Although there are two pending mental health reform bills (S.1945, H.R. 2646) that have kicked up the national dialogue swirling around what many call “controversial” measures, there is a major shortage of psychiatrists and other mental health professionals nationwide. In fact, there are an estimated 4,000 areas designated in the U.S. as having such a shortage where there is only one psychiatrist per 30,000 people. That is not a typo. It’s hard to imagine but explains in part why only 10% of individuals with mental health issues seek care. This leaves 90% of that population with unmet behavioral health needs, Lisa A. Marsch, PhD, director of the Center for Technology and Behavioral Health (CTBH) at Dartmouth College told Healthcare Dive. “There is a huge opportunity and unmet need to think about how we’re going to reach that 90%.”
Telehealth bridging the gap
This is where technology fits into the new behavioral health paradigm. Telehealth is being adapted very quickly not only by large health systems but also in rural areas where access is limited. Teledoc, a telehealth company established in 2002, increased its membership by 51% last year to 12.2 million members and recently added behavioral health visits in November 2015. Despite initial concerns by those in the industry about the difficulty in establishing a provider-patient relationship, Dr. Monika Roots, senior medical director for behavioral health at Teledoc and a child psychiatrist, said, “developing that rapport with patients is even easier with telehealth. The kids like the technology and think it’s fun to see a doctor on the screen.” Adults realize it saves time and increases access to care. “These things really bridge that gap so that the quality of care is better and the continuity of care is better – and it really helps provide access to people who need it,” Dr. Roots added.
The company’s technology platform had to be upgraded and developed for behavioral health, along with secure connectivity to the platform that is HIPAA-compliant. Their providers only have access through an EHR that is also HIPAA-compliant. “We found that patients are becoming owners of their own data, but we’re highly cognizant of the secure data that we keep in our portal,” remarked Dr. Roots.
Providers in Teladoc’s network have the ability to collaborate since they have access to the same EHRs and to medical care if needed. “So for example, if someone has severe agoraphobia and can’t leave their house, we have the ability to bring exposure therapy to them to get them out of the house,” explained Dr. Roots. “We’re not just focused on prescribing medication – we offer psychotherapy, family therapy, etc. so the amount of care we can provide in many ways can be more – simply because of the ease of use and access.”
A need for standardized guidelines
State guidelines for telemedicine vary, which requires the company to investigate those prior to adding services. A federal judge recently sided with Teledoc, in a case against the Texas Medical Board (TMB). The board has a rule which requires providers to meet patients in person before remote treatment or requires other providers to be present in the same room during the first face-to-face visit via telehealth. Teladoc sued the board in April 2015, citing the rule violated antitrust laws. TMB filed a motion to dismiss the case, but the judge denied it so the case will now move forward.
Julian Cohen, president of behavioral health sciences at Teledoc, told Healthcare Dive there is a “movement towards standardizing regulations -- towards providers and provider licensing and practicing across state lines.” The American Psychological Association (APA) is one organization that has been involved in developing guidelines for telepsychological practice and in the development of regulatory guidance for psychology licensing boards to oversee telepractice – intrastate and interstate, according to the organization’s website.
There are currently 29 states and the District of Columbia that require insurance companies to pay for telehealth services if those same services would be covered when provided in person. More commercial insurers are offering telehealth visits to behavioral health professionals, according to Forbes. Companies, including Aetna, Anthem, Cigna, and UnitedHealth Group, are increasing access to Teledoc, MDLive, and Doctor on Demand – which just added behavioral health to its services last month.
“I think the technology…is finally at the point where the user sees the value, understands it’s easy to do and that allows better access and removes stigma concerns. We’re at the tipping point with behavioral telemedicine and I think we’re going to see over the next few years that it’s going to grow by leaps and bounds,” Cohen said.
Incentives for EHR implementation by behavioral health providers
A recent proposal by Sen. Sheldon Whitehouse (D-RI) for a pilot program with financial incentives for mental health and substance misuse providers to obtain EHRs is being backed by the Behavioral Health IT (BHIT) Coalition. In a recent letter to the U.S. Senate Committee for Health, Education, Labor and Pensions (HELP), the organization said the Meaningful Use program, “needs major legislative reforms encompassing improved interoperability, better EHR usability, and enhanced transparency including the star-rating system authorized in S. 2511. At the same time, Meaningful Use reform efforts cannot be completed without providing HIT incentive payments to front line acute care behavioral health providers.”
It’s anyone’s guess why behavioral health and substance abuse treatment providers were not included in the HITECH Act – what the Coalition refers to as a “fundamental policy error.” A recent Substance Abuse and Mental Health Services Administration (SAMHSA) study shows there is a high incidence of cancer, heart disease, diabetes, and asthma among the 6 million or so people served by the mental health system, according to BHIT.
The big issue now is, without EHRs, efforts to improve care coordination for that population with chronic health conditions are being challenged. In addition, efforts to integrate primary care and behavioral health services, or collaborative care, are also being thwarted without the ability to share patient data.
The challenge of behavioral health data inclusion in HIEs
Key to improving the quality of care is including behavioral health data in health information exchanges (HIEs). Laura Young, executive director of the Behavioral Health Information Network of Arizona (BHINAZ), told Healthcare Dive there are very few exchanges that include behavioral health or substance abuse data due to the strict privacy and security policies: “One of the biggest challenges in adding behavior health data to an HIE is the required 'opt-in' consent. It has to be a complicit consent from the patient agreeing to exchange their data. And the problem is, is that many HIEs are set up as an 'opt-out' consent – the patient is opted in by default unless they choose to opt out. That’s not sufficient to meet the 42 CFR Part 2 requirements."
SAMHSA released a proposed rule last month to change 42 CFR Part 2 for confidentiality of substance misuse records. “The new proposed rule would allow us to put on a consent form that an individual’s data can be released to anyone that has a treating provider relationship instead of an entire list of actual organizations,” said Young. “That makes it much easier.” The new rule would also require on the consent form that HIEs have to include the name of the program where the data would be coming from. Young said it’s going to be a challenge for some HIEs because many wanted to have a more broad HIE designation. The comment period for the proposed rule is open until April 11.
There are 15 organizations currently exchanging data through the BHINAZ, as well as the state HIE and a large lab company. Although there are about 250 behavioral health providers in Arizona, and an initial goal was to connect them all, Young said the focus has been shifted to more outcomes-based connections. “We connected all the serious mentally ill organizations so we could offer them connected crisis services. Another was targeting children’s services – connecting children providers and children’s hospitals. There’s another project we’re hoping to kick off around opium treatment programs.”
Young told Healthcare Dive BHINAZ is currently working with other HIEs around the country to help them add behavioral health data. “We’re pushing in that direction and being involved in the national dialogue around HIE in behavioral health so we can see that happening on a larger scale because it really isn’t happening in many places. I think it’s critical for care coordination efforts and having the whole health of a patient is crucial for not only the health outcomes but from a cost saving perspective.”
Outside of Nebraska, which also has a behavioral HIE called eBHIN (Electronic Behavioral Health Information Network), Young said she wasn’t aware of any other stand-alone behavioral health HIEs. However, there are HIEs starting to share behavioral health data, such as the Colorado Regional Health Information Organization (CORHIO), which recently announced its plans to launch a pilot program to add behavioral health data on a patient-by-patient basis -- if they consent -- and share it with hospitals and long-term care facilities.
Technology for collaborative care
“I think there is a terrific opportunity to leverage science-based technology tools in making entirely new ways to embed them in primary care systems,” Dr. Marsch of CBTH told Healthcare Dive. “I think that’s really key in light of the shortage of mental health professionals…This is not about replacing clinicians but extending the reach of the workforce that we have. The data we have shows it can be done quite effectively.”
A 16-year, $40 million project, funded by the National Institutes of Health (NIH) and overseen by Dr. Marsch, studied behavioral aspects of managing chronic diseases, like diabetes and obesity, and has resulted in new technology that will launch (a beta version) in about three weeks. “We’ve been studying the fundamental principals of behavior change – what really drives changes in behavior and what reinforces that over time? We developed a mobile platform called ‘Square 2’ that integrates all the science of behavior. The intent is to facilitate the integration of behavioral health into primary care for the collaborative care model,” Dr. Marsch explained.
The way the platform works is by addressing behavior that may be affecting health, such as depression. It then provides resources that have been tested to address that combination of issues. “It’s a tool that’s been designed for the collaborative care model because it can embed all these different aspects of health and wellness,” she added. The platform is web-based but can be used on any mobile device and ideally, Dr. Marsch said, “as a daily resource for checking progress towards health goals and learning new skills and providing in-the-moment resources to successfully navigate through certain circumstances.”
The promise of technology to address behavioral health, although challenging, seems set to make an impact. There's a big demand from consumers who want more tools to provide new models of patient engagement, explained Dr. Marsch, as well as more interest from insurance companies in terms of potentially improving the quality of care and saving costs. “We’re really well positioned to have a transformation of healthcare delivery models with technology systems. Technology has changed so much of our lives now and how we operate. We haven’t fully harnessed it to create new models of healthcare that extend the reach and quality of personalized care."