At first, the pandemic actually kept us in our homes. Y’all remember that? Being on lockdown?
For many, COVID and the response to it only intensified the need for health care. And by health care, I mean physical and mental.
But have the body and the mind been treated with the same importance? That’s what we’re trying to figure out within the realm of virtual health care, or telehealth.
The state of Pennsylvania made it widely available, the same for your doctor as your family therapist. The state directed practitioners to continue patient care and services through telehealth to fight the spread of COVID-19.
Insurance companies appear to have fallen in line, too, and covered telehealth similarly for physical and mental health needs. Among Medicare recipients, the use of telehealth soared 13,000% over pre-pandemic rates for utilization, according to the Centers for Medicare and Medicaid Services.
There are concerns with telehealth over insurance coverage, privacy and Internet availability, along with social and racial equity concerns. Latinx and Black patients use telehealth at significantly lower rates as a result of disparities in technology access, digital literacy and provider bias.
The unprecedented access to telehealth was appreciated by many patients and doctors, like the patients receiving physical therapy without leaving home and doctors seeing more patients in a day and managing those more effectively. It was a sigh of relief not only to keep safe from the virus, but also for reasons that existed before the pandemic. Telehealth is generally a more accessible experience for people with disabilities or those lacking transportation or providers near their homes. And it’s simply convenient to avoid waiting rooms and sterile offices whenever possible.
But some investments in telehealth offerings in Pennsylvania could expire at the end of June if the pandemic waiver Act 14 from April 2020 expires. So, what’s going on is right now is there is no law allowing or prohibiting telemedicine in Pennsylvania. Without an explicit law or waiver extension of Act 14 by the PA General Assembly, access and insurance coverage for telehealth could be rolled back, disrupting Pennsylvanians’ access to both medical and health care.
Also, it may not be. Here’s the rub: We just don’t know. Because the access to telehealth for any kind of health need is not codified. Are we are comfortable with just a little more uncertainty when it comes to health care, health needs? Let’s look at the opportunities and challenges of telehealth and what’s at risk for Pennsylvanians who’ve become accustomed to using telehealth for their mental health care.
Elaine Houston of Pittsburgh has relied on telehealth for all of her appointments, physical and mental health related, since the beginning of the pandemic. Elaine, who uses a power wheelchair, was born with a rare genetic disease: Ehlers Danlos syndrome, which affects connective tissues, primarily skin, joints and blood vessel walls. Elaine says her physical condition has a significant impact on her mental health. But telehealth made her treatment more accessible.
Elaine Houston: One of the big issues that affects mental health care to a much higher degree than physical health care is that more mental health care providers are in offices that are like a hole in the wall. For example, I live in East Liberty and so there’s a fair number scattered across Shadyside. But they’re in like, you know, the little side door in the old Victorian home. Finding equally accessible mental health care, one, is just me getting in the door. Step one is next to impossible to find …
Which it’s kind of sad when we’re starting there. …But then to get a clinician who is competent enough in understanding chronic illness, disability, a lot of the other challenges that I face, managing home care staff, and just all of the things that come with the physical disability because unfortunately — and I can say this with in all honesty — that most of it is directly tied to my physical health struggles of getting the appropriate physical health care. That’s a lot of what drives my need for mental health care. Unfortunately, just because of the nature of the beast and just constantly struggling to get appropriate health care.
Jourdan Hicks: Telehealth isn’t just a benefit to patients, but to practitioners as well. Elaine shared this about her own clinician.
Elaine: And I will recognize that it’s a different experience in my case. But for me and my clinician, it’s not just an accessibility thing for me. It’s an accessibility thing for her, too. And so that changes a lot of this, too, that it’s not just [telehealth has] given her an ability to work more and continue working even with some health issues that are involved, which I don’t think would have necessarily been possible if she was doing this all in the traditional setting up in the office and having to commute to work every day.
Kevin Basil: The ability to do telemedicine actually allows closer scheduling so we can see more people every day.
Jourdan: Meet Kevin Basil. He’s a behavior consultant and mobile therapist in Monroeville, Glassport, Elizabeth, Liberty, McKeesport, Duquesne and West Mifflin. Mobile therapists travel to homes, schools or other locations to provide counseling. Kevin told me patients like Elaine have had more access to routine check-ins on their mental health state with telehealth. He believes mental health care should be treated the same as physical health care, just like your annual doctor’s office visit or your trip to the dentist every six months. He endorses regular mental health checkups.
Kevin: I think it makes it more convenient for some families also because of the same thing like scheduling. Obviously, families have a lot of things going on, a lot of different roles, jobs, school responsibilities, all that kind of stuff. So even not related to pandemic, like sometimes now I’ll have a parent be like, ‘Hey, can we do a telehealth session tonight because we have this going on’ or, you know, ‘We went over to their grandparents for the night, so can we just do a telehealth?’ So I think that makes it more available. And then transportation is a big aspect to a lot of the families that we work with who are low income. They have a lot of barriers to treatment and a lot of them don’t have transportation and can’t afford like an Uber or some sort of ride to get to an office to do therapy. So I think that has been a really helpful aspect for them as well.
Jourdan: What are, in your experience, some of the hindrances, barriers that telemedicine has presented to people getting mental health care and access to mental health care?
Kevin: Well, I think in terms of access to it, I think that’s another one that that is especially impacting low-income families. That don’t have the technology. They don’t have, you know, different devices or they don’t have high-speed Internet, whatever. But I think the biggest barrier, the biggest negative aspect is just the quality at times, the quality of care that is being received, because my experience is mostly with adolescents. So, that’s kind of a different ballgame than with adults, I think. Adults probably don’t have as many of the barriers that adolescents do, but adolescents, there’s so many problems with, you know, attention and focus and trying to get these kids to not be looking at their phones or playing games or, you know, any number of things.
It’s there’s a such a bigger disconnect when you’re not in person because, you know, they’re in their house, they’re in their whatever, their room, you know, and they feel like, you know, well, I’m just talking to a person on a screen. I can do whatever I’m doing. And so it’s a lot harder to have that one-on-one focus conversation that a lot of times they need, you know, kids with autism, depending on the level of autism, you know, communication and social skills is a big struggle for them. So obviously, again, sitting here on a device is just not as productive. So I think definitely those types of things. But then I think there are special just other considerations like people that have trauma, you know, PTSD or not even like trauma, but just trust issues because of other struggles that are going on in their life.
Jourdan: Let’s double back to early pandemic 2020 again. The Pennsylvania Department of State made proposals around telehealth that led to the ACT 14 waivers. It was an explicit green light for telehealth. One specific thing about it, it allowed out-of-state practitioners to treat residents in Pennsylvania.
Jourdan: Neil Holmes has been a behavioral specialist and therapist since 2018. He moved to Memphis, Tennessee, in 2021 for a new job, but he is still licensed to practice in Pennsylvania and still sees his patients living here. He thinks allowing out-of-state providers like himself to practice expands access to health care and doing so through telehealth has removed barriers to building trust between patient and provider.
Neil Holmes: I think in the therapeutic space when we work in an office constantly, patients don’t really always get to see like that personal side of us, right? We may have pictures on our desk, but most of the time is filled with paperwork, etc. But in the home setting they’re like, oh wow I never knew you had a pet or that’s interesting, I love that piece of artwork, so it brings in a more personalized piece to me, which is really important because it lessens the power dynamic.
Jourdan: So I spoke with a clinician yesterday who is a behavioral health specialist, and they also do mobile therapy. They work with children with autism. They work with people with behavioral issues. They felt like they were some clients that they had where the virtual medium didn’t work for them because there were certain observances they could make of each other and certain connections that they had a harder time making over this virtual medium. Is this something you experience?
Neil: I think for the nonverbal cues, for me, because I don’t see your whole body, I think it takes a very like in-depth nature of communication to make sure that you’re on the same page with your client, that you understand those nuances and that even if my clients want me to join with them, I have stress balls here, that I will work with in tandem with my clients if my client is coloring, that’s relaxing to them. I’ll actually bring out my coloring book while we’re talking and we’ll color right so that they can feel not only that I’m joining them, but I have like a semblance of understanding of where they are in space and time.
Jourdan: No shows have long been an issue for doctor’s appointments, especially in mental health. For Cydney Cooper, a Pittsburgh resident in her 30s, telehealth made it so that she didn’t have to skip sessions.
Cydney Cooper: I think sometimes in life you can become super busy and it’s like, OK, I’m not able to make that session. But when I’m taking them at home or in a convenient location, that goes out the window, which obviously is is good for me because I’m staying consistent with the level of care that I’m getting from my counselor or the level of guidance that I’m getting from my counselor. So I think it just, again, eliminated the option for or the reasons why I wouldn’t attend those sessions.
I think having the option to speak with someone who you are growing comfortable with or if in the case of me, I had been seeing her for a couple of years now, then it was just like, you know, we were kicking it at home and we’re just having a conversation just as we were in her office. But now I’m in the comfort of my own space, in my own home. I would say the only thing would be the times when your internet will possibly be giving issue. If I was accessing from my phone or something like that, there would be times where maybe my connection wasn’t as strong. I would say that would be the only one, connection. But again, you learn to troubleshoot, move forward quickly with that and you’re good.
Jourdan: Still, cost can be an issue.
Cydney: I don’t know how much the sessions were in total because I only wound up having to pay like $60, $70. But even 60, $70, if I’m going once a week, that’s $280. That adds up. … I was just coming, you know, for myself and my sanity and keeping myself on track. But there may be someone who might have needed it a little bit more because of some things they were battling. And the fact that cost could potentially be the barrier between somebody getting the help they need is really not making much sense to me. So, yes, ask them that question.
Demetrios Marousis: Some of that interaction did not transfer as readily during the initial phases of the pandemic, and that’s where we had to adjust our expectations.
Jourdan: Meet Demetrios Marousis, director of behavioral health at Highmark Blue Cross Blue Shield. It’s Demetrios’ responsibility to review patient plans made by behavioral health doctors to make sure that they meet the guidelines for the appropriate levels of care. Highmark offered coverage for telehealth services before the pandemic, but saw a 98% increase in patients and practitioners using telehealth for mental health services, more so than with physical health needs.
Pennsylvania doesn’t have a law that requires insurance companies to reimburse doctors for services done via telehealth. However, many of the larger insurance companies like Highmark, UPMC, Aetna, along with Medicaid and Medicare, include coverage for telehealth in their policies, even if it isn’t mandated by state law.
Over the years, there have been several studies comparing reimbursement rates of nationwide insurers for mental health care providers versus medical providers, even when they offer the same or similar services. With a few exceptions, those studies regularly show that mental health providers are reimbursed at lower rates.
Is there a difference in the coverage that’s extended for medical health care services via telemedicine and mental health care services through telemedicine?
Demetrios: There is not. There is not a difference. …From where we’ve been sitting, it’s really been about the providers and their ability to bring on the tools. You know, for some, it was a very sudden change. Others who had been doing telemedicine previously may have found that their tool couldn’t handle the bandwidth, and so they had to adjust their tools accordingly and adopt different methods because now it was everyone, as opposed to one or two that were interested. All of that sort of preexisted. And it was really about just sort of sudden mass adoption and mass movement into the telemedicine and delivery of services.
Jourdan: Although Demetrios said there was no difference in the coverage of medical care versus mental health care through telehealth, he did say that there may have been differences in the skills or tools providers possess to treat patients via telehealth.
How do you determine how much will be reimbursed? How do you determine that?
Demetrios: I mean, so Highmark has sort of a standard fee schedule and that is, you know, sort of the base of what is offered to a provider when they are contracted with us and that rate is available. And that’s what they would get. That’s what they would get paid for those services.
Jourdan: Highmark follows the Center for Medicaid and Medicare Services guidelines for telemedicine visit, coverage and reimbursement. According to Demetrios, again, these visits are considered the same as in-person visits and are paid at the same rate as regular in-person visits. Telehealth has become so widely integrated into care access that insurance companies will most likely continue to cover telehealth services. But who’s responsible for the long-term monitoring of telehealth billing and reimbursement for medical and psychological health going forward, y’all?
State Rep. Michael Schlossberg, who represents Allentown and South Whitehall Township in Lehigh County, Pennsylvania, said he hasn’t seen a therapist or his medical doctors since the before times. He told me he thinks insurance companies need to be legally required to cover telemedicine, not just in times of crisis.
Michael Schlossberg: There’s questions about rates and levels of reimbursement. Those are appropriate. But you’ve got to require that everyone has access to telemedicine. There’s no doubt about that in my mind.
Jourdan: What do you think the long-term solution is?
Michael: Legally require insurance companies to cover telemedicine, allow negotiation to come from there. They have some concerns with levels of reimbursement. Those are appropriate because telemedicine is cheaper, and you need to you need to reimburse as such. But there’s got to be a fair solution that enables everybody to get access to telemedicine.
Jourdan: Since as far back as 2016, there have been proposals before the Pennsylvania House and Senate that would make telehealth permanent and regulated. But they’ve never made it out of committee. In 2018, it passed the Senate. It stalled in the House. Two years later, a 2020 version of the bill passed both chambers. But Gov. Tom Wolf vetoed it after Rep. Cathy Rapp, a Republican and chair of the House Health Committee, amended it to block providers from prescribing certain medications via telehealth. In the end, it was a partisan disagreement over medication related to abortions.
Michael: Unfortunately, telehealth issues have gotten caught up in abortion politics … there’s been a lot of efforts to restrict the ability of a doctor to provide abortion-related health care through telemedicine. And that has stopped the entire process from moving forward. You’ve got a lot of folks, myself included, that say doctors know best, let a doctor prescribe whatever they think is appropriate between them and their patient. You’ve got others who are obviously trying to restrict the right of a woman to control her own body. So that’s kind of the framework there. And that’s led to some really difficult conversations about telehealth, which is categorically ridiculous. We should be approving telehealth permanently the way a lot of other states have done, and unfortunately, it just keeps getting caught up in abortion politics.
Jourdan: Extension after extension is not a long-term solution.
Michael: You can’t keep extending something six months and expect the healthcare system to be reliably built upon it. We’ve got to have this. It’s better than nothing, no question. But we’ve got to have a long-term solution to this.
Jourdan: When I asked Rep. Schlossberg if he was hopeful the waivers will be extended, he said he was confident that they would be. But Rep. Dan Miller, representing parts of Allegheny County at the Pennsylvania House of Representatives, was not so optimistic about a June extension.
Dan Miller: Look, I hope Mike’s right, but I’ve never been impressed with the majority’s commitment to disability and mental health supports. If anything, during this time, I find it being used for political purposes more than health purposes. And so that’s my concern. As long as too many people on the other side view these issues through political lenses and how to, you know, do partisan jabs, then we then know it is difficult for me to be as optimistic as some. However, I’d love to be proven wrong.
Jourdan: For the last nine years. Rep. Dan Miller has convened the Disability and Mental Health Summit. It’s a yearly resource fair that offers free sessions on a variety of intersecting disability and mental health topics.
Dan: … One of your lenses I think you talk about is this parity. You know, well I’m tired of talking about what isn’t parity. So it is frustrating. Everybody should be caring whether or not mental health services are as available and accessible as physical health services. And so it may not be an issue for somebody directly, but I guarantee you they are no less than two degrees separated from somebody to which it could make a big difference. And that’s as if you need that connection in order to care. I’m still surprised that so many people may, but I believe that this is an issue that strikes home for the vast majority. And if it isn’t at home, it’s very close and that everybody should be caring. It’s not like February 2020 was the promised land for mental health and disability services in the state. February 2020, right before the pandemic, was not the Golden Age. We weren’t leading the nation in accessibility and supports. We weren’t doing that.
Jourdan: Dr. Shantal Villalobos is a family medicine doctor. She works in a hospital and at the East Liberty Family Health Center. She says she has roughly a couple hundred patients in her panel.
Shantal Villalobos: So babies, pregnant women, children, adolescents, adults, elderly folks and everything in between, but also specialize in HIV. …
Jourdan: Do any of the patients you train bring up issues accessing telehealth services or any hindrances accessing care through telehealth? Did you see any clients who brought up issues of accessing telehealth or remote health care services?
Shantal: So there’s a couple barriers and things that we can get into. But you know, when first virtual visits were coming around and we were in the thick of it or people weren’t physically coming in, and that can be very difficult if we have another big scare where we have to really try to back off and limit it as much for people to come in person. We get into scary things. I mean, in general, people were saying, I don’t want to go into the office. I’m going to do everything I can not to leave the house, not to be exposed. And then you’re not seeking care that you need and you can get into some serious trouble. And so that virtual option may have some folks be worried that it’s still a big concern to go physically in person. And you may put that off more than you should and miss a lot of things that should have been caught or not be receiving treatment sooner than later.
Jourdan: Are you aware that the emergency waivers that explicitly grant Pennsylvania practitioners’ and patients’ use of telehealth services will expire on June 30? How do you think that’s going to impact your work?
Shantal: To be fully transparent, I didn’t know that it was coming so soon. I think you made me aware of that timeframe and it kind of hit to think, Oh, we’ve just become accessible in a new platform, in a new way to patients. We’ve become more efficient at it, learned a new skill. I was aware that it was temporary when it first came around. When insurance said, Hey, you can go ahead and do this virtual visit for your patients. We were doing as much as we could, modifying, finding ways that physicians’ schedules could rotate so that not everybody was around at the same time, minimizing contact between each other. It helped everyone, the providers and patients. So I was very concerned to hear that it’s already coming up, and I would hope that is something that would get extended because I don’t even see it as something that needs to be temporary. I think it’s just something that needs to stick around and be here to stay. Just like going to see a doctor in the office is a norm. Just having a virtual option is a norm. And not just for mental health concerns, but any concerns.
Jourdan: What’s been a uniquely positive aspect of having access to health care through telehealth for you?
Shantal: I mean, I think of myself as a physician. We never get to go see the doctor and the virtual option made it actually possible for me to get care, made it possible for me to say right now, I’m going to take 20 minutes either at my lunch hour or this time frame to sneak in this visit. And then I keep on working.
Jourdan: The Pennsylvania Department of State made the initial request to Gov. Wolf to suspend or waive Pennsylvania’s restrictions impacting pandemic era care at this time. The department says there are no plans to advocate for the extension of the waivers, although the department did say it supports legislation cementing telemedicine’s place in health care in Pennsylvania. The power to extend or expire these waivers rests exclusively with the General Assembly. So bottom line, let’s go back to Rep. Schlossberg who sums this up. What happens if the waivers on Telehealth Act 14 expire?
Michael: Hypothetically, if Act 14 expires and someone relies on virtual or remote mental health sessions, or if they have a therapist out of state and the act expires — here’s the honest answer — they’re screwed. Someone will have to be able to then find a therapist that is in the state and that they can meet with in-person or pay out of pocket. And frankly, that’s another reason we have to extend Act 14 permanently. And another reason why the current situation is completely untenable.
Jourdan: Again, how much uncertainty are you comfortable having around your health care? Because it looks like we won’t know the future of telehealth access in Pennsylvania until after June 30.
Until then, I want to hear from you. If you have a story about telehealth or how mental health and physical health are approached similarly or differently, reach out to me, Jourdan Hicks at email@example.com.
We at PublicSource are a part of the Mental Health Parity Collaborative, a group of newsrooms covering challenges and solutions to accessing mental health care in the United States. The partners on this project include the Carter Center, the Center for Public Integrity and newsrooms in Arizona, California, Georgia, Illinois, Pennsylvania and Texas. This story was produced by Jourdan Hicks and Andy Kubis, edited by Halle Stockton and fact-checked by Matt Maielli.
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The Jewish Healthcare Foundation has contributed funding to PublicSource’s healthcare reporting.
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