Often Undiscussed 2021 Telehealth Barriers

Prior to the pandemic, only 2.4% of employer health plans used telehealth in 2018. A few months into the pandemic, telehealth accounted for approximately 7 in 10 medical visits and Amazon is announcing that they will soon offer telehealth services to employers. The loosening of licensing regulations and location restrictions on providers and patients/clients across state lines to assist with healthcare during COVID-19 made health care accessible in ways that were previously unavailable.

Nonetheless, a serious shortage of mental health providers currently exists, with approximately 6,450 practitioners needed to serve thousands of geographic areas and populations in facilities such as prisons. Despite this growing provider shortage, federal efforts seem to be working at cross-purposes. On one hand, the federal government and some states are looking to make permanent changes that have supported the growth of telehealth to help meet these needs. On the other hand, the December 2020 Consolidated Appropriations Act of 2020 requires behavioral health providers to have seen their client in person during the prior six months before a telehealth visit will be covered by Medicare.

While many telehealth barriers are lifting, new ones are being introduced and yet others still exist because of conflicting agendas by stakeholders; confusion and lack of regulatory enforcement by licensing boards, and telehealth fraud. This article will look at each in turn.

Telehealth Barriers: Access

While telehealth has increased accessibility to care for millions of Americans, it is not without its flaws and critics. Some groups with limited/no access to telehealth technology, such as the elderly, poor and non-English speaking patients may be left unserved. Although specialized services and related professional training exist such as telehealth English translation services, many professionals are unaware of their availability or how they work. Underserved populations are finally beginning to get the care they need, but progress is slow and still has a long way to go. See Telehealth Disparities Under the COVID-19 Pandemic for more information related to telehealth disparities and their impact on underserved populations.

Telehealth Barriers: Competition

Competition poses growing threats. Telehealth interstate access creates a dilemma for many in-state providers. Some regulatory boards fear that the influx of out-of-state telehealth providers will threaten the viability of small in-state practitioners by competing for their clients/patients. They also worry that out-of-state providers may or may not meet the licensure requirements or be aware of the particular laws of the state they are entering. This is particularly true in less populated states, which can easily be targeted by neighboring state professionals who often live in urban areas where they find competition to be stiff.

Telehealth Medicare & Medicaid Providers, Patients, and Clients

Telehealth reimbursement complications run deeper than many professionals imagine.

• Adding to the growing list of complaints about telehealth reimbursement is the fact that competent counselors are being denied the right to obtain Medicare reimbursement when social workers have had that right for years. See Medicare Telehealth Reimbursement: Act Introduced to Allow Counselors to be Reimbursed by Medicare for details.
• Some larger healthcare operations have tiered contracts that allow them to serve both Medicaid patients and privately insured clients at different rates. Larger healthcare operations use that rate difference to help settle subsidize Medicaid patients. In essence, they are allowed to bill private clients at market rates in exchange for accepting to bill Medicaid patients at lower rates. The relaxing of telehealth jurisdictional laws could put some of those contracts at risk by allowing out-of-state providers to compete for privately insured patients.
• Behavioral providers are often struggling to make ends meet on their healthcare salaries, which tend to be at the low end of the pay scale when compared to other healthcare professionals with similar years of education. These same professionals also commonly hire billing agents to manage insurance companies to collect fees. Throughout the country, behavioral health billing agents typically require 5-10% of gross receipts for their services. In metropolitan areas where most behavioral professionals live, that rate is usually in the 10% range. Many professionals choose to pay these rates to avoid dealing with insurance companies that often require several hours per week to manage.
• Then there are unexpected twists that make no sense at all. In what appears to be a two-step shuffle, the December 2020 Consolidated Appropriations Act of 2020, section 123 includes language that requires behavioral health providers to have seen their client in person during the six months prior to billing Medicare for telehealth. See New Medicare Law Requires In-Person Visit for Telehealth Coverage for details.

How can a healthcare system thwarted by competing by such priorities expand to scale needed services through telehealth? Sadly, the real problem is that clients and patients needing services are often caught in the middle.

Telehealth Barriers: Confusion and Lack of Enforcement by Licensing Boards

Licensing boards also have led to frustration by many practitioners who find that boards are vague in their requirements for telehealth. Serious differences between boards in different states pose barriers to the expansion of telehealth.

• Notable movement has been made by the medical, psychological, and nursing boards in the United States, but much work still remains to be done, as detailed in Telehealth.org’s Telemedicine Across State Lines Post-Pandemic.
• Nonetheless, some states have made significantly more progress than others: Report of Telehealth Regulations by State.
• Even within states, boards for one behavioral profession can be diametrically opposed to boards for different professions.
  • Take the example of Georgia, where the master’s level Composite Board required at least 6 hours of professional telehealth training starting October 2015 for professionals using any form of telehealth.
  • To date, psychologists in Georgia however, are not required to take any professional training at all. Are psychologists that much more educated about telehealth than counselors, MFTs, or social workers? Two studies that Telehealth.org Faculty conducted in 1999 and 2018 would suggest that psychologists are not adequately educated about telehealth issues either.
• Regardless of the specificity of licensing regulations for practitioners, the widespread lack of enforcement of existing rules leaves many professionals at a loss. Lack of enforcement even before the many COVID-related waivers and enforcement direction for HIPAA in the United States raises further questions about the often archaic rules that exist.
• Given the lack of consensus across states as well as within states, clinicians are left to wonder if the rules enforced by their boards or the practices learned in training really matter.

Interjurisdictional Practice?

While efforts to establish a bar for expected regulatory compliance have been visible by some regulatory associations, more state licensing boards have opted to not participate in shared telehealth licensure models than those who have to date.  Without the needed support and guidance, professionals are all-too-often left to their own to figure out how to legally proceed. Consider these examples of thorny issues faced by many behavioral health professionals today:

• What to say to a desperate single mom who needs help for her acting-out 13-year old, who now is in another state, living with her brother and his family. Even if the Mom were to seek professional help, how can the 13-year old and relatives legally participate in family therapy?
• What about the blind, 89-year-old dad who lives alone in a double-wide trailer in Arizona, and who refuses to move to a safer environment? How can a caring daughter in Illinois legally work with her Dad’s team of professionals in Arizona to provide more of a safety net for her father?
• What about the immigrant worker who explodes in anger after being reunited with his family in Northern Washington state after being released from a detainee camp in California? Perhaps he can get medical care for the brain injury sustained while detained for 15 months, but how can his brother and sisters in Mexico help him by providing a needed biopsychosocial history?

Luckily, a number of bills have been proposed to help with interjurisdictional practice and other telehealth barriers, but these bills have not been signed into law, and much advocacy is still needed. See US Congress Meets to Discuss Telehealth after COVID: HELP Committee and Telehealth Reform: US Congress Heeds Public Outcry.

More Competing Agendas

Behavioral health startups were funded with more than a half-billion dollars in the first four months of COVID alone. Internet startups often spent from 20-30% of their gross operational budgets on marketing. Meanwhile, traditional insurance companies using traditional therapies often make it difficult to quickly call for help when it is needed. Finding a phone number to call in an emergency is often difficult if not impossible.

Given the many telehealth services offering “text-messaging therapy” and other minimal, often unvalidated interventions, people now have a better chance of finding an internet-based therapist without adequate telehealth training before having access to one paid by an insurance company. Where is this going? Who has the power to intervene?

Telehealth Fraud on the Rise

The expansion of telehealth has also led to a tremendous increase in telehealth fraud. According to the Office of Investigations of the Department of Health and Human Services (HHS), these are some of the reported types of fraudulent activity on the rise:

1. Billing for unperformed services
2. Overcharging
3. Providers not being licensed in the United States
4. Attempted theft and  sale of patient identities on the black market

For specific examples of telehealth fraud, see Telehealth & Healthcare Fraud: US Justice Department Reports Shakedown as well as $1.2 Billion International Telemedicine Medicare Fraud Crackdown. For more information on telehealth barriers and government efforts to improve the accessibility of telehealth services see President Issues Executive Order on Improving Rural Health and Telehealth Access.

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