The COVID-19 pandemic prompted state and federal policy changes that enabled behavioral health providers to rapidly shift from in-person to telehealth visits to continue treating clients. This IHPI brief examines Michigan providers’ experiences with virtual care and outlines policy considerations to sustain and improve access to telebehavioral health.
Behavioral Health Provider Experiences with Telehealth in Michigan During COVID-19
Telebehavioral health involves providing behavioral health services via remote technologies, including intake, assessment, diagnosis, prescribing, psychotherapy, and crisis management.1 Historically, providers were relatively slow to adopt telehealth tools, often because of regulatory barriers such as inadequate reimbursement or lack of provider authorization.
The COVID-19 pandemic disrupted the delivery of behavioral health services. In order to continue treating clients and keep them safe, and as a result of state and federal policy changes, providers rapidly expanded their use of telehealth. Policy changes at the state and federal level expanded telehealth authorization and reimbursement across insurers, allowed for services to be delivered via video or audio-only methods, and removed requirements for written consent for treatment, allowing verbal consent, among other changes.
Between late July and mid-August 2020, a team at the University of Michigan Behavioral Health Workforce Research Center conducted in-depth interviews with 31 Michigan behavioral health providers* across the state providing telebehavioral health services during the COVID-19 pandemic.
This Behavioral Health Workforce Research Center report summarizes the interview findings and outlines policy considerations to sustain and improve access to telebehavioral health services. Two accompanying IHPI briefs contain the key takeaways and policy considerations – one focused on state policy implications and the other on federal.
Takeaways from our study
Between late July and mid-August 2020, a team at the University of Michigan Behavioral Health Workforce Research Center conducted in-depth interviews with 31 Michigan behavioral health providers* across the state providing telebehavioral health services. A summary of Michigan behavioral health providers’ experiences with telebehavioral health during the COVID-19 pandemic is below (the number of respondents who spoke to each theme is noted):
1. Quality of care and provider/client satisfaction
- 31 respondents: Telebehavioral health reimbursement alleviated and prevented financial shortfalls for providers during the COVID-19 pandemic.
- 30 respondents: From the providers’ perspective, clients were satisfied with telebehavioral health services.
- 18 respondents: Remote care quality was the same or better than in-person care quality.
- 15 respondents: Audio-only telehealth services were as effective as audio-visual services and were sometimes preferable for clients with anxiety or trauma, who were uncomfortable with video.
“...on the phone and through the ear, you’re just less vulnerable...a lot of my clients are willing to go there more because it’s like I’m not staring at them or we’re not sitting in the same space...it just is a less threatening thing.”
2. Access to care for isolated and/or vulnerable clients
- 31 respondents: Providers felt better-equipped to meet their clients’ diverse needs after receiving flexibility to offer telehealth services when appropriate.
- 28 respondents: Telehealth mitigated frequently-cited barriers to accessing behavioral health care (e.g., lack of transportation, missed work, arranging childcare).
- 22 respondents: Providers reported decreased no-show and cancelation rates.
- 13 respondents: Audio-only telehealth services allowed for expanded access to care for clients who are geographically isolated, lack transportation, lack adequate internet access or internet-connected devices, or for certain populations such as older adults.
“If we want to provide ongoing and sustainable treatment...we have to meet those clients where they’re at. And one of the places that they’re at is in their home, and many don’t have other options.”
3. Challenges and limitations of telehealth
- 15 respondents: Many clients, especially in rural areas, had inadequate access to the internet or internet-connected devices and persistent barriers to in-person care.
- 11 respondents: Certain behavioral health services were not well suited for telehealth, such as group services and physical health care services (e.g., injections).
- 5 respondents: Obtaining written consent for treatment proved difficult when clients lacked the technology to email or fax physically signed forms. The temporary allowance for verbal consent during the pandemic alleviated these barriers.
*The interviewees included: a psychiatrist, psychologists, registered nurses, clinical social workers, mental health counselors, substance use disorder counselors, applied behavior analysts, and peer support providers, among others.
What are the implications for state policy?
All providers interviewed indicated that they would like to see telebehavioral health continue moving forward after the pandemic to allow them to best meet their clients’ diverse needs. Looking past the pandemic, as policymakers consider which policies should remain permanent, the following policy options could be considered:
Continuing audio-only telehealth authorization
- Currently, private insurers in Michigan can choose to cover audio-only services if they deem that they can be appropriately provided. Legislators could consider amending the Insurance Code2 to instead mandate such coverage. This would allow providers to use their professional judgement when determining which services are appropriate for audio-only provision.
- Michigan did not cover audio-only services via Medicaid historically. The state received time-limited authorization to cover audio-only services during the public health emergency.3 Michigan Medicaid could consider requesting authorization of these services to continue after the pandemic.
Improving telebehavioral health coverage
- For private payers, telehealth service parity existed historically in Michigan4 and was expanded during the pandemic.5 However, insurers may interpret the word “cover” as requiring service parity but not service and reimbursement parity, for example. Policymakers could consider amending the Insurance Code to mandate equivalent reimbursement.
- For Medicaid, telehealth reimbursement parity existed historically and is still in place, with the same procedural codes being billed for in-person and telehealth services.6 However, service parity could be expanded to cover more services. Michigan Medicaid could allow providers to bill for all services via telehealth, provided the service is of equivalent quality as in-person care (disqualifying some services, such as injections) and in-person care is not feasible for the client. This added flexibility may empower providers to offer services to their clients via the most appropriate modality.
Service parity laws: These laws require insurers to cover the same services for telehealth as in-person services, as long as they can be provided appropriately via telehealth.
Reimbursement parity laws: These laws require insurers to reimburse health care providers for telehealth services at rates that are similar or equal to rates for the same in-person services.
Approving verbal consent for treatment
- The Michigan Public Health Code7 allows written or verbal consent for treatment. However, providers may be unaware that verbal consent is allowed. Policymakers, including insurers, could further clarify that verbal consent is permitted.
1 Telehealth programs. Health Resources and Services Administration. https://www.hrsa.gov/rural-health/telehealth. Updated September 2020. Accessed September 2, 2020.
2 Michigan Insurance Code Section 500.3476(2)(b). Michigan Legislature. Legislature.MI.gov. http://www.legislature.mi.gov/(S(s4u3piwn2but3f0gj5zev0qe))/mileg.aspx?page=GetObject&objectname=mcl-500-3476. Updated 2020. Accessed November 20, 2020.
3 Re: Request for Waivers Under Section 1135 of the Social Security Act. Michigan Department of Health and Human Services. Michigan.gov. https://www.michigan.gov/documents/coronavirus/Initial_1135_Request-MI_4.1.2020_685589_7.pdf. Published April 1, 2020. Accessed November 20, 2020.
4 Michigan Insurance Code Section 500.3476(1). Michigan Legislature. Legislature.MI.gov. http://www.legislature.mi.gov/(S(s4u3piwn2but3f0gj5zev0qe))/mileg.aspx?page=GetObject&objectname=mcl-500-3476. Updated 2020. Accessed November 20, 2020.
5 Michigan Enrolled House Bill No. 5413 (2020). Michigan Legislature. Legislature.MI.gov. http://www.legislature.mi.gov/(S(0zmuf0xbj0vlpfmeccexzfk5))/mileg.aspx?page=GetObject&objectname=2020-HB-5413. Updated June 24, 2020. Accessed November 20, 2020.
6 Telemedicine: Policy, Billing & Reimbursement. Michigan Department of Health and Human Services. Michigan.gov. https://www.michigan.gov/documents/mdhhs/Telemedicine_2019_671338_7.pdf. Published 2019. Accessed November 20, 2020.
7 Michigan Public Health Code Section 33.16824. Michigan Legislature. Legislature.MI.gov. http://www.legislature.mi.gov/(S(4tvte520nayo4k4aevvc5pqv))/mileg.aspx?page=getObject&objectName=mcl-333-16284#:~:text=333.16284%20Telehealth%20service%3B%20consent%20required%3B%20exception.&text=16284.,indirectly%20obtaining%20consent%20for%20treatment. Updated 2016. Accessed November 20, 2020.
Cory Page, MPH, MPP, School of Public Health Behavioral Health Workforce Research Center, University of Michigan
Jessica Buche, MPH, MA, School of Public Health Behavioral Health Workforce Research Center, University of Michigan
Angela Beck, PhD, MPH, School of Public Health Behavioral Health Workforce Research Center, University of Michigan
Maria Gaiser, MPH, Caitlyn Wayment, MPH, Victoria Schoebel, MPH, Amanda Mauri, MPH
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