Digital Tools for Behavioral Health Hold Up Post-COVID...But More Needs to Be Done

Our Take:

Mental health needs in the U.S. have increased substantially driven in part by the isolation, stress and anxiety of the COVID pandemic. At the same time there has been increased recognition and acceptance of the importance of addressing the mental health needs of patients along with their physical health. However, as treatment rates have increased, existing shortages of behavioral health professionals and high out-of-pocket costs have created even larger gaps in coverage and care. While digital behavioral health services and tools may help reduce the shortfalls of traditional care models impacting access and quality, they may end up exposing other issues. For example, many argue that on their own digital health tools lack the ability to provide comprehensive mental health treatment, particularly for individuals with complex and co-occurring behavioral health needs. In addition, until reimbursement parity is reached for digital health services, tele-behavioral health may end up being relegated to a support for traditional care models rather than a complement or replacement.

Key Takeaways:

More than half of the U.S. population (160M people) live in a Mental Health Provider Shortage Area-HPSA (Commonwealth Fund)
Nearly 60% of adults in need of mental health treatment reported cost as a reason for not receiving services according to a 2022 survey (Mental Health America)
Approximately 59 million adults reported having a mental illness and nearly half did not receive treatment as of 2022 (SAMHSA)
The national average wait time for behavioral health treatment is 48 days, compared to 26 days for new-patient, non-emergent treatment and 21 days for family medicine (National Council for Mental Well Being, Merritt Hawkins)

The Problem:

According to the CDC’s Morbidity and Mortality Weekly, “the prevalence of symptoms of anxiety disorder was approximately three times those reported in the second quarter of 2019 (26% versus 8%), and prevalence of depressive disorder was approximately four times that reported in the second quarter of 2019 (24% versus 7%)”. In addition, “suicidal ideation was also elevated; approximately twice as many respondents reported serious consideration of suicide in the previous 30 days than did adults in the United States in 2018 (approximately 11% versus approximately 4%).” While there were certain methodological differences that may not make these numbers directly comparable, the trend does appear to be increasing. During the COVID public health emergency (PHE) State and Federal officials relaxed regulations for behavioral health services, thereby increasing access to treatment, medications, community, and care. While the telemedicine flexibilities have been extended through the end of 2024 and legislation is pending, the shape of such legislation and any unwinding or redesign poses a threat to the expanded care models enabled during the Pandemic. For example, behavioral health services delivered via telehealth are often not covered or are also reimbursed at a lower rate than in-person services and behavioral health providers are also less likely to accept insurance due to low reimbursement rates and administrative burdens.

In addition to coverage gaps and low reimbursement rates, high out of pocket costs for behavioral health services are also major barriers to access. As a result of all these factors, according to the 2022 survey nearly 60% of adults in need of treatment reported cost as a reason for not receiving services. In addition, while “Medicaid Expansion was also expected to improve access to mental health care, since Medicaid is the single largest payer for mental health services in the USA, studies have found limited effects. (which may be due to certain populations not being counted or having previously receiving care from sources like community health clinics, etc.)”

Background:

The opioid epidemic and COVID pandemic have also played major roles in the increase of mental illness and substance use rates. The compounding of loss, grief, unemployment, and loneliness contributed to increases in reported alcohol and drug use, as well as delays in care, cancellations of appointments, and poor access to prescriptions. As noted, forced by the experience of COVID, authorities had to experiment with ways to expand new and existing methods of care. In addition, the expansion of reimbursement for telehealth services during the pandemic was also broadened to include previously uncovered audio-only services, thereby bringing access to many communities struggling with limited or no broadband access. These flexibilities did appear to increase access. For example, a recent article in The Journal of Primary Care for Community Health found that “telehealth services for depression, specifically telephone with audio or video access, mitigated technology challenges that included accessing the internet and limited bandwidth for patients with lower incomes.” Also according to SAMHSA, during COVID, the availability of outpatient substance use treatment delivered via telehealth increased by 143% between January 2020 and January 2021.

In addition, some of the flexibilities provided under the PHE have now been permanently authorized under certain legislation. For instance, under the Consolidated Appropriations Act of 2023, Federally Qualified Health Centers (FQHCs) and Rural Health Clinics can continue to serve as distant site providers for behavioral health services thus allowing Medicare patients to receive behavioral health services via telehealth. Moreover, Medicare patients will continue to be eligible to receive telehealth services for behavioral/mental health care in their home and audio-only behavioral telehealth services are still allowable. Also, there will continue to be no geographic restrictions for originating sites for behavioral/mental telehealth services and Rural Emergency Hospitals (REHs) will continue to be allowed to be originating sites for telehealth.

Nevertheless, persistent workforce shortages, and unequal distribution of existing workforce leave many individuals seeking care without access as well, particularly in rural communities. As of December 2023, more than half of the U.S. population (160M people) live in a Mental Health HPSA (Health Provider Shortage Area) according to the Commonwealth Fund. Rural counties are more likely than urban counties to lack behavioral health providers and receive care from primary care providers. Individuals in rural counties are also more likely to experience one or more behavioral health conditions. Recent Data from the CDC shows that as of 2020 the highest state and county estimates of depression are observed along the Appalachian and southern Mississippi Valley regions.

Commonly used digital health tools include mobile health applications, wearable technology, internet based cognitive behavioral therapy, virtual reality, and machine learning. The use of wearable technology has the potential to reduce limitations in diagnosis and treatment of behavioral health conditions by providing objective measures based on a patient’s true behavior outside of their appointments.

However, given that wearable technologies may be subject to user error and comfort may impact adherence and tolerability, the ability to have periodic in-person visits with providers can be essential. Moreover, many digital behavioral health tools often work best when treatment is combined in a hybrid model. For example, internet-based CBT can expand access, maintain engagement, enhance privacy, and reduce costs to both patients and the healthcare systems. Additionally, electronic consultation can offer an opportunity for digital health to support providers, particularly specialists like psychiatrists, who may already have limited availability to see new patients. The ability to do electronic consultation both synchronously and asynchronously (at least between providers) may also reduce wait time for referrals, medication management and support peer learning.

Implications:

Expanding the integration of physical and behavioral health through the use of tele-behavioral health tools may help meet needs and close access gaps for particularly vulnerable populations. This is particularly important as poor mental health impact has been shown to significantly impact an individual’s daily life and overall wellbeing. According to the World Health Organization, depression is a leading cause of disability worldwide and is tied to multiple chronic illnesses. For example, people with depression have a 40% higher risk of developing metabolic diseases, lower rate of employment and higher risk of substance use than the general population. Similarly, research has found that people with one or more chronic diseases also experience higher rates of behavioral health conditions such as depression, anxiety, and substance use, often exacerbating their conditions. Recent research, including a study from the Annals of Medicine have “provided evidence that treatment via telemedicine interventions were beneficial for depressive symptoms and quality of life in patients with depression.”

Thus, access to behavioral health care is essential to the prevention of total morbidity and premature mortality for many individuals with a behavioral health need. Digital health tools have been shown to reduce stigmatizing encounters, transportation costs and other geographic barriers. Additionally, participation in digital mental health interventions such as virtual support groups or group therapy can increase social connection. A recent study on the effectiveness of digital mental health tools in reducing depression and anxiety found them to be moderately to highly effective in low resource settings. However, to successfully implement the integration of tele-behavioral health will require significant organizational commitment as well as a change in training and systems to ensure clinicians are all aligned in ensuring that patients have the capacity to access and utilize platforms for care. In addition, for underserved communities with limited access to clinicians, low digital literacy, poor broadband or other issues, providers and payers will have to be creative to ensure these developments don’t further exclude them from care. This may include looking for public/private partnerships to improve technology access, using asynchronous technology (like store and forward) where necessary or even in some cases just resorting to the old analog telephone if necessary. Digital behavioral health tools present an opportunity to address workforce shortages and supply issues but policy officials and those looking to expand access must remember inability to deploy these technologies will further impact already medically marginalized communities.

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