I’m an ER doc, and in one of my urban emergency departments, I haven’t seen a psychiatrist in person for about a year. That might seem somewhat surprising, but our covering mental health group switched over to 100% telepsychiatry coverage for our site some time last year, and they haven’t looked back.

We still wave to each other on the portable video screen, but for our psychiatrists, there’s no more commuting in, fighting for a spare computer to use, or smelling the invigorating smells of the ER. I felt like I had been hearing about the promise of telepsychiatry and telemental health for ages but nothing had ever changed, and then one day it suddenly appeared. And it doesn’t seem to be going away.

In my other work, here at Spruce, I’ve loved watching the growing number of mental health practices that use our platform to keep up with their patients outside of the office. Some of them use us just for our telephony features, such as second and third phone lines with secure voicemail storage and shared team inboxes, while others have adopted our encrypted messaging or even our full-blown video telemedicine capabilities. All of them, though, keep me thinking about the uniquely good fit that mental health has with telemedicine in all of its forms.

Research has been suggesting for some time that telemental health is safe, effective, and capable of bringing better care to millions of people, but we’ve mostly been hearing about it like a huge wave far out at sea.^1,2 Well, I think that wave is finally hitting shore, and it’s time to ride it or end up under it.

You came for the clickbait headline, and I will not let you down. Based on recent industry trends and published reports, paired liberally with my own biased observation, here are nine types of patients that you’re going to lose if you don’t adopt some type of telemental health…and soon.

1. The patient who lives far away

As of 2016, more than one in eight Americans lived outside of a “Metropolitan Statistical Area,” and more than one in five lived in a “Health Professional Shortage Area” (HPSA).^3,4 One of those two designations is currently required for a Medicare beneficiary to be eligible for telemental health services, and though that amount of coverage is terribly inadequate, the number of potential patients is still huge.⁵ More than 65 million, to put a point on it.

Furthermore, in order for an area to qualify as an HPSA for mental health services, it needs to have a psychiatrist-to-population ratio of 1:30,000. It does not take much empathy or imagination to understand that 65 million people sharing 1-to-30,000 psychiatrist access is not where we want our health system to be. Telemental health technology may be the only pragmatic solution to this disastrous, deadly shortage, and we write it off as experimental or as a plaything for the rich only at our own great peril.

2. The patient who moves

People also move around; it’s inevitable. But it seems like a waste to lose a great therapeutic relationship to distance when we have telemental health technology to bridge the gap.

On Spruce, we have a number of practices that are keeping their patients despite the distance, and I can’t help but think that this is the way it should be for functioning mental health provider-patient relationships. Why start from scratch or risk a patient losing touch with care altogether? I know from the ER that the latter situation, especially, can lead to seriously bad outcomes, so please consider telemental health for continuity of care (regardless of whether you use Spruce or not).

3. The travelers

I’m going back to the well of geography again, but I promise that this is the last time and then we’ll move on. However, it is undeniable that many people travel. Not permanently like the patients who move, but temporarily, for vacation or work or school or many other reasons. Specifically, young people often travel a great deal, and they are also a demographic that is at high risk for mental health disease, especially relative to the total burden of any type of disease in their age group.

It is therefore becoming progressively more mandatory that mental health providers develop a way to maintain contact with their patients when they can’t come in for an office visit. There is always the old-fashioned telephone call, of course, but consider these other types of telemental health that might aid your diagnosis and management across a distance:

• Live video
• Secure messaging (app-to-app, encrypted)
• SMS text messaging (sometimes patients demand it)
• Asynchronous telemedicine (e.g., standardized symptom inventories, such as the PHQ-9 for depression or the GAD-7 for anxiety, both of which can be performed via smart telemedicine question sets)

4. The busy

This one has nothing to do with geography, as promised. Sometimes people live close to you but still have trouble getting into an appointment. Many high-functioning, busy people have a definite need for mental health care, and meeting them at least somewhat on their own terms can sometimes be a necessity if you want to see them at all.

Furthermore, it’s not just a hectic schedule or egocentric nature that keeps patients out of your office even when they live nearby. Recent research has quantified the time and financial expense of in-person ambulatory care, beyond the direct clinic time and fees, and has found that a typical appointment costs a patient 37 minutes in travel time and $43 in missed earning opportunity.⁶ That may be a burden even for patients who have plenty of time, and telemental health, again, may be the answer.

5. The young

Youths! Always so frustrating. And now they will be pushing you toward telemedicine and telemental health.

In one 2016 study of 2,025 American adults, for instance, more than half of surveyed 18- to 34-year-olds reliably indicated a clear preference for telehealth care options:⁷

• 64% reported that they would be open to virtual care treatment options as an alternative to in-office doctor’s visits for non-urgent matters,
• 70% said that they would choose a primary care doctor who offers a patient app over one who does not, and…
• 52% agreed that they would choose a primary care doctor who offers virtual care treatment options over one who does not (e.g., video conference call)

A separate study of 2,019 adults in 2014 found data to corroborate this, with 74% of respondents aged 18 to 34 indicating that they would consider seeing their doctor for an online visit.⁸ Concerningly, 11% of this same millennial demographic reported that they would even go so far as to switch doctors based on the availability of online visits, making them nearly four times as likely as those 65 or older to feel this way.

6. The sick or elderly

I apologize; I misled you a little bit with my millennial wiles, and it’s not just the young that want telemedicine and telemental health. Other demographics, such as the elderly, the ill, and the mobility-challenged are also looking for a way to see the doctor without having to undertake the expense (and difficulty and pain) of travel, and without potentially exposing themselves to other ill people.

In the same 2016 survey study referenced above, for instance, a full 57% of baby boomers (ages 55+) indicated that they would be open to virtual care as an alternative to in-office appointments.⁷

Perhaps most interestingly, of the survey respondents who said that they would be open to virtual care, 74% felt that way because it would be more convenient, but only 40% felt that way because it would be easier on their schedule. This implies that “convenience” is not always about scheduling, and perhaps it often has more to do with travel requirements or other pragmatic issues that become more difficult as age increases and health declines.

7. The governmentally insured

Despite Medicare being extremely narrow with its telemedicine reimbursement criteria, the amount of telemental health performed and reimbursed for Medicare beneficiaries has been quietly skyrocketing. A recent analysis of fee-for-service claims data found a 45% annual increase in telemental health visits between 2004 and 2014.⁹ The trend line speaks for itself:

The situation for Medicaid on the state level may actually be even better. The American Telemedicine Association (ATA) tracks the reimbursement climate in each state, and their 2017 analysis grades 15 states as an “A” for Medicaid reimbursement of telemental health services and another 34 as a “B.”¹⁰ They further state that, generally, “mental health assessments, individual therapy, psychiatric diagnostic interview exam, and medication management are the most covered via telemedicine.

Having followed the governmental telemedicine reimbursement trajectory for several years now, I can say that it has been uniformly positive. It may be slow, but it is already good, and the changes are all for the better. Now is the time to start thinking of the government as a friend for telemental health providers.

8. The privately insured

Surprise again! It’s not just governmental coverage that is warming up to telemedicine and telemental health services; private insurance is getting in on the game, whether by choice or force. Most important in this topic, there is a class of legislation on the state level that is referred to as “telemedicine parity” legislation. These parity laws, to varying degrees, force private insurers to reimburse medical services that are provided via telemedicine if they also reimburse those services when performed during in-person visits.

In its latest assessment, the ATA has graded 24 states (as well as Washington, D.C.) at the “A” level for telehealth parity laws, stating that these states have laws that mostly or fully “provide state-wide coverage, and have no provider, technology, or patient setting restrictions.”¹⁰ Another four states grade out at the “B” level, too, so more than half the country has explicitly declared open season for telemental health.

9. The emergent and urgent

As I discussed at the beginning of this article, in at least one of my ERs, if I’m not seeing you on a telemedicine video screen, then I’m not seeing you at all. Emergent and urgent mental health services are increasingly moving to telehealth technologies, and if these services are an important part of your practice, then you’ll need to have telemedicine options available to stay relevant.

Even if you don’t have any emergency department or other emergency coverage as part of your practice, increasing access options for your patients when they have severe needs outside of business hours is inarguably better medicine. And don’t worry, technology can also help you guard your personal time, so telemental health doesn’t have to mean you’re always on and available.

References:

1. García-Lizana, F. & Muñoz-Mayorga, I. What about telepsychiatry? A systematic review. Prim. Care Companion J. Clin. Psychiatry 12, (2010).
2. Hilty, D. M. et al. The effectiveness of telemental health: a 2013 review. Telemed. J. E. Health. 19, 444–454 (2013).
3. U.S. Census Bureau. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2016 – United States ― Metropolitan Statistical Area; and for Puerto Rico. U.S. Census Bureau, American FactFinder (2010). Available at: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. (Accessed: 20th July 2017)
4. Primary Care Health Professional Shortage Areas (HPSAs). The Henry J. Kaiser Family Foundation (2017). Available at: http://www.kff.org/other/state-indicator/primary-care-health-professional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. (Accessed: 20th July 2017)
5. Medicare Learning Network. Telehealth Services (calendar year 2017). (Centers for Medicare & Medicaid Services (CMS), 2016).
6. Ray, K. N., Chari, A. V., Engberg, J., Bertolet, M. & Mehrotra, A. Opportunity costs of ambulatory medical care in the United States. Am. J. Manag. Care 21, 567–574 (2015).
7. Steinfeld, J., Salesforce Research & Harris Poll. 2016 Connected Patient Report: Insights Into Patient Preferences on Telemedicine, Wearables and Post-Discharge Care. (Salesforce, 2016).
8. Modahl, M., Meinke, S., American Well & Harris Poll. Telehealth Index: 2015 Consumer Survey. (American Well, 2015).
9. Mehrotra, A. et al. Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States. Health Aff. 36, 909–917 (2017).
10. Thomas, L. & Capistrant, G. State Telemedicine Gaps Analysis: Coverage and Reimbursement (2017). (American Telemedicine Association (ATA), 2017).