Professionals looking for current metrics related to opportunities in telemental health or telebehavioral health will find a treasure-trove in the recent Centers for Medicare and Medicaid (CMS) Congressional report. The November 15, 2018 CMS Congressional report is entitled, Information on Medicare Telehealth. It offers a wide number of recently compiled metrics, expressed concerns and overall telehealth opportunities about the overall industry serving Medicare recipients, and succinctly compiles a useful array of facts that can be of use to behavioral professionals and their organizations.
Below, the Telebehavioral Health Institute (TBHI) has extracted key telebehavioral health and mental health information from the CMS Congressional report. It is offered to the TBHI community as a sample of relevent information of potential help to hospitals, clinics, agencies and practices as well as internet start-ups objectively assess the current marketplace. Key sections of the CMS Congressional report have also been bolded.
Why consider the CMS Congressional Report?
The CMS report to Congress not only defines Medicare reimbursement policy but such policy also serves as a bellwether for third-party insurance carriers, state lawmakers, regulators and professional associations seeking to expand services. The selected excerpts below may be particularly helpful to stakeholders who are planning to expand their efforts in developing telehebehavioral care. Metrics offered by the CMS Congressional report are current, comprehensive and free to use in bolstering grant requests, position papers, business plans and other reports.
Telebehavioral Health, Telemental Health and Substance Use Disorder Excerpts from the CMS Congressional Report
Telehealth Service Delivery by State
In 2016, the total number of Medicare FFS beneficiaries using telehealth services varied substantially across states, ranging from the lowest use in Vermont (50 beneficiaries and 295 services) to the highest use in Texas (10,565 beneficiaries and 33,279 services) (p 13).
Chronic Condition, Mental Health, and Substance Use Diagnoses.
The analysis of the beneficiary characteristics and telehealth services indicates that telehealth is being used primarily to treat beneficiaries with mental health diagnoses. In 2016, 85.4% of all telehealth users (74,547 beneficiaries) had a mental health diagnosis. The overwhelming majority of Medicare telehealth users in all years studied were diagnosed with one of eight common mental health and substance use conditions. Approximately 37% of Medicare beneficiaries who received telehealth services in 2016 had diagnoses of a recurring major depressive disorder, bipolar disorder and schizoaffective disorders. An additional 7,032 individuals (7.9%) were treated for schizophrenia and 4,554 (5.1%) for an episode of depression. Treatment for physical chronic conditions, such as diabetes and heart failure, are not among the most common diagnoses and there were fewer than 1,000 Medicare beneficiaries treated by telehealth for these conditions (p 23).
Medicare Beneficiaries with Behavioral Health Disorders
Behavioral health disorders encompass both mental health and substance use disorders (SUD) and telehealth has emerged as an important tool in the treatment of behavioral health disorders for Medicare beneficiaries. The current evidence describing the use of telehealth for these types of conditions is discussed below, including the potential for telehealth to expand access to treatment for opiate use and abuse.
More than 75 percent of all U.S. counties are considered mental health shortage areas, and half of all U.S. counties have no mental health professional at all. In fact, according to SAMHSA (2015), adults with unmet mental health needs reported structural barriers (transportation issues, inconvenience, and time constraints) as the top reasons for not using mental health services. Psychiatric care is also difficult to obtain for rural nursing home residents because of these same limitations.
Emerging research indicates that telepsychiatry can reduce disparities in access to psychiatric care. For example, psychiatric care delivered remotely increases the chances that individuals living in rural communities will be able to access professionals who are culturally and linguistically competent. While not limited to Medicare, research also shows that telepsychiatry obtains the same results as face-to-face therapy for bulimia nervosa, PTSD, and depression and can be considered a viable alternative when face- to-face therapy is not accessible. Furthermore, research on telepsychiatry utilization in rural nursing homes found cost savings for the psychiatrist, nursing homes, and patients, in addition to enthusiastic support from patients, family members, and nursing home personnel.
In 2014, approximately 21.2 million individuals in the U.S. had a substance use disorder (SUD), but only 2.5 percent of those individuals received treatment. It is estimated that the number of adults aged 50 years and older who will have a SUD by 2020 could be between 4.4 million to 5.7 million individuals. The Medicare population has among the highest and fastest-growing rates of opioid use disorders, currently more than 6 of every 1,000 beneficiaries. Many seniors take multiple medications and receive prescriptions from multiple doctors, making tracking and controlling any misuse of these prescriptions a substantial challenge.
Research into county-level access to treatment facilities showed that there were lower proportions of treatment facilities in southern and Midwestern states than in other regions. Furthermore, it is estimated that outpatient SUD treatment services are almost four times less likely to be available in rural hospitals than in urban hospitals (12.1 percent versus 43.7 percent, respectively, with treatment services offered either directly or by arrangement). In addition, hospitals in large rural areas are about twice as likely to offer SUD treatment services (17.9 percent) as hospitals in small (8.2 percent) or isolated (8.5 percent) rural areas.
Rural areas are particularly short on detoxification (detox) services. A survey conducted by the Maine Rural Health Research Center in 2008 found that 82% of rural residents live in a county without a detox provider. More than half of all rural detox providers serve patients across a 100-mile radius limiting referral options to SUD treatment, especially in isolated rural areas.
Although not specific to Medicare, a preliminary study that compared a videoconferencing telehealth SUD treatment program with a comparable in-person counterpart from the same organization found that the completion rates were double for the online version compared with traditional outpatient treatment (80 percent versus 41 percent, respectively). Additional studies suggest that the reasons for increased completion rates using telehealth programs may be convenience and increased confidentiality. Research has also found telehealth SUD services to be as effective as in-person treatment, although small sample sizes are a recurring limitation to determining statistically significant results.
Every geographic region, population, and age group has been impacted by the opioid epidemic, including Medicare beneficiaries, but treatment barriers persist throughout the country. Although individuals living in rural areas report higher rates of prescription opioid misuse than urban residents, only about 3 percent of all opioid treatment programs are located in rural areas. Telehealth may serve as a valuable tool to improve access to evidence-based treatment, including for Medicare beneficiaries. Telehealth has the potential to help bridge the rural-urban treatment gap for Medicare beneficiaries by linking rural clients to high-quality behavioral health services and providers located in more populated areas. Telehealth seems to provide the intervention most similar to office-based treatment, and research shows that telehealth patients, while not specific to Medicare, have satisfaction levels and outcomes similar to those of clients receiving in-person therapy (pp 20-22).
Section 2. Activities by the Center for Medicare and Medicaid Innovation which test increased access to telehealth services
Although the Medicare telehealth requirements generally must be met in order for Medicare to pay for telehealth services, section 1115A(d)(1) of the Social Security Act permits waiving those requirements as may be necessary solely for purposes of testing models under section 1115A.x
x Effective January 1, 2020, section 50324 of the Bipartisan Budget Act of 2018 (P.L.115-123) removes the geographic limitations under section 1834(m)(4)(C)(i) of the Act, treats the beneficiary’s home as an originating site described in section 1834(m)(4)(C)(ii) of the Act, and provides that no originating site facility fee will be paid when the originating site is the beneficiary’s home for otherwise covered telehealth services furnished by physicians or practitioners in certain Innovation Center ACO models for services furnished to a Medicare fee-for-service beneficiary assigned to the applicable ACO (p. 22).
For the complete 2018 CMS Congressional report, download your free copy here: Information on Medicare Telehealth. Your comments about the CMS Congressional report are also invited below.