Deep Dive: Patient-Related Barriers to Adoption of Telemedicine for Mental Health Services
It is no secret that the COVID-19 pandemic catalyzed the rapid adoption of virtual care, telemedicine, mobile health, healthcare technology, and other forms of healthcare innovation nationwide.
While the technology for telehealth has been around for years, the relaxation of federal regulations coupled with the effect of pandemic-related measures on patients ushered widespread adoption by payers, providers, and patients. To portray the magnitude of this change in healthcare, McKinsey estimated that telehealth claims were 38x higher in February 2021 than in February 2020.
Adoption of telehealth has indeed skyrocketed, illustrated by the explosion in claims; however, there is significant variation across specialties. According to Bestsennyy, Gilbert, Harris and Rost, psychiatry and substance use treatment accounted for over 80% of claims in February 2021. According to Rock Health’s report on consumer adoption of telemedicine in 2021, out of all patients that sought telehealth, 11% were seeking mental healthcare. In comparison, 18% of telehealth patients were seeing care for chronic conditions. (cont’d)
This is notable if we take prevalence into account. Roughly 60% of Americans suffer from chronic disease while only ~20% suffer from mental illness. Evidence from various providers and HCIT companies paint a similar picture. In December 2021, CareCloud, an EHR provider, reported 400x more behavioral telehealth appointments now than the beginning of 2020. Demand for mental and behavioral healthcare continues to be the major driver of telehealth activity, in comparison to other therapeutic areas. This is why it is crucial to understand the dynamics of adoption surrounding telehealth for mental & behavioral health. Through analysis of different factors affecting adoption, we can identify ways to address these challenges while improving value.
Barriers to Telehealth Adoption
While adoption of telehealth has certainly accelerated, serious challenges exist. We have grouped these challenges into four categories: 1) technology-related 2) regulation & reimbursement-related 3) provider-related and 4) patient-related.
In technology-related challenges, it is obvious that rural areas have less access to high-speed internet, which effectively means that people there have less telehealth access, as the most popular medium for telehealth is live video. However, the recently signed Infrastructure Investment and Jobs Act includes over $40 billion in funding to expand broadband access. This funding will focus on expansion of broadband in rural areas and other areas without access to broadband internet. Regulation & reimbursement is arguably the most crucial factor affecting telehealth adoption. In November, CMS announced that it will continue to reimburse telehealth through 2023. However, many state-level policies are still up in the air, and could revert to pre-pandemic policies. Regulation and reimbursement are especially relevant to behavioral health. At the beginning of the pandemic, relaxation of rules from the DEA made it much easier for patients suffering from substance use disorder to access virtual care, given the spike in deaths from opiates. According to NPR, “[these changes] also eliminated some common barriers to care that have plagued addiction treatment, like a shortage of health care providers able to prescribe them, lack of transportation to get to the doctor, or having a suspended driver’s license.” Thankfully, Congress has changed the law so telehealth could be used for mental health services after the public health is lifted. So right now, reimbursement dynamics and regulations for telehealth for mental health services look positive. Nevertheless, providers are relatively powerless to address these challenges.
While there are significant challenges that slow down initial adoption for providers, physician adoption has been relatively robust already. According to Bestsennyy et al., “As of April 2021, 84 percent of physicians were offering virtual visits and 57 percent would prefer to continue offering virtual care. Furthermore, the focus of this report are opportunities for providers that already offer virtual care.
Currently, in many cases, patients have broadband access and virtual care in areas where telehealth is legal and reimbursed and have significant demand for mental and behavioral healthcare. Even in these situations, adoption is still low. In patient-related challenges, we identified telehealth awareness, digital literacy, mental illness symptoms, and language as significant barriers to adoption. Unlike technology-related or regulation-related challenges, it is possible for virtual care providers to address these patient-related barriers to adoption, while improving the value of care.
Telehealth Awareness
Background: Telehealth awareness refers to; 1) patients understanding that telehealth is accessible, 2) patients understanding that telehealth for mental and behavioral health is widely considered to be just as effective and high-quality as in-person care by researchers, experts, and organizations including APA. According to Rock Health, 36% of patients who did not utilize telemedicine, said they did not access telehealth because they unaware that it was an option and/or because of quality concerns.
The most likely telehealth users were young (between the ages of 18 and 44), had higher incomes, were from urban or suburban areas, and had advanced degrees. Given this profile, elderly patients, pediatric patients, and patients in rural areas are likely not targeted by virtual care provider marketing. This is not for lack of demand. According to USDA, “the effects of the opioid epidemic are more intense in rural communities where employment opportunities are often limited and isolation is pervasive.” In October, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a pediatric & adolescent mental health crisis. Just a few weeks ago, the Surgeon General, Vivek Murthy, released a new advisory describing the mental health crisis among American youth. Additionally, the prevalence of dementia and other neurodegenerative diseases is still growing, due to the aging population. Indeed, reviewing earnings calls from publicly traded mental healthcare providers shows that the focus remains on adults in urban areas. For example, LifeStance Health, one of the largest publicly traded mental healthcare providers, announced in the last earnings call that their most recent acquisitions deepened their presence in Atlanta, Austin, Chicago, Seattle, DC, and South Carolina.
Recommendation: One way mental healthcare providers can address the challenge of lack of telehealth awareness is to increase marketing to elderly patients, patients in rural areas, and to the families of pediatric patients. This would involve 1) dedicated additional resources for marketing to these demographic groups 2) leveraging demographic-specific marketing channels and 3) tailored messaging. For example, adolescent patients are likely to be most responsive to new social media platforms such as TikTok. Rural and elderly patients are more likely to respond to phone, mail, and email marketing campaigns. Providers can also tailor messaging to address specific types of treatment relevant for each group. Addiction treatment is direly needed in rural areas, elderly patients have increased need for neurodegenerative disease treatment, and adolescents are seeking treatment for depression and anxiety.
Value: This would effectively increase access to mental healthcare, by showing patients that telehealth is an option. Since our recommendation only concerns marketing efforts, this would not affect the type of care or quality.
Digital Literacy
Background: Lack of access to broadband has frequently brought up as a reason for lower adoption rates of telehealth. However, even if hypothetically everyone in the United States had access to broadband internet — digital literacy would still hinder patient adoption. If a patient does not proficient internet and computer skills, utilizing telehealth will not be possible. According to researchers at the University of Chicago, digital health literacy played a significant key role in telehealth utilization and telehealth willingness. Low levels of digital health literacy led to less engagement and interest in using video telehealth. Digital health literacy was differentiated from health literacy. Health literacy was not a predictor of patient willingness to use telehealth (video/phone). In addition, they found significant telehealth adoption gaps for video technology. Lack of digital literacy is likely a significant barrier to telehealth adoption for mental health services, especially for patients in rural areas and elderly patients (demographics with a high need for mental health services). According to recent research, 1.4 million adult Texans say that a lack of digital literacy is their main barrier to adopting home broadband service. Video telehealth would definitely not be a viable option for people who are unfamiliar with using broadband internet. Additionally, according to US Census, over 20% of Americans do not speak English at home. While most of those people will likely have the ability to speak English, a portion of that population will not. In addressing digital literacy for telehealth adoption, it is crucial to address the problem from a multi-cultural and multi-lingual lens. Addressing digital literacy, specifically digital health literacy, would certainly increase adoption rates and have a positive effect on the value of care.
Recommendation: We have two recommendations for providers addressing digital literacy to increase telehealth adoption: 1) Creation of a seamless patient experience 2) Consider other media for delivery. If a virtual care provider provides education and step-by-step resources of how to use telehealth, this can overcome lacking digital literacy. Furthermore, making sure the patient journey requires minimal self-direction and input from patients can reduce the hurdle to using telehealth. A report published by McKinsey recommends that providers continue to focus on “creating a seamless consumer interface, breaking down silos in care provision (across virtual and in-person) with improved data integration and insights.” This can also help bolster continued adoption as the pandemic comes to an end, lowering barriers to in-person care. Part of creating a seamless patient experience (reducing the need for high digital literacy) is creating an experience that caters to foreign language speakers. An example of this is Mt Sinai Health System announcing the integration of interpreter services in over 200 languages into its telehealth platform. The language and conceptualization of mental health is very different from language to language, and culture to culture so integration of language is crucial.
We recommend in-house interpreters or third-party interpretation vendors. Focus on reducing friction for an interpreter to directly join a video telehealth visit is important. In addition, time to connection should be at a minimum as well. Call routing architecture as well as contracts with external vendors should optimized to reduce the time it takes for interpreter to join a telehealth appointment.
Our second recommendation involves considering alternatives to video telehealth such as text messages and phone calls. According to a study published in Frontiers in Psychiatry in 2020, “text-messaging is an appropriate tool for low digital literacy populations and underserved groups. For instance, our own HIPAA approved texting platform, HealthySMS, was developed with and for low-income populations (mostly Spanish speakers) and shows high acceptability in underserved populations.” The University of Chicago study referenced earlier found no telehealth adoption gaps for phone usage between patients with low digital health literacy and high digital health literacy. Providers can offer telehealth through text message and phone calls, along with video — wherever clinically appropriate.
Value: Addressing digital literacy directly through the patient journey (including interpretation services) would effectively increase access to mental healthcare, by showing patients how to use telehealth. This would not detrimentally affect quality of care, and has the opportunity to increase quality by resulting in higher patient engagement during treatment. However, this could raise costs slightly. Reducing fixed costs associated with offering integrated interpretation services is one way to mitigate this concern. While our second recommendation may reduce costs slightly while increasing access, there is the risk of reducing quality, as telephone calls and text messaging offer less effective treatment than video, according to some sources.
References:
i. Bestsennyy, Oleg, Greg Gilbert, Alex Harris, and Jennifer Rost. “Telehealth: A Quarter-Trillion-Dollar Post-Covid-19 Reality?” McKinsey & Company. McKinsey & Company, July 22, 2021. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality.
ii. Ibid.
iii. “Consumer Adoption of Telemedicine in 2021: Rock Health.” Rock Health | We’re powering the future of healthcare. Rock Health is a seed and early-stage venture fund that supports startups building the next generation of technologies transforming healthcare., December 13, 2021. https://rockhealth.com/insights/consumer-adoption-of-telemedicine-in-2021.
iv. Ibid.
v. Jercich, Kat. “CareCloud CEO Predicts What’s around the Corner for Telehealth.” Healthcare IT News, December 1, 2021. https://www.healthcareitnews.com/news/carecloud-ceo-predicts-whats-around-corner-telehealth.
vi. “The Largest U.S. Investment in Broadband Deployment Ever.” Benton Foundation, November 6, 2021. https://www.benton.org/blog/largest-us-investment-broadband-deployment-ever.
vii. Sullivan, Thomas. “CMS Proposes to Extend Telehealth Flexibilities through 2023.” Policy & Medicine, October 24, 2021. https://www.policymed.com/2021/10/cms-proposes-to-extend-telehealth-flexibilities-through-2023.html.
viii. Noguchi, Yuki. “Limits on Virtual Addiction Treatment May Soon Return, Making Care Harder to Access.” NPR. NPR, December 30, 2021. https://www.npr.org/sections/health-shots/2021/12/30/1064818982/telehealth-addiction-treatment-prescribing.
ix. Robeznieks, Andis. “Telehealth Keeps Patients Connected to Care. Now Congress Must Act.” American Medical Association, December 27, 2021. https://www.ama-assn.org/practice-management/digital/telehealth-keeps-patients-connected-care-now-congress-must-act.
x. Bestsennyy et al., “Telehealth: A Quarter-Trillion-Dollar Post-Covid-19 Reality?” https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality.
xi. “What Is Telepsychiatry?” What is telepsychiatry? Accessed December 31, 2021. https://www.psychiatry.org/patients-families/what-is-telepsychiatry.
xii. “Consumer Adoption of Telemedicine in 2021: Rock Health,” Rock Health. https://rockhealth.com/insights/consumer-adoption-of-telemedicine-in-2021.
xiii. Shipley, Ahlishia. “Opioid Crisis Affects All Americans, Rural and Urban.” USDA, August 3, 2021. https://www.usda.gov/media/blog/2018/01/11/opioid-crisis-affects-all-americans-rural-and-urban.
xiv. Ritchie, L. Carol. “The U.S. Surgeon General Issues a Stark Warning about the State of Youth Mental Health.” NPR. NPR, December 7, 2021. https://www.npr.org/2021/12/07/1062112212/the-u-s-surgeon-general-issues-a-stark-warning-about-the-state-of-youth-mental-h.
xv. Cheng, Jessica, Nicole Kappel, Hanna Vollbrecht, Vineet M. Arora, David O. Meltzer, and Valerie G. Press. “Telehealth and COVID-19: The Role of EHealth Literacy in Patient Telehealth Preferences and Utilization.” Pritzker School of Medicine | The University of Chicago. The University of Chicago. Accessed December 31, 2021. https://hdsi.uchicago.edu/wp-content/uploads/2021/09/CHENG_Telehealth-and-COVID-19-The-Role-of-eHealth-Literacy-in-Patient-Telehealth-Preferences-and-Utilization.pdf.
xvi. Siwicki, Bill. “Mount Sinai Eases Translation in 200 Languages through Its Epic Telehealth Platform.” Healthcare IT News, June 9, 2021. https://www.healthcareitnews.com/news/mount-sinai-eases-translation-200-languages-through-its-epic-telehealth-platform.
xvii. Figueroa, Caroline A., and Adrian Aguilera. “The Need for a Mental Health Technology Revolution in the COVID-19 Pandemic.” Frontiers in psychiatry. Frontiers Media S.A., June 3, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283500/#B24.
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