Public Policy Update

Telemental Health: Eight Key Considerations

Despite mixed results, there’s strong potential for future use.

By Topic: Law Policy and Regulation
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In the United States, telemedicine played a secondary role in healthcare delivery until the pandemic elevated its significance, particularly for populations who are immunocompromised or have physical disabilities or transportation challenges. 

During the pandemic, the prevalence of mental illnesses hit record highs; 22.8% of U.S. adults aged 18 years or older (57.8 million) experienced a mental illness, according to the Substance Abuse and Mental Health Services Administration’s 2021 National Survey on Drug Use and Health. Among those who experienced a mental illness in 2021, 26.5 million (47.2%) reported receiving mental health services either in person or virtually in the past year. 

Studies of the use of telehealth solutions, including telemental health, have shown mixed clinical efficacy outcomes. Whereas some research has shown increased access to mental health providers as a result of telemental offerings, reduction in anxiety and mood disorders from increased access remains unknown. Despite these mixed results, there appears to be strong potential for telemental health owing to its popularity among patients and counselors. That use is expected to continue to grow as it’s used more widely for chronic and acute conditions, and as managed care models and private equity-financed primary care gatekeeping models expand its use, especially as studies begin to demonstrate clinical efficacy.

Prevalence of Mental Illness and Treatment 
The 2021 National Survey on Drug Use and Health also found that 14.1 million adults (5.5%) aged 18 or older had a serious mental illness, which is defined as having any mental, behavioral or emotional disorder that substantially interfered with or limited one or more major life activities. Among those who experienced a serious mental illness in 2021, 9.1 million (65.4%) received mental health treatment in the past year. 

The survey defines mental health services as having received inpatient or outpatient treatment and/or counseling, or having used prescription medication for problems with emotions, nerves or mental health. The assessment included diagnostic modules assessing mood, anxiety, eating, impulse control, substance use, adjustment disorders and a psychotic symptoms screen, but did not include adult attention deficit hyperactivity disorder, autism spectrum disorders, schizophrenia or other psychotic disorders.

Notably, only one in two people with any mental illness and two of three people with a serious mental illness received care, with telemedicine (video calls, telephone calls, SMS text messages) accounting for more than half of their interactions with providers. 
In addition to the high prevalence of mental illness and treatment, the Centers for Disease Control and Prevention noted a spike in suicide deaths reported, with a 36% increase seen between 2000 and 2021. In 2021, 12.9 million Americans contemplated suicide, 1.7 million made an attempt and 48,183 succeeded in ending their lives. Significantly, suicide was the second leading cause of death for people aged 10–14 and 20–34 the same year.

Lastly, Gallup’s latest National Health and Well-Being Index, published in February 2023, indicates that the gap between mental illness prevalence and treatment access has continued. “The percentage of U.S. adults who report having been diagnosed with depression at some point in their lifetime has reached 29%, nearly 10 percentage points higher than in 2015. The percentage of Americans who currently have been or are being treated for depression has also increased to 17.8%, up about seven points over the same period. Both rates are the highest recorded by Gallup since it began measuring depression using the current form of data collection in 2015.”

Drivers of Demand for Telemental Health
Mental illness is a major health issue; media coverage of the nation’s epidemic of mass shootings has consistently speculated unattended mental illness as its root cause. Loneliness, resulting from the pandemic lockdown, is framed in healthcare circles as a critical social determinant of health. Schools, employers and communities are grasping for solutions, and shortages of mental health professionals are widely acknowledged. Thus, interest in telemental health is especially strong now given the following eight considerations. 

  1. Demand for mental health services is significant and growing. Demand is significant in every age cohort and is especially problematic among the most at-risk populations, including adolescents, young adults and those in low-income populations. Telemental health can be a core strategy for improved accessibility in all populations including those underserved.
  2. The supply of mental health providers is inadequate to meet the demand. Telemental health is a necessary capability in serving less severe mental illnesses and those whose condition is stable, and it is a necessary element of an organization’s digital health strategy to deploy the mental health workforce more effectively. Telemental health plays a vital role in right-sizing the mental health workforce of health systems, mental health practitioner groups or managed care plans.
  3. Telemental health screening tools can improve care for other patient populations. Thorough screening for mental illnesses and integration of behavioral health interventions in treatment plans in every clinical program is vital. Telemental health is a necessary element in care management for all chronic and episodic populations. Care planning may benefit from telemental health-aided diagnostics surveillance.
  4. Access to and treatment for mental illnesses is enhanced by telemedicine. It’s a necessary part of managing soaring demand, but its adoption has not kept up. One recent study showed outcomes were equivalent for telemental health and in-person interactions, and patient satisfaction levels were even higher. Some providers have been reluctant to embrace telemental health, suspicious of payers who encourage its use; however, telemental health is here to stay.
  5. Telemental health interventions are becoming more timely, customized and cost-effective. With the development of customized mental health treatments, the clinical quality of telemental health solutions is improving. Additionally, users are satisfied, relieved of any stigma for seeking treatment. 
  6. Regulatory policy for telemental health services is progressing. Uncertainty about compliance and restrictions will likely be resolved before the end of 2024. Monitoring state and federal policy-making is essential but favorably inclined toward telehealth use.
  7. Strategic investors are making big bets on virtual care. This includes health systems, healthcare-focused retail chains and health plans. Case in point: In May 2023, a venture capital firm announced it raised $200 million to launch a digital health-focused fund, including an investment by Dallas-based Texas Health Resources, a 27-hospital system. Telemental health solution providers are attracting capital to fund innovative solutions and may be suitable partners for organizations.
  8. Operational risks in telemental health appear manageable. For example: 
  • Credentialling and performance evaluation of telemental health providers varies widely across states and in regions. There are no national standards, but interstate compacts are helpful.
  • Private insurers, employers, Medicaid and Medicare have not aligned on the relative value that should be designated to telemental health services. For example, how does payment for telemental health interventions compare with in-person treatments? Nonetheless, coverage determinations appear favorable.
  • Fraud remains a major risk factor in telemental health. Access to controlled substances and inaccurate or willful deception in coding patient encounters pose considerable risks to provider organizations. 

Telemental health involves risk, but enterprise risk management policies, procedures and best practices around credentialling, contract negotiations with payers and coding are emerging.

For health systems and local provider organizations, addressing heightened attention to mental illness requires a coherent telemental health strategy. Telehealth waivers from the pandemic have been extended through 2024 for Medicare enrollees. For commercial populations, coverage varies. However, what’s assured is the necessity of telemental health proficiency in every organization’s care management strategy.

Paul H. Keckley, PhD, is managing editor of The Keckley Report (