To: Robert Smith
From: Daniel Crosby
Date: July 10, 2021
Re: Mental Health Access for the Elderly: Telemedicine coverage and post-COVID concerns
Statement of Issue: Roughly 470,000 US citizens over 65 have died because of the COVID pandemic. However catastrophic the scale of mortality, the impact of the pandemic on mental health and wellbeing should not be overlooked. Prior to COVID, 20% of adults over 55 were estimated to face mental health challenges such as depression, anxiety, and cognitive impairment (“State of Mental Health and Aging in America,” 2020). Maintaining a strong social support system and regular social interaction is essential in combatting problems of mental health in the elderly. Due to the constraints of quarantine, many older Americans have been left without this support. Fortunately for many, Medicare covered telemedicine has allowed access to important appointments with therapists and psychiatrists for those elderly in need. The use of telehealth has the potential to be of great benefit to these older patients. However, section 123 of Consolidated Appropriations Act of 2021 jeopardizes future access to mental health care as the US recovers from COVID, stipulating that there must be a documented in-person visit within the last 6-month period in order to be covered by Medicare (Lacktman, 2020). While not enforced during the crisis, once section 123 is applied access to mental health telemedicine will be limited, and many homebound seniors risk losing coverage.
Anxiety & Depression in Seniors
- 46% of adults 65 and older report COVID has had a negative effect on mental health
- 24% of adults 65 and older report anxiety and depression, up from 11% in 2018
Behavioral and Mental Health Crisis
- 56% of US counties are without a psychiatrist
- 64% of US counties have a mental health provider shortage
- Unemployment, isolation, and stress will exacerbate behavioral and mental health issues and drive costs upward for associated chronic health conditions. Behavioral health conditions make up 60% of total cost of care while being only 23% of those insured. Lack of contact with patients during pandemic will drive these costs up further (Bestsennyy, 2021).
Telemedicine During the Pandemic
- Use of telehealth has stabilized at 38x the levels pre-COVID
- This makes up to 17% of all visits
- Rates of anxiety and depression are highest among those with low income, poor health, and those living alone. These populations may benefit most from telemedicine availability
Impact of Section 123
- When waivers and exceptions expire, providers at risk of false claims accusations where no evidence of face-to-face visits in the last 6 months can be shown.
- Once section 123 is instated, patients may lose telehealth eligibility until a face-to-face visit can be arranged
Policy Options
Eliminate the “Face-to-Face” Requirement for Mental Health Telemedicine
Advantages: While the face-to-face requirement for mental health services does not apply during the pandemic, once section 123 is enforced access to these services will be unnecessarily complicated for those who rely on the convenience of telehealth such as senior citizens. Furthermore, the sudden ‘activation’ of the requirement will place physicians at risk of false claim accusations if an oversight occurs where the requirement is not met (Relias Media, 2021).
Disadvantages: Strictly digital interactions with patients for extended periods of time may have result in lost opportunity for more thorough and engaged consultations and therapies. The extent of any physical exams are limited and the benefit of a video component is not guaranteed. Additionally, telehealth may make for more impersonal disclosure of serious health news.
Extend Coverage of Audio-only Telemedicine Beyond the COVID Crisis
Advantages: While including a video component may be optimal, many elderly patients may have limited access to, or familiarity with, the technology required. Additionally, physical limitations of advanced age my present it’s own obstacles. With 9.2 million Americans over 65 suffering from significant vision impairment, audio-only telehealth makes for a simplified and efficient process (Feke, 2021).
Disadvantages: Despite the prevalence of telemedicine appointments, reimbursement continues to be an issue for providers. Audio-only patient interaction is often considered equal to audio-video, however compensation for the former remains significantly less than for the latter (D’Ambrosio, 2020).
Policy Recommendation: With so many elderly at risk of mental health issues, it’s important that we make the most of available technology to attain unprecedented accessibility of care for these citizens. The COVID public health emergency has brought telemedicine to the forefront as a means of extending care into the homes of patients who are unable to make face-to-face visits. Especially valuable was the efficiency of audio-only telehealth, which perfectly suits patients who do not have the adequate technology or technological experience to employ more complicated video conferencing software or smartphone applications. By ensuring Medicare coverage of audio-only telehealth following our public health crisis, we can continue to reach these patients. The revision of section 123 of the CAA, allowing establishment of mental health related care without face-to-face encounters, is a critical step toward doing all we can for those who have become dependent on telehealth during the pandemic. These recommendations seek to build upon the advances in accessibility for all patients in recent years, as well as to attain an unprecedented distribution of care to an elderly population in great need of mental health support.
Sources
Barrasso, J. (2021, March 18). Text – S.828 – 117th Congress (2021-2022): Mental Health Access Improvement Act of 2021. Retrieved from https://www.congress.gov/bill/117th-congress/senate-bill/828/text
Bestsennyy, O., Harris, A., & Rost, J. (2021, July 09). Telehealth: A quarter-trillion-dollar post-COVID-19 reality? Retrieved from https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality
D’Ambrosio, A. (2020, July 13). Audio-Only Telemedicine: Docs Say Payment Falls Short. Retrieved from https://www.medpagetoday.com/practicemanagement/telehealth/87531
Dockett, L. Increasing Access to Mental Health Care for Seniors. Retrieved 2018, from https://www.psychotherapynetworker.org/blog/details/1570/increasing-access-to-mental-health-care-for-seniors
Feke, T. (2021, June 02). Is audio-only the future of telehealth for Medicare enrollees? Retrieved from https://www.medicareresources.org/blog/2021/06/02/is-audio-only-the-future-of-telehealth-for-medicare-enrollees/
Lacktman, N. M. (n.d.). Is This the Worst Medicare Telehealth Law of 2020? Retrieved from https://www.natlawreview.com/article/worst-medicare-telehealth-law-2020
Marsa, L. (2020, August 31). What to Know as Telehealth Goes Mainstream. Retrieved from https://www.aarp.org/health/conditions-treatments/info-2020/telehealth-goes-mainstream.html
Relias Media (2021, April 1), Telemedicine Law Changes Confusing, but Waivers Protect During Pandemic. Retrieved from https://www.reliasmedia.com/articles/147799-telemedicine-law-changes-confusing-but-waivers-protect-during-pandemic
Robeznieks Senior News (2021, April 05). Why audio-only telehealth visits must continue. Retrieved from https://www.ama-assn.org/practice-management/digital/why-audio-only-telehealth-visits-must-continue
State of Mental Health and Aging in America (MAHA). (2020, August 21). Retrieved from https://www.cdc.gov/aging/publications/mental-health.html
Wicklund, E. (2021, February 15). Questions Arise Over Medicare Coverage for Mental Health Services by Telehealth. Retrieved from https://mhealthintelligence.com/news/questions-arise-over-medicare-coverage-for-mental-health-services-by-telehealth
