Telehealth Availability for Mental Health Care Declined After COVID-19 Public Health Emergency

Following rapid expansion during the COVID-19 public health emergency (PHE), the availability of telehealth services at outpatient mental health treatment facilities (MHTFs) in the US has declined since the end of the PHE, according to a study published in JAMA Network Open.¹ The findings suggest there may be a need for targeted health policies to maintain telehealth access for mental health care.

“Over the course of the COVID-19 pandemic, telehealth availability expanded rapidly,” the authors explained. “This change was marked and persistent for mental health care, for which most services do not require in-person physical examinations or diagnostic tests. State and federal policies enacted during the pandemic promoted the telehealth transition by altering Medicare to reimburse for telehealth services and state Medicaid agencies to approve reimbursement for audio-only telehealth, for example.”

With the end of the PHE in May 2023, many policies aimed at fighting the spread of COVID-19 came to an end, although the Medicare reimbursement levels for telehealth services were protected through 2024.² Still, a number of telehealth regulations from the COVID-19 PHE expired with the end of the PHE.¹

In a longitudinal cohort study, researchers analyzed the availability of telehealth services at 1001 MHTFs before and after the end of the PHE through a national secret shopper analysis. The main outcomes related to whether MHTFs offered telehealth services, and if they did, the types of services they offered.

Researchers analyzed the availability of telehealth services at MHTFs across the US before and after the end of the PHE through a national secret shopper analysis | Image credit: insta_photos - stock.adobe.com

Initially, callers posing as prospective clients contacted a random sample of 1404 MHTFs identified through the Substance Abuse and Mental Health Services Administration’s Behavioral Health Treatment Locator. Wave 1 (W1) of calls was conducted during the PHE from December 2022 to March 2023, and W1 participants were contacted again during wave 2 (W2), which took place from September 2023 to November 2023. The data were analyzed in January 2024.

Callers collected information on whether centers offered telehealth during both W1 and W2 (sustainers), W1 but not W2 (discontinuers), W2 but not W1 (late adopters), or not at all (nonadopters). Regarding types of care offered, callers inquired about the following:

• Audio-only telehealth (vs audio and video)
• Telehealth for therapy, medication management, and/or diagnostic services
• Telehealth for comorbid alcohol use disorder (AUD)

A total of 1001 MHTFs were contacted successfully during W2, with 71.2% located in metropolitan counties. Additionally, 15.1% of the MHTFs were publicly operated, and 93.4% accepted Medicaid. Overall, 72% of MHTFs were sustainers, 9.9% were discontinuers, 11.2% were nonadopters, and 7% were late adopters. After adjusting for facility and area characteristics, sustainers were more likely to be private for-profit or private nonprofit MHTFs compared with discontinuers.

There was a drop in the proportion of centers offering telehealth after vs during the PHE, with 799 (81.6%) offering telehealth services during W1 and 765 (79.0%) during W2 (OR, 0.84; 95% CI, 0.72-1.00; P < .05). In W2, a smaller percentage of the MHTFs that offered telehealth offered audio-only telehealth vs W1 (49.3% vs 34.1% [OR, 0.53; 95% CI, 0.44-0.64; P < .001]). While 76.3% of MHTFs offered telehealth for comorbid AUD in W2, this proportion dropped to 66.5% in W2 (OR, 0.62; 95% CI, 0.50-0.76; P < .001). MHTFs were also more likely to only offer telehealth under certain conditions for therapy and medication management in W2.

The study was limited by potential nonresponse bias, changes in telehealth policies separate from the PHE that may have influenced operations at MHTFs, and the inability to compare across additional sociodemographic categories, the authors noted.

Still, their findings outline changes in telehealth availability for mental health care in the time since the COVID-19 PHE ended and stress the importance of continuously monitoring access to these services.

“Our results suggest telehealth coverage for mental health services have contracted slightly since the end of the PHE, coincident with changes (and anticipated changes) in public and commercial payer reimbursement policies following the end of the COVID-19 PHE,” the authors wrote. “While only 2.6% fewer MHTFs were offering telehealth after the PHE, there was lower adoption and higher discontinuation of telehealth in public than in private MHTFs, suggesting that publicly owned MHTFs may face additional barriers to telehealth promotion.”

References

1. McBain RK, Schuler MS, Breslau J, Kofner A, Wang L, Cantor JH. Telehealth availability for mental health care during and after the COVID-19 public health emergency. JAMA Netw Open. Published online July 10, 2024. doi:10.1001/jamanetworkopen.2024.20853

2. Bonavitacola J. End of the national public health emergency for COVID-19: what does it mean for the public?. AJMC^®. March 2, 2023. Accessed July 31, 2024. https://www.ajmc.com/view/end-of-the-national-public-health-emergency-for-covid-19-what-does-it-mean-for-the-public-