Introduction

Telebehavioral health (TBH) changed the way clinicians provided services over the course of the COVID-19 pandemic. In response to the public health emergency (PHE) that ensued, federal and state governments adjusted regulations so that individuals could more easily receive behavioral health services. This resulted in fewer access disruptions, lower care costs, and helped establish TBH as a viable treatment modality.

Although the PHE has ended and in-person visits have increased, TBH remains popular. Providers and regulators are now working to establish how TBH can best serve individuals who need care, while also supporting providers in a post-pandemic world.

History

A service gap

A behavioral health services gap existed in the U.S. long before the COVID-19 pandemic. On average, one in five adults experiences mental illness annually. However, fewer than 50% receive treatment.¹ 

Many factors have contributed to this gap, including cost of services, travel expenses, stigma, and a lack of practitioners. Currently more than 160 million people live in areas with mental healthcare provider shortages.²

How telebehavioral health evolved

While TBH usage and acceptance rose significantly during the COVID-19 pandemic, TBH had already existed in some form for decades. Providing psychiatric services via videoconference, for example, began in the 1950s.³ However, TBH scalability pre-pandemic was hindered by misconceptions about efficacy as well as regulatory and reimbursement challenges.

The COVID-19 catalyst

Movement decreased dramatically during the pandemic as buildings closed and people stayed home. As a result, TBH underwent rapid adoption, as it became the only viable behavioral health treatment modality for many individuals. 

American society adopted TBH so quickly that by March 2020, utilization had increased by 154% compared to March 2019.⁴ In Medicare populations, TBH visits increased from 1% of all BH visits in 2019 to 50% by the end of 2020.⁵

Carelon Behavioral Health’s response

Carelon Behavioral Health was poised to respond to the pandemic’s challenges, as it was already providing expanded access to care with national provider groups. 

Acting on the changing regulatory and policy landscape, Carelon Behavioral Health quickly implemented TBH in multiple states and markets. Changes included:

• Training: The Provider of Quality Management (PQM) team learned how to better support providers transitioning to TBH.
• TBH readiness survey: Providers were asked to share the challenges they faced due to the pandemic. Carelon Behavioral Health assessed the providers’ comfort level and readiness to implement TBH according to state and national requirements. 
• Caring through COVID-19 training series: Providers received TBH training through virtual sessions on clinical management, crisis planning, and population-specific care delivery.
• TBH operating system: PQMs shared resources with providers, including Carelon Behavioral Health’s operating system platform, at no cost.

These changes supported Carelon Behavioral Health’s mission to improve population health outcomes and behavioral health integration. Patient and provider experiences were enhanced, and costs were reduced.

Additionally, Carelon Behavioral Health supported the 988 Suicide & Crisis Lifeline rollout by operating backup call, text, and chat services nationwide.

Telebehavioral health’s current advantages

Today, TBH utilizes a variety of software, devices, and connectivity platforms. Providers use TBH in in-patient, outpatient, and community settings. Services including evaluations, consultations, medication management, psychotherapy, and provider training can all be performed using TBH. Other benefits include:

• Improved access to care, allowing patients to bypass the uneven distribution of providers associated with in-person visits. 
• Fewer barriers, such as those associated with travel, mobility restrictions, and work absenteeism. 
• Less stigma, enabling more privacy when accessing treatment from home. This is especially helpful to individuals seeking treatment for substance use disorders. 
• Optimization of services, allowing providers to treat more patients more efficiently without sacrificing quality.

Vulnerable populations and the mental healthcare treatment gap

In 2021, approximately 35% of 14.1 million adults who experienced a serious mental illness did not receive treatment.⁶ For several reasons, this gap is even wider for vulnerable populations. Stigma associated with seeking treatment, a lack of culturally competent providers, and an uneven distribution of clinicians between urban and rural areas can keep people from getting the help they need. Populations that are often disproportionately affected by gaps in care include:

• Rural communities. More than 60% of individuals residing in rural areas live in a designated mental health provider shortage region.⁷ 
• Black, Indigenous, People of Color (BIPOC). Suicide ranked as the leading cause of death in 15- to 24-year-old Black Americans in 2020.⁸ Only 35.1% of Hispanic/Latinx adults experiencing mental illness receive treatment annually, compared with an average 46.2% of the general U.S. population.⁹ 

LGBTQ+. According to a recent survey, 60% of LGBTQ+ youth could not access mental health care in 2022, and nearly half contemplated suicide.¹⁰

How vulnerable populations can benefit from TBH

TBH helps address the challenges that vulnerable populations face when seeking treatment for mental illness.

Advantages for individuals

• Allows people to bypass the stigma and discomfort associated with receiving mental healthcare in person
• Helps those who experience social anxiety, PTSD, paranoia, or agoraphobia to access treatment
• Provides patients the opportunity to connect with a culturally supportive provider without geographic restrictions

Clinician benefits

• Removes the geography barrier, enabling the provider to serve more patients
• Fosters a stronger therapeutic relationship between provider and patient
• Bypasses the risk of harassment 

Systemic factors

• Offers a convenient, cost-effective alternative to in-person treatment
• Provides a time-saving option that reduces work absenteeism
• Eliminates travel expenses and burdens

TBH’s impact on medication-assisted treatment for opioid use disorder

In recent years, the opioid epidemic has grown into a public health emergency. Medication assisted treatment (MAT) has emerged as an effective care option for individuals experiencing opioid use disorder (OUD). MAT, which includes the use of methadone, naltrexone, or buprenorphine, shows better clinical outcomes when compared to abstinence-based approaches.¹¹  

When MAT is combined with TBH, barriers such as provider shortages, stigma, and geography are reduced. This treatment became even more effective during the pandemic when regulators removed in-person requirements prohibiting prescribing medications via TBH. Patient outcomes improved with higher MAT retention rates and a reduction in overdoses.¹¹

TBH utilization rates

Telebehavioral health utilization continues to increase and gain societal acceptance. In 2021, 37% of adults over 18 reported using TBH in the past year.¹² Individuals received treatment for issues such as anxiety disorder, severe stress, and major depressive disorder. More than 88% of facilities offered telebehavioral health services in September 2022, compared with just under 40% of facilities in April 2019.¹³ 

Leveraging TBH

Carelon Behavioral Health strives to continually improve the quality of care that members receive. The main goal is to make TBH as effective and accessible as possible by:

• Prioritizing convenience and care choice.
• Improving access, particularly as it relates to equity.
• Increasing quality of services.
• Improving affordability.
• Expanding coverage.
• Enabling providers to attract and retain more patients.

“Carelon Behavioral Health is committed to incorporating information and communications technologies to support expanding care access. We intend to do so in a manner that meets our members where they are, while offering increased choices and conveniences in access,” says Dr. Hossam Mahmoud, Regional Chief Medical Officer for Northeast/Southeast, Carelon Behavioral Health.

Provider readiness

Carelon Behavioral Health expands access to care by supporting providers who would like to incorporate TBH into their practices. TBH helps reduce wait times, increases provider availability, and makes in-person services more available to those who prefer a face-to-face intervention. 

Quality management system

Carelon Behavioral Health uses the latest advances in technology to support telebehavioral health service delivery including:

• Measurement-based care (MBC) using artificial intelligence (AI) to determine treatment efficacy. 
• Healthcare effectiveness data and information sets (HEDIS). 

Member and service delivery diversification

• Providing care for specialty needs that affect youth and adolescents, such as eating, autism spectrum, and substance use disorders
• Integrating behavioral and physical health
• Providing patient care coordination and referral pathways
• Utilizing data analytics for predictive modeling and data sharing

Telebehavioral health trends

Leaders at Carelon Behavioral Health believe that TBH should include measures to improve access to and quality of care. “The data has demonstrated the effectiveness, cost-efficiency, and scalability of TBH. The discussion now focuses on leveraging TBH technology to enhance quality and outcomes, mitigate health inequities, and improve costs,” explains Dr. Mahmoud. He recommends the following:

• States need to develop updated policies on the direction of TBH, including how to maximize quality and service delivery. Streamlining regulations regarding prescribing medications via TBH is an example.
• Enhanced support for traditional outpatient services via TBH, so that more intensive therapies can occur in person.
• Prescribing of medications for opioid use disorder (MOUD) to treat individuals with OUD.
• Expanding network capacities to allow more individuals to be served, particularly in underserved communities.
• Implementing alternative payment models.

TBH after the COVID-19 pandemic

The U.S. Department of Health and Human Services allowed several telebehavioral health flexibilities during the COVID-19 pandemic. Some changes have become permanent while others are temporary.¹⁴ 

Permanent Medicare changes¹⁴ 

• Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) can serve as a distant site provider for telebehavioral health services
• Medicare patients can receive telebehavioral health services in their homes
• Originating sites are not subject to geographic restrictions for telebehavioral health services
• Providers can deliver telebehavioral health services using audio-only communication platforms
• Rural Emergency Hospitals (REHs) are eligible originating sites for telebehavioral health

Temporary Medicare changes through December 31, 2024¹⁴ 

• FQHCs and RHCs can serve as a distant site provider for non-telebehavioral health services
• Medicare patients can receive telebehavioral health services in their homes
• There are no geographic restrictions for originating sites for non-telebehavioral health services
• Some non-telebehavioral health services can be delivered using audio-only communication platforms
• An in-person visit within six months of an initial telebehavioral health service, and annually thereafter, is not required
• Telebehavioral health services can be provided by all eligible Medicare providers

Prescribing controlled substances via telehealth¹⁵ 

During the PHE, the Drug Enforcement Administration (DEA) allowed providers to prescribe selected medications via TBH, suspending the in-person evaluation requirement and issuing additional flexibilities. The DEA and SAHMSA issued an extension on TBH prescription flexibilities through November 11, 2023. These flexibilities are extended through November 11, 2024, for provider-patient relationships established before November 11, 2023.

Pediatric telebehavioral health¹⁵ 

The Bipartisan Safer Communities Act provided the Health Resources and Services Administration an additional $80 million in multi-year funding for the Pediatric Mental Health Care Access grant program. The program funds pediatric mental healthcare teams that provide consultations via teleconference to practitioners working in primary care practices, emergency departments, and schools. 

Supporting TBH as it continues to evolve

The COVID-19 pandemic served as a catalyst to expand telebehavioral health utilization. However, many barriers remain that keep patients from receiving care. Transportation costs, potential loss of pay due to missed work, child and elder care issues, provider distance, and wait times are all obstacles that TBH can work around. Additionally, TBH removes hurdles for individuals who live in rural communities or need specialty care, and leads to improved outcomes. 

By continuing to advance TBH, with the appropriate HIPAA safeguards in place, we can enhance the behavioral healthcare delivery system, advance treatment access, and improve care. 

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1 National Alliance on Mental Illness, Mental Health by the Numbers (accessed September 2023): nami.org.

2 Health Resources & Services Administration, Health Workforce Shortage Areas (accessed September 2023): data.hrsa.gov.

3 National Library of Medicine, National Center for Biotechnology Information, Telemedicine and psychiatry – a natural match (accessed September 2023): ncbi.nlm.nih.gov.

4 Centers for Disease Control and Prevention, Trends in the Use of Telebehavioral health During the Emergence of the COVID-19 Pandemic (accessed September 2023): cdc.gov.

5 JAMA Network, Increased Use of Medicare Telebehavioral health During the Pandemic (accessed September 2023): jamanetwork.com.

6 National Institute of Mental Health, Mental Illness (accessed September 2023): nimh.nih.gov.

7 National Center for Biotechnology Information, National Library of Medicine, A call to action to address rural mental health disparities (accessed September 2023): ncbi.nlm.nih.gov.

8 U.S. Department of Health and Human Services Office of Minority Health, Mental and Behavioral Health – African Americans (accessed September 2023): minorityhealth.hhs.gov.

9 NAMI, Hispanic/Latinx (accessed September 2023): nami.org.

10 The Trevor Project, The Trevor Project: 2022 National Survey on LBGTQ Youth Mental Health (accessed September 2023): thetrevorproject.org.

11 National Institute on Drug Abuse, Increased Use of Telehealth for OUD Services During COVID-19 Pandemic Associated with Reduced Risk of Overdose (accessed September 2023): nida.nih.gov.

12 Centers for Disease Control and Prevention, Telemedicine Use Among Adults, 2021 (accessed September 2023): cdc.gov.

13 JAMA Network, Expansion of Telehealth Availability for Mental Health Care After State-Level Policy Changes From 2019 to 2022 (accessed September 2023): jamanetwork.com.

14 Telehealth.hhs.gov, Telehealth changes after the COVID-19 public emergency (accessed September 2023): telehealth.hhs.gov.

15 American Health Law Association: Health Law Connections, Behavioral Health Integration: Opportunities and Advancements for Primary Care and Beyond (accessed September 2023): americanhealthlaw.org.