Al Guida quoted in new Politico piece on Telehealth in the COVID-19 Crisis

Al Guida, President and CEO of Guide Consulting Services was quoted in an April 9, 2020 Politico article discussing the urgency behind creating access to behavioral health telehealth services during the COVID-19 pandemic. GCS is proud to help our clients in navigating these challenging times.

America’s having a nervous breakdown. Can telemedicine fix it?

By Mohana Ravindranath

04/09/2020 12:29 PM EDT

Locked-down America has become a country desperately in need of virtual therapy, but the health care system has been left scrambling to use telemedicine to help connect people with mental health professionals.

Years of restrictive federal and state policies kept America’s therapists from embracing telemedicine, and now behavioral health providers are rushing to move online — often with little guidance on best practices or assurances that the care will continue after the coronavirus fades.

"Everybody is struggling with this issue,” said Lynn Linde of the American Counseling Association, which represents licensed professional counselors.

The Trump administration, amid the crisis, has temporarily eased some restrictions to make it easier for therapists to video chat with patients across the country, and states and insurers have followed suit. President Donald Trump, who will meet with mental health providers Thursday afternoon, acknowledged the stresses Americans are feeling at one of his task force briefings this week.

“They need help,” Trump said Tuesday. “It’s a big problem."

The health care industry was notoriously slow to move online, but behavioral health providers are especially hustling to catch up to the new socially distanced reality after they were overlooked in previous efforts to expand digital health. Congress over a decade ago excluded them from a $30 billion investment toward putting electronic health records systems in physician offices and hospitals. Medicare payment for telehealth has been typically spotty, and uneven state licensing rules have made it difficult to expand the technology across the country.

"There's been a huge potential for this move for a long time, but ... regulatory and reimbursement barriers have prevented it from happening," said Chuck Ingoglia, president and CEO of the National Council for Behavioral Health.

Even with the new flexibility to practice remotely, mental health providers are still struggling on multiple levels. They are trying to adapt to telehealth visits without sacrificing the personal connection to the people they help. They are trying to navigate a maze of licensing rules while figuring out what the emergency flexibility really means. And they are trying to accommodate growing numbers of online patients facing depression, fear, panic, grief, isolation and economic distress — often on top of mental health conditions they had before the pandemic.

“There is a mad scramble to shift mental health and addiction treatment services online,” said Al Guida, a lobbyist representing behavorial health providers. “The question becomes: during a period extreme economic challenge, how do we invest heavily in tele-mental health?”

There are a lot of unanswered questions, including what the rapid changes may mean for patient privacy over the long term, whether in one-on-one teletherapy or in group sessions after digital Alcoholics Anonymous meetings were crashed by online trolls.

Providers are “kind of trying everything right now and seeing what can work,” said John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center. That includes meeting patients virtually on popular video chat apps like Google Hangouts and Skype after the Trump administration temporarily relaxed rules that long restricted health care’s use of these platforms over privacy concerns.

In addition to the people who were already receiving therapy or treatment for behavioral health, many more are now confronting isolation and anxiety because of the health and financial crisis. Nearly half of Americans say the pandemic is already affecting their mental health, according to a recent Kaiser Family Foundation poll.

"I would expect with these kinds of deprivations or stressors that those numbers would only increase," said Elinore McCance-Katz, Trump’s top mental health official. The agency she runs, the federal Substance Abuse and Mental Health Services Administration, has been hosting calls with behavioral health providers to walk through conducting virtual care during the pandemic.

Adopting telehealth will be a massive paradigm shift for behavioral health providers, an expansive category that includes psychologists, psychiatrists, licensed clinical social workers and licensed practicing counselors, among others. The field has been typically slower to embrace telehealth compared with other disciplines, according to a 2018 study from the University of Michigan's Behavioral Health Workforce Research Center.

Today's complicated patchwork of payment rules determining who can provide online counseling services may be holding back even broader adoption of telehealth. State regulators are generally relaxing restrictions on telehealth , at least temporarily, though some haven’t yet. Some private insurers are paying for online therapy visits at the same rate as in-person, though others still pay less.

Mental health professionals may still feel pressure to treat clients in person, putting themselves at risk, without stronger encouragement from health care payers, like state and federal governments and insurers, said Robert Caudill, a psychiatry professor at the University of Louisville. "Until we get clarification that says, 'Yes, absolutely do this, you're going to be fine,'" the shift toward telehealth may be restrained, he said.

Medicare during the crisis has relaxed federal rules to expand telehealth, including mental health, and HHS Secretary Alex Azar has urged states to loosen licensing requirements to allow out-of-state providers where there are shortages.

There are still some limits. Medicare still generally requires that telehealth visits have both audio and visual elements — so it typically won’t pay for phone calls — which could disadvantage those without internet access. Medicare says it will for pay for virtual visits with psychiatrists, clinical psychologists and licensed clinical social workers, but won't for licensed professional counselors — even though they often do similar work — because of what some behavioral trade groups called a quirk in federal law.

And while Medicaid tends to provide better coverage for mental health services than private insurers, access to telehealth services more broadly during the national emergency varies across the states. In California, telehealth companies employing out-of-state doctors can get approval to treat new patients within two to four days; temporary rules in Florida allow interns to lead more remote mental health sessions during the pandemic. Mississippi sets a much higher bar, only allowing out-of-state doctors to treat existing patients virtually.

There are already signs the practically nationwide lock-in is driving more mental health services online. Doctor on Demand, a well-known telehealth company, said it’s seen a 130 percent increase in behavioral health visits compared with the same time last year, as well as a significant uptick in the weeks since President Donald Trump formally declared the coronavirus a national emergency. NOCD, an app-based provider specializing in obsessive-compulsive disorder, said virtual visits have more than doubled since the beginning of March. Multiple behavioral health clinics tell POLITICO they've had to take 100 percent of their visits online during the pandemic, compared with a tiny fraction just weeks before.

The virtual shift hasn’t been without drawbacks, though. Reports about harassment of digital AA meetings could make people wary of seeking mental health care online.

"There's always a concern about confidentiality," said McCance-Katz, the federal mental health chief. "An individual just needs to decide the risk [of online therapy] versus gain ... If they're more concerned about something revealed about them that they don't want to be revealed, then they probably won't use the service."

For therapists, there’s an added challenge of building trust with their patients when there’s a digital barrier between them.

“So much of counseling has to do with body language, being physically present in the room, intonation,” Linde said. “Sometimes, that's lost when you don't have good internet connection, or one of you starts getting garbled.”

And other barriers appear poised to challenge the demand for mental health care. Lower-income Americans bearing the brunt of the country’s rapid financial collapse might not have access to phones or the internet, while the rolls of uninsured Americans seem bound to explode.

Some think the pandemic will force patients and providers to get more comfortable with using telehealth for behavioral care, even after the disruption to daily life ends. The crisis could be a "tipping point for the way we practice," said Peter Yellowlees, a professor of clinical psychiatry at the University of California, Davis and former president of the American Telemedicine Association.

Telehealth advocates say a further embrace of technology can prove to be an invaluable tool, giving providers deeper insight into their patients’ well-being. Beth Israel Deaconess psychiatric patients are now using an app that tracks sleep, step count and other biometric markers, for instance.

"This could be a really important testing case for telehealth," Torous said.