Harika Rayala

The use of social distancing to “flatten the curve” and prevent the spread of 

 It has become critical to conduct patient encounters by telephone or video conference during the current pandemic, especially as many patients are currently experiencing increased levels of stress and anxiety. Their psychotherapy and psychiatric management must continue to prevent further decompensation and avoid potential consequences like suicide attempts, emergency department visits, and psychiatric hospitalizations in the face of a pandemic that strains health care resources. Because face-to-face appointments both risk the transmission of COVID-19 and use personal protective equipment that is in dire shortage, telehealth has emerged as an important alternative.

Telehealth innovation is thought to offer many opportunities, including improvement of the patient’s experience, increased health care access, and reduction of health care costs.

 Research demonstrates that telehealth interventions produce positive outcomes when used for remote patient monitoring for chronic conditions, communication, counseling, and psychotherapy.

 Psychotherapy provided via telemental health has demonstrated efficacy in reducing pain, disability, depression, and anxiety comparable to traditional face-to-face encounters and without significant risks or adverse effects.

 expanded significantly from 2017 to 2019.

 All 50 states and the District of Columbia provided some coverage for telehealth services for their Medicaid members. Furthermore, 42 states and Washington, DC had telehealth commercial payer laws but there was enormous variability across states.

 Uncertainty regarding state-to-state differences and lack of reimbursement parity dissuaded many providers from entering telemental health.

Federal and state legislation and regulation has rapidly changed in response to the current pandemic in order to increase availability of telemental health services.

 As these actions have occurred through multiple avenues across various levels of government, it is challenging for many providers to keep up with the swift changes while caring for their own, potentially distressed, patients.

There has been broad bipartisan support to increase access to telehealth at the federal level. The House of Representatives voted to allow the easing of telehealth restrictions for Medicare patients on March 5, and the Senate passed a similar bill 96-1. On March 6, HB 6074, 

Coronavirus Preparedness and Response Supplemental Appropriations Act 2020

With implementation of the bill on March 17, The Center for Medicare and Medicaid Services (CMS) revised regulations that previously limited the patient location during telehealth encounters for Medicare patients, and then challenged state Medicaid agencies to adopt the same rules.

 Whereas previously, telehealth services could only take place in certain designated locations with the use of synchronous video technology, the bill allowed patients to receive services at home, using their telephone with some limitations on the type of phone. In addition, this bill included $500 million for an emergency waiver that will expand coverage for telehealth services in Medicare. Requirements around qualified providers and eligible services remain the same.

The Department of Health and Human Services Office for Civil Rights (HHS OCR) announced that it would waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.

 The Department of Health and Human Services and Vice President Mike Pence announced an easing of regulations to allow providers to practice across state lines “to meet the needs of hospitals that arise in adjoining areas.”

 While the details of this are unclear, many suspect that this may allow telehealth to be practiced across state lines.

The Drug Enforcement Agency (DEA) announced suspension of the federal Ryan Haight Act upon the declaration of a public health emergency in order to facilitate the use of telehealth in providing medication-assisted treatment.

 The Ryan Haight Act previously required that physicians must conduct a face-to-face examination before prescribing controlled substances via telehealth to ameliorate concerns about online trafficking of controlled substances. The current exception allows prescribers practicing via telehealth to prescribe controlled substances to patients without a prior face-to-face exam while the designation of a public health emergency remains in effect.

Substance Abuse and Mental Health Services Administration (SAMHSA) released 

 to ensure that substance use disorder treatment services are uninterrupted.

 Their guidance includes increasing flexibility in providing pharmacotherapy for opioid use disorder, allowing patients up to 1-month supply of doses of take-home medication, and waiving requirements for written patient consent forms.

Forty-two states, along with Washington, DC, have telehealth payer laws pertinent to commercial payers. The statutes and regulations dictate coverage and reimbursement that vary from state-to-state.

Before the COVID-19 pandemic, 21 states mandated Medicaid coverage of telehealth but a range of state regulations affected telemental health utilization. Some state policies restricted the patient’s setting or location, requiring that the patient be located in a health care facility or within a certain distance of the provider during the encounter. Others restricted the specific technology used for the encounter, such as requiring the use of a synchronous technology, which may be an obstacle for patients who are living in rural areas with limited broadband connectivity, although this population has been a target of telehealth efforts.

Since the pandemic, many states have made both legislative or regulatory changes to loosen these restrictions and increase telemental health access as well as reimbursement.

 As of April 7, at least 46 states have applied and have been approved for Section 1135 waivers that allow for greater flexibility with certain Medicaid and Children’s Health Insurance Program requirements.

 Most of the states with the waivers now allow out-of-state providers to temporarily provide care for their Medicaid patients.

 Most of the states and Washington, DC have now expanded telehealth access to Medicaid patients in other ways such as removing restrictions on location and allowing telehealth to be delivered by telephone as well as video.

Regulation of private payers has also varied by state. A few states have required private insurers to waive copayments (copays) for telehealth.

 Some insurers, such as Aetna and Blue Cross Blue Shield, had already waived copays on telehealth visits. Beyond the efforts mentioned, some states are taking more aggressive actions.

New York Governor Andrew Cuomo authorized the New York Licensed Office of Mental Health Programs to waive sections of regulatory requirements pertaining to telehealth to reduce barriers and increase access to mental health treatment across the state (Ann Marie Sullivan, personal communication, March 11, 2020). This aims to streamline the approval process governing telehealth in order to increase the number of providers who can utilize telehealth to treat patients.

The New York State Department of Financial Services (DFS) adopted a new emergency regulation under New York Insurance Law requiring New York State insurers to waive cost-sharing, including, deductibles, copays, or coinsurance for in-network telehealth.

 Moreover, New York created a new platform for mental health services during the pandemic that is available free of charge and unrelated to insurance status called the COVID-19 Emotional Support Hotline.

 More than 6000 mental health professionals volunteered to provide free online mental health treatment during the pandemic, and residents of New York can call the state's hotline to schedule a free appointment.

The Ohio Department of Mental Health and Addiction Services announced expansion of telehealth for the treatment of mental health and substance use during the COVID-19 pandemic.

 This measure will permit telephone encounters, eliminate the requirement that new patients must be seen face-to-face for their initial encounter, and increase flexibility of monitoring medication-assisted treatment of opioid use disorders. This will allow patients to both establish and continue mental health and substance use treatments via telemental health during the pandemic.

Massachusetts Governor Charles Baker mandated that health insurers cover telehealth services for all in-network providers, reimburse these services at the same rates as face-to-face encounters, and they cannot require prior authorizations for these services.

 Furthermore, all carriers were instructed to cover all telehealth copays to promote its use.

 An additional executive order authorized licensed Massachusetts providers to extend telemedicine services across state lines to their already established patients, who were enrolled during the 2019-2020 in a college or university located in Massachusetts.

 Massachusetts’ Board of Registration in Medicine processes were modified to expand the number of providers who may be able to respond to medical needs, including providers abroad, for the duration of the state of emergency.

Many advocates and lobbyists continue to ask Congress to mandate that all insurers expand coverage for telemental health, require reimbursement parity, allow providers to practice across state lines, eliminate geographic restrictions and cover multiple modalities including telephone. While many states moved quickly to reduce barriers, others have not. Most legislation and regulations have targeted Medicare or Medicaid, but fewer have addressed private payers.

 is a Clinical Fellow in Psychiatry, Harvard Medical School; 

 is an MD candidate, University of Michigan Medical School; 

 is a Fellow, Harvard Medical School Center for Bioethics and Director, Policy and Business Relations, Department of Accountable Care and Integration, Boston Children’s Hospital; 

 is a Clinical Fellow in Psychiatry, Harvard Medical School; and 

 is a Fellow in Clinical Psychology, Boston Children’s Hospital. They report no conflicts of interest concerning the subject matter of this article.

-The authors thank Michelle Riba, MD, MS, University of Michi

https://www.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/

gan Medical School, David DeMaso, MD, Boston Children’s Hospital, and Mildred Solomon, EdD, Harvard Medical School.

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Articles

The use of social distancing to “flatten the curve” and prevent the spread of COVID-19 has catapulted the use of telehealth.

Expanding Telemental Health in Response to the COVID-19 Pandemic

Public health emergencies may present a range of unanticipated potential stressors to vulnerable patients and communities. Psychiatric patients can be disproportionately affected by these conditions due to pre-existing health disparities, lack of resources, or limited executive functioning under stress, all of which may impede effective responses during an emergency. As college students comprise a demographic with a growing burden of mental illness, public health emergencies pose special challenges to this population.

 are uniquely vulnerable to both everyday stressors and severe mental illness, and psychiatric symptoms among college students appear to be on the rise. Stress, anxiety, depression, suicidal ideation, and self-harm all appear to be increasing among this population.

 Suicide is currently the second most common cause of death in this age range, and the rate of suicide continues to climb.

These psychiatric symptoms can have a widespread effect on the overall health of students as mental health conditions and viral diseases remain linked by a range of biological and behavioral pathways, with mechanisms varying by viral illness.

 While depression and stress may increase vulnerability to 

, depressive symptoms may also lead to a delay in help-seeking or reduced likelihood of detection of health conditions including communicable diseases.

 Studies show that people with severe mental illness (SMI), including schizophrenia, bipolar disorder, schizoaffective disorder, and major depressive disorder, have an excess mortality that is two- or three-fold higher that in the general population, shortening life expectancy by 13 to 30 years.

The current public health emergency in response to 

 has disrupted life on many university campuses, and increased anxiety and distress in many college students. There are a litany of reasons that college students may encounter unique challenges, stressors, and barriers to mental health treatment.

Many universities have extended spring breaks to delay the return of students to campus so campus leadership can have more time to prepare for a potential health care crisis and implement infection precautions. Other universities have cancelled all events, shifted to online classes, or ended their semester early. Many students have been mandated to vacate their dormitories with only a few days’ notice.

Dormitory evacuation is a stressful scenario for college students. International students may not be able to return home. Students from families with financial stressors, marginal housing, or other challenges that limit their capacity for support may have disproportionate difficulty arranging last-minute transportation and housing. Food insecurity, a significant problem affecting students with limited financial resources, may worsen if college cafeterias close or financial aid for the academic year is cut off.

 As local businesses close, it will be more difficult for students to find low-wage jobs to earn income. At home, some students do not have the technological infrastructure to be able to keep up with online classes and engage with their now-virtual social communities, leading to academic stress and further social isolation. The few students who are granted exceptions to the evacuation mandate will be isolated in otherwise vacant campus dormitories with significantly limited services.

Other students may be quarantined due to perceived risk of spreading the virus. These students may lose opportunities critical to their scholarly or professional advancement. The social isolation and decreased activity during quarantine may exacerbate rumination and feelings of hopelessness. The circumstances could understandably perpetuate stress, anxiety, and low mood.

Even students not under quarantine and from well-resourced families are stressed about the rapidly changing and uncertain climate of relocations, academic deadline changes, shifts to online teaching modalities, and cancellation of anticipated events such as graduation ceremonies. In a population that is already vulnerable to mental health problems (eg, anxiety, depression) and is simultaneously experiencing a potentially traumatic public health crisis, these stressors may lead to clinically significant psychiatric symptoms and illness. This is compounded by the social isolation intrinsic to many of the containment efforts as well as the potential stigma and limitations of accessing psychiatric care at home and having to switch from typical sources of on-campus support.

College mental health services must swiftly respond to this changing landscape to support their students during this stressful and potentially isolating experience. Many are attempting to rapidly shift to virtual visits and other forms of 

. However, building technological infrastructure and negotiating reimbursement takes time. While a range of legislative and regulatory hurdles had previously restricted the use of telemental health, state governors and regulatory agencies are taking action to eliminate barriers and expand use of telehealth to both protect clinicians and improve access for patients.

 authorized the New York Licensed Office of Mental Health Programs to waive sections of regulatory requirements pertaining to telehealth to reduce barriers and increase access to mental health treatment across the state (Ann Marie Sullivan, MD, personal communication, March 11, 2020). This aims to streamline the approval process governing telehealth in order to increase the number of providers who can utilize telehealth to treat patients.

Ohio Department of Mental Health and Addiction Services

 announced expansion of telehealth for the treatment of mental health and substance use concerns during the COVID-19 pandemic (Lori Criss, personal communication, March 14, 2020). This measure will permit telephone encounters, eliminate the requirement that new patients must be seen in-person for their initial encounter, and increase flexibility of monitoring medication-assisted treatment of opioid use disorders. This will allow patients to establish and continue mental health and substance use treatments during the pandemic.

 has mandated that health insurers must cover telehealth services, reimburse these services at the same rates as in-person encounters, and cannot require prior authorizations on these services.

 Furthermore, an additional executive order mandated that providers in Massachusetts can provide care to patients in other states who were enrolled in college in Massachusetts during this academic year.

Requirements that clinicians have a license to practice in the state where the patient physically resides is a significant barrier for college students continuing mental health treatment after their campus evacuation. Many students may stay with family members in a state different from their university and be left unable to receive services from on-campus mental health providers.

Some universities who had implemented a telemental health platform in a limited capacity prior to the pandemic were often able to more rapidly roll out online resources with relative ease. For example, 

 was able to provide their entire student body access to a secure online cognitive behavioral therapy program within one week because of a prior trial based on a grant from the Substance Abuse and Mental Health Services Administration (Holly Wilcox, MA, PhD, personal communication, March 12, 2020).

Less conventional communication modalities may create access for students who are juggling logistical challenges and find it difficult to regularly attend in-person appointments during a relocation or quarantine. Many clinicians have expanded their use of telephone appointments as hurdles related to both privacy and billing have been gradually addressed (Melissa Eshelman, MD, personal communication, March 16, 2020).

Some universities are inviting students within driving distance to attend in-person appointments although students are encouraged to reschedule or use telehealth if they are medically symptomatic. A few psychiatrists, who are seeing patients in-person, have relocated to larger offices to maintain social distancing during sessions (Melissa Eshelman, MD, personal communication, March 16, 2020). However, as the pandemic expands, many such as The Ohio State University are transitioning to solely telehealth appointments and encouraging staff to work from home as much as possible.

As mental health clinicians provide services with more flexibility, psychiatrists are reducing barriers as well. Programs that had previously enforced policies regarding providing medication refills only during in-person appointments have liberalized their stance to include prescribing refills based on a phone encounter, allocating more refills, or providing 90-day rather than 30-day prescriptions. Many college mental health clinics are implementing practices typically utilized at the end of the semester in preparation for potential coverage gaps during summer break.

Some Intensive Outpatient Programs (IOPs) and Partial Hospitalization Programs (PHPs) are transitioning to telemental health delivery while others have stopped accepting new patients. IOPs and PHP are important levels of care for our system to both limit psychiatric hospitalizations and facilitate safer discharges from psychiatric hospitals. As these programs care for the highest-risk patients outside of psychiatric hospitalizations, it is crucial to develop innovative ways to deliver these services.

Anticipated clinician shortages across the entire health care system may affect university mental health clinics as well as clinicians, as family members are quarantined and schools and childcare centers close. While many programs hope to facilitate telehealth appointments that can be utilized from clinicians’ homes, if resource scarcity and clinician shortages become severe, it may be necessary to triage urgent appointments while minimizing routine follow-up.

College students are psychiatrically vulnerable, psychiatric patients are physically vulnerable, and the current circumstances on college campuses are exceedingly stressful and potentially socially isolating. Given these factors, college students are likely at an elevated psychiatric risk right now, and college mental health services must adapt to support their students during these circumstances. Continued enactment of legislation and regulatory changes that facilitates telemental health and allow treatment across state lines is critical to ensuring adequate mental health treatment access for college students during this pandemic.

 is an MD Candidate at the University of Michigan Medical School; 

 is a Senior Staff Psychiatrist at The Ohio State University and Co-Chair of the American Psychiatric Association Caucus on College Mental Health; 

 is an MD Candidate, Harvard Medical School. The authors report no conflicts of interest concerning the subject matter of this article.

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College students are uniquely vulnerable to both everyday stressors and severe mental illness, and psychiatric symptoms among college students appear to be on the rise.

Author | Harika Rayala

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