In a new paper at Medical Care Research and Review, Li et al look at service use by individuals whose insurance is regulated by the Affordable Care Act. They split the analysis into individual market enrollees with Cost Sharing Reduction subsidies (CSR), individual market enrollees without CSR, and small group market enrollees. CSR helps lower income (100-250% Federal Poverty Level (~$15-36K in 2024 for a single individual) enrollees reduce their cost sharing by lower deductibles, co-pays, coinsurance and out of pocket limits. They find some disparities and variation among service category and type of enrollee on how much spending dropped in 2020 and the 2021 rebound. That is expected.
However one figure leapt out at me. They look at professional claims that are served by telehealth. Pre-pandemic, this is low for all types of claims. It spikes for all types of claims immediately in Spring 2020. And then for physical health services, it declines again. However, telehealth for mental health spiked to 80% of all visits in that modality and a year later 60% of all mental health visits were still telehealth.
This was fascinating to me. We know that we have a mental health access problem in this country. Telehealth may modestly reduce the matching and search problems especially when folks in specific need subgroups are looking for identity concordant or affirming therapists. It makes some visits less costly as a patient can block out an hour on their calendar on Tuesday afternoon to go online instead of needing to leave work early, drive forty minutes, find parking, go to the session and then drive another hour home. But it does not magically create new capacity. If anything telehealth likely takes some capacity out of the system as cancellations are less likely.
Figuring out how to add capacity while maintaining an easy to access modality will be a big challenge.
Anonymous At Work
Hence the rise of online telehealth networks for mental health providers, not just psychiatrists. Tele-mental-health is a lower barrier to entry than setting up a traditional office in a strip center. And organized networks of providers naturally help create network effects.
I’m seeing a bit at my level that the networking and growth in mental health is a growth area for practitioners.
Jeanne
As a mental health therapist my clients love Telehealth. I miss aspects of in person but will never go back. Very few of my colleagues see people in person. A lot of it is much less no shows or cancellations right before an appointment. But clients no longer come to my office sick or with their sick kids in tow because they are home from school. So I am sick less. However, we are desperate for more therapists, especially therapists who will see children. Tough tough job.
suzanne
On a personal note, I will share that Spawn the Elder has been using telehealth very successfully since the pandemic for his mental healthcare. It’s been a lifesaver. He doesn’t drive, so he would need to bum a ride, bus, or Uber. He can schedule it around his other activities.
I will also note that we have had shit luck with some of these hospital-based clinics. He is prescribed Adderall, and has been on it for years, and it’s been going well. But of course, there’s been shortages and he needed a new prescription. I took him to a hospital-based behavioral health clinic that also served a lot of low-income people, and when we got there, and they said, “We don’t prescribe that”. Telehealth has meant that I haven’t had to deal with this bullshit.
David Anderson
@Jeanne: Does telehealth improve expected revenue stability/variance for you as a therapist?
Several of my colleagues are working on a variety of telehealth questions and I want to be able to listen intelligently to them.
jonas
So I’m looking for a therapist recently because, hey, who doesn’t need a good shrink these days, amirite? And virtually *nobody* in my entire area sees people in person any more. Telehealth is the only option. The problem is, I don’t want to talk to someone over Zoom. I hate that shit and it would be hard to find a completely private place to do so in any case. I want the nice couch in a dimly-lit office with a ficus in the corner and the in-person relationship and all that. And so the search continues…
Eolirin
We’re not going to be able to fix the capacity problem, especially with psychiatric services, as long as it continues to pay less, instead of significantly more, than alternatives.
Some pressure could be taken off the social workers we have doing therapeutic services if we expand peer support services, but there’s going to be a lot of resistance to that.
Fake Irishman
You’re right that it doesn’t increase capacity, but it can balance out capacity problems for a regional or national scale provider. In the VA, where we have considerable problems with high demand in some areas and lower demand in others, as well as a lot of rural patients, it’s pretty useful that a patient in Lyons Kansas can get treated by a therapist in Chicago.
Scout211
I was glad that I retired 10 years ago, before online therapy became a reality. After seeing people in-person for 40 years, I really didn’t want to learn a new way to do therapy. Plus, all of those decades of ethics seminars warning us of privacy breaches if we even communicated with our clients using a computer were in my head.
But that being said, I do think Telehealth for mental health sessions is a good development for all the reasons already mentioned, especially ease of accessing services. And most new therapists will have been trained on this method so they will adapt easily.
Telehealth for child therapists will be harder to do, though, with most child therapists using play therapy, etc. in their therapy.
I do see it as an overall positive development in mental health treatment and an added choice for patients.
One note: Recently, two health care professionals, when they learned I was a retired therapist, expressed frustration with Telehealth for mental health services. They were not happy with what they had experienced referring patients to Telehealth providers. So there is a learning curve still.
Jeanne
@David Anderson: yes my revenue is stable more stable because I don’t have last minute cancellations. Previously, I would probably have at least 3 to 4 no shows a week which means I don’t get paid for those sessions but it is also 3 to 4 people I declined to see. Now I may get one every few weeks. Use to make me nuts. I also love taking insurance especially Medicaid. I am in SE PA so could probably make twice as much all self pay but want to see as many people as I can.
@David Anderson:
Jeanne
@jonas: if you live in central PA I can give you names of colleagues seeing people in person.
Scout211
You just described my office. And I loved it as much as my clients loved it.
If you are using your insurance, you can contact them and insist they give you a list of therapists in your area who do in-person sessions. In my experience, the insurance companies will give patients a short list but not the whole list. If you have to do the choosing yourself from an online list, that can be much more frustrating. It’s been 10 years for me, but back then you could call for referrals if you could tolerate the phone wait times.
Trivia Man
@jonas: i know someone who has been struggling with connecting to the online model. They just dont feel that personal connection. Luckily an in person option may happen soon. It doesn’t need to always be face to face but they feel making that relationship in person is very helpful for trust and support.
Jeanne
Just an fyi, I know that I have a list of colleagues who are seeing people in person. So if you get routed to a Telehealth provider, ask if they have recommendations. I am always willing to reach out to my colleagues and ask about availability in their schedule for people who reach out and want in person. Also, if you work for corporation and can go through an EAP they send email blasts to lots of us and can ask specifically for in person. It is a way to get in relatively quickly.
Trivia Man
@Jeanne: in the last few years it seems that every podcast i listen to was spamming ads for an online therapy service. I don’t recall the name but it seems to have tapered off. In your experience, does this sound sketchy? Nationwide, huge ad push, promising everything to everyone at LOW LOW PRICES.
frosty
@Jeanne:
My son needs a consultation for ADHD and is having trouble getting a referral from his provider in our corner of PA (he’s covered by Medicaid). Telehealth would be fine. Any suggestions?
Yarrow
@Jeanne: This is so interesting. I just yesterday spoke with a friend in the UK who has a second career as a therapist. He only really got started after Covid, so doesn’t have pre-lockdown experience with seeing clients in person or otherwise. Even so, his clients are all in person. He’s trained in seeing clients via telehealth but none of them want that. They want the room with the sofa and potted plants.
A friend in the US recently told me that she has started therapy via BetterHelp, which is all online. She started with one therapist and had the first appointment. Then the therapist rescheduled the second appointment, then canceled, and by that time my friend got frustrated. She contacted BetterHelp, and they helped her pick a new therapist, who is working out well for her. She says it’s very helpful.
Jeanne
@Trivia Man: I do not recommend those at all. A lot of it is just by texting. No noticing body language or tone. Worrisome and I know mostly younger people using them. Also as a person in my sixties texting in general makes me nuts. People do not know how to have difficult conversations in person.
Jeanne
@frosty: how old is your son?
narya
An ex-coworker is a therapist, and, while I think she still sees some folks in person, she has found that the online version can be really helpful for some people. For example (she has said), someone with anxiety might spend a part of the session dealing with the anxiety of getting to the appointment; online, that’s gone, and they can more quickly get to working on other stuff. She also noted a lower no-show rate.
The one thing I wanted to see at my old agency but never did was a setup where a person could come to the health center and have an online appointment in a private room. I thought it would be particularly helpful for people who don’t have a private space for online therapy (which is not uncommon among lower-income folks), and it could work for the agency as well, in that they could have a therapist sit anywhere and still serve folks at the outlying clinics without the travel time. I might have been missing something.
frosty
@Jeanne: 29
Jeanne
@frosty: have some additional questions, but yes I think I can help find someone. Is there a way for you to email me without putting it online here?
Jeanne
@narya: not the best but sometimes people sit in their car for privacy when taking a break from work.
JaneE
I am waiting for my rheumatologist to start the telehealth visit with me as I type. If the appointment starts on time I have another 25 minutes, but I hope he gets in early.
I think it is wonderful, especially for specialist visits that would mean an hour or more drive just to get to his office. Follow ups especially, where I say “it’s still good” and he says “Fine, lets check in X months, contact us if it gets worse”. Labs can be done anywhere so unless a really physical exam is needed the video works just fine for many specialties.
Any visit that is just talking works well. Video calls will let the doctor/therapist see if they need to.
frosty
@Jeanne: Yes, email WaterGirl and she’ll forward it to me, then we can take her out of the loop.
[email protected]
Shana
Based solely on my daughter’s experience she found that there was more flexibility in timing for mental health telehealth appointments so she could have a session without taking time away from work. And then she had an ongoing relationship with her therapist and wanted to stay with her.
Urza
My work was proud to offer telehealth for mental health during Covid. I signed up some time later wanting to talk to someone. Did a survey of current state. A month later it asked whats changed and I said nothing has. Then a month later another survey. And another even though I stopped responding they still send one every month. Never could figure out how to get to a real person.
Jeanne
@frosty: sent
Hazmat
As a therapist, I switched to all telehealth during the pandemic, then a year ago went back to one day/week in person, where I ask folks to switch to an online appointment if they aren’t feeling well or have had a covid exposure. In recent weeks, most of the new people contacting me about therapy have requested in person, enough that I’m looking for a space to add a second in-office day. I prefer in person work, but some people do fine with teletherapy, and I think it depends on the individual and their needs and ways of relating. It’s certainly convenient to avoid the commute on the telehealth days!
Ruckus
I was a teletherapy and in person mental health counselor decades ago when in college. One 4 hr shift a week, the location was a city mental health location. Very interesting work. Also found out that as much as I thought that this was the career for me, it wasn’t. We counseled people that had minimal normal human issues. The big, important problems we referred to full time professional therapists.
Sister Golden Bear
I agree that tele-sessions don’t increase capacity, but they definitely increase the pool of available therapists for subgroups who need affirming care — in my case seeing a gender therapist back in the day meant a 45 minutes drive every week for a couple years. More recently, when I did ketamine therapy, while I could do the ketamine sessions nearby, finding a therapists who’s both queer affirming (and queer) herself and specializes in ketamine therapy would’ve meant an even longer drive.
An important point is that for subgroups like mine, it’s not just that a therapist is affirming is that we don’t have to spend multiple sessions educating our therapist, which often happens with trans people who end up having to do lots of Trans 101 with their therapists if they can’t find one versed in trans issues. Likewise, with a therapist who’s queer/trans (or at least knowledgeable and affirming) there’s a huge value in not having to disagrees to explain things because they “get it” already.
Kofuu
Re. mental health, I thought of you when reading this article about an Ambetter insurance “ghost network” that failed to serve Ravi Coutinho. He had his mom also working the connections, trying to find support for him. He died.
‘I Don’t Want to Die.’ He needed mental health care. He found a ghost network. NPR, 9/22/24.