The future of teletherapy
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What a time strange time it is. Earlier I wrote some of my predictions about what psychotherapy will look like during and after the pandemic. (See Post-pandemic psychotherapy.) Many of those predictions are coming true. In this post, I will focus on the increasingly complicated future of teletherapy in the psychotherapy world. 

What are insurance companies doing about teletherapy?

Responding to the COVID pandemic, government entities and insurance companies opened the door wide for teletherapy. Yet even as that was happening, no one was clear on how long the door would stay open. Would insurance companies quickly move back to the pre-COVID standards of care and reimbursement?  

Silly us. We should have known. It is now very quite clear that all insurance companies are rapidly moving back to the pre-COVID rules. 

As we have moved through this time, it is increasingly clear why insurance companies are moving to pre-COVID rules. In short, insurance companies have no choice in the near term but to go back to the old rules. Why?

First and foremost, contracts define the implementation of insurance benefits. These written agreements between employers, patients, providers, and insurance companies circumscribe which treatments will be paid for and at what rates. As COVID emerged and emergency orders were established, those contracts were temporarily modified. But now as government entities are resetting back to the “new normal,” insurance must go back to the old contractual arrangements.

Furthermore, in many cases, an insurance plan is defined by an employer. Insurance companies merely implement what the company wants. In these cases, the company hires the implementing insurance company and therefore has the final say on decisions about benefits. Insurance companies do not decide but merely administer the plans.

Then there are government entities that provide insurance, the largest being the federal government. With COVID, rules were temporarily suspended. Now the end of the suspension is rapidly approaching. 

But will insurance make permanent changes?

Insurance companies are ambivalent about paying for the use of teletherapy. Adding a new treatment protocol that is widespread means increasing costs for the insurance company. Not surprisingly, each company is watching all the others, waiting to see what they decide. If they can pay less for teletherapy, they might be interested in expanding teletherapy. But when it comes to reimbursement, no company wants to get ahead of the pack. 

In my view, no insurance company will pay for teletherapy sessions at the same rate as face-to-face until governments require it. Why should they?

And for government bodies to make permanent changes in the rules is a drawn-out process at all levels. And this sort of change does not happen without political pressure. That pressure has to come from somewhere. We’ll come back to this theme later.

On top of these issues, we have just experienced the chaos of how insurance companies operate during a crisis. Consequently, the most natural thing for them to do is to go back to what they know. And contractually, there may be no other immediate option for them. 

That said, in the long run, what will happen? Continue reading. 

What are governments doing about teletherapy?

Discussions are loudly going on at the state and federal levels regarding teletherapy. The topic is generally about telemedicine, but sometimes, it also includes teletherapy. Here, for example, are a few samples of news articles:

No doubt, there will be other states weighing in. 

And at the federal level, the debate has also begun:

Teletherapy has been used extensively in the Veterans Administration. The VA has been a pioneer in the teletherapy area and has made many legislative efforts to provide the service across state boundaries. At the federal level, no one is objecting to expanding teletherapy within the VA. 

And now, politicians are paying attention to telemedicine in general. Some are seeing its advantages. Of course, within each governing body are those resistant to telemedicine, especially around the costs associated with opening up access and the rates paid for these services. As usual, the concern is about increased costs.  

Will clients get what they want?

In the online version of Psychiatric ServicesDr. Dror Ben-Zeev, Ph.D. writes about his belief that The Digital Mental Health Genie Is Out of the Bottle. He writes:

It is unlikely that we will see a full return to traditional in-person mental health service models when the COVID-19 pandemic subsides.

He makes several important points: 

Evolving patient preferences, provider attitudes and capacities, and new digital mental health research will facilitate ongoing integration of technology at all levels of care. 

Patients who transitioned to treatment via digital platforms are now learning, perhaps for the first time, that such options exist. . . .

Moreover, there will also be a segment of new mental health service users who sought treatment only after the COVID-19 pandemic took hold. For them, stepping away from the only treatment modalities they have ever come to experience would not constitute a return to “normal.” 

Whether they are new or veteran treatment seekers, we can expect many patients and their family members to advocate for a continuation of technology-supported services.

In essence, he is arguing that public demand and everyone’s increasing comfort with technology-mediated mental health experiences, will win the day. 

The New York Times article, Teletherapy, Popular in the Pandemic, May Outlast It, is subtitled, “Some therapists find that remote therapy is so convenient to their patients that they will continue with it.” The author is suggesting that therapists see benefits for the continuation of teletherapy. 

So are these writers correct? Will the public demand be persuasive with elected officials and, ultimately, insurance companies?

My analysis

To the degree that governments and insurance companies are responsive to the public, teletherapy will become a standard and routine tool for delivering mental health services. 

HOWEVER, there will be a significant battle over reimbursement for telehealth visits. The debate is over whether governments should support reimbursement parity, i.e., the same compensation for teletherapy as for in-person visits, for the same service. You can guess who lines up on each side. 

  • Insurance companies and some in the federal government will be against reimbursement parity. Why? Because increasing access and reimbursement parity will increase costs. And until they can figure out how to pass on those costs, they initially pay. 
  • Providers want reimbursement parity. Doing a teletherapy session takes the same time as an in-person session. Providers prefer to have equal pay for that time.
  • The public cares mostly about the continuation of telemedicine. Not in the providers’ fees. They want the option without additional out-of-pocket costs.

The battle between payers and providers, is, of course, nothing new. As in the past, the decision will likely come down to the perceived benefits to the public. And while the public is not heavily invested in the fees providers collect, they want happy providers. 

Can providers get their message across? Here is where our political advocacy will matter. And frankly, the outcome is not clear at this time. Pitting two of the largest lobbying groups, medicine and insurance companies, against each other is anyone’s guess. (In 2019, the most significant spending sectors were health followed by insurance.)

And what about HIPAA?

I believe that the HIPAA rules will come back and stay back. I do not see a future where those standards of care will erode. The technology is here, so there are no reasons for exceptions anymore.

And jurisdictional authority?

The fate of the jurisdictional issues involved with teletherapy across state lines is less clear. Some in government want to break down the siloing effect of separate state licensing laws. Philosophically, they believe that licensing requirements add unnecessary and costly barriers to practice. 

The counter-argument is this. Of course, licensing adds barriers. The point of licensing is to require specific training and experience before practicing. But the public needs the protection afforded by requiring candidates to meet licensure standards. Mandating these requirements is the only way to ensure ethical practice. Furthermore, licensing laws enable regulators to sanction those who violate a code of ethics, thereby protecting the public.

As far as I can see, the jurisdictional argument will be fought state by state, with the results varying. Many states already have provisions for temporary practice for a practitioner licensed out of state. For example, Arizona allows out of state licensees to practice for up to 20 days per year. (See here for a list of all state regulations on this topic for psychologists.)

And some states have already removing barriers for out-of-stated licensees to do teletherapy in their jurisdiction. For example, even before COVID, Florida’s law allowed licensed out-of-state to do teletherapy in their state under certain conditions.

Furthermore, as mentioned before, the federal government is already moving that direction and has been for years via the Veteran’s Administration. And now, they have done so temporarily:

I do not doubt that some at the federal level will attempt to make this temporary arrangement permanent. 

So what will happen?

First, the public’s demand for the continuation of teletherapy is growing. And the pandemic has provided practitioners, clients, insurance companies, and government entities with experience with the pros and cons of teletherapy. 

Second, I believe that the heightened demand for teletherapy will eventually lead to a legislative endorsement. 

And yet even as governments promote teletherapy, two unknowns remain: 

  • Will teletherapy to paid at the same rate as face-to-face therapy?
  • Will the majority of states allow out-of-state practitioners to conduct teletherapy within their boundaries?

We will have to wait to see the answer to these two questions. Early results are mixed. I believe it will take years for the answers to emerge. 

The last word: Advocacy

We have a chance to influence the outcome of these questions. State and national trade associations are all actively working on changing the results in favor of providers. 

My advice? Get involved and stay active. We can shape our future. 

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