment of patients and practitioners, slipping restrictions into policy that do not serve patients overall. Paying therapists less -- sometimes by as much as 50% -- for the same amount of their professional time, demanding the use of costly, exclusive platforms (in which the insurer sometimes has a financial stake) when free ones are equally secure and HIPAA-compliant, and attempting to determine treatment modality,protect neither patients nor practitioners, and amount to treatment rationing.
We at the Psychotherapy Action Network appreciate that distance consultation with a mental health professional is no substitute for in-person treatment. We have spoken out previously against many efforts to exploit available technologies to offer seemingly more convenient, but generally far less useful, interventions as if they were a substitute for a true therapeutic partnership. But when therapists are forced to abandon patients in situations of maximum stress because of insurance restrictions, a second-wave mental health crisis will be the likely result, at a time when our society can least afford it. There is clear evidence to document the rise in suicides, addictions and general personal distress with all its ramifications in times of social isolation and rupture. Adding patient abandonment to this mix will likely serve to accelerate those trends.
Further, restricting distance mental health treatments in times of crisis is not only deleterious to patient well-being; it penalizes our overstressed health system. Additionally, experience has repeatedly shown that the use of mental health treatment results in a decreased use of other medical services, an especially crucial factor when our medical resources are already drastically overtaxed. Surely insurers should be able to recognize a win-win, for themselves and their subscribers.
Taking steps to make mental health available remotely is consistent with efforts insurers are making in the face of COVID-19 to allow virtual visits between medical doctors and their patients. The Wellstone-Dominici act of 2008 mandated parity between coverage for physical and emotional interventions, and this assurance is never more important than in a time of crisis. We have reached a point of convergence between good law and good practice. Insurance companies should recognize this.
Insurance providers, both public and private, must lift their restrictions on telementalhealth and reimburse for telephone/video sessions at the same rate as in-person sessions, and make these changes permanent. The COVID-19 crisis will be ongoing for quite some time. Insurers must not require that therapists enroll and use exclusive networks, erecting additional barriers to care. Our hope is that patients, providers and health systems alike can use the lessons we have learned during this crisis to create telehealth policies that can better serve us in the long term. Treatment providers are willing to do their part by making reasonable efforts to assure that the media they use are secure, and patients are willing to do their part by acknowledging the disadvantages – in terms of both cybersecurity and therapeutic efficacy – in such distance treatments, as well as their importance.
Now it's time for insurers to do their part and fulfill their promises to their subscribers. The path towards support of their members is clear. It is imperative that they take it.