Online Therapy Works. Will It Stick Around?

SHANOOR SEERVAI: Before the pandemic, the way to get mental health care in the U.S. was face-to-face therapy. But when we locked down last March, the mode of delivery changed. Suddenly people were seeking mental health care on Zoom and other online platforms, and at a time when the need for support was greater than ever. This rapid shift disrupted the traditional system. But 18 months later, where do things stand? Will mental health services stay online? How do we plan for the future, especially for young people, who report rates of social anxiety and depression that keep rising?

I’m Shanoor Seervai, and on today’s episode of The Dose, I asked two experts in digital and mental health to help me answer some of these questions. Latoya Thomas is the senior director of policy and government affairs at Doctor On Demand and Grand Rounds Health, a national telehealth provider. Solome Tibebu is director of the Upswing Fund for Adolescent Mental Health, a fund with the focus on the mental health of young people who are of color and/or LGBTQ+.

Latoya, Solome, welcome to the show.

SOLOME TIBEBU: Thanks for having us.

LATOYA THOMAS: Thanks very much for having us.

SHANOOR SEERVAI: I’m curious to hear from each of your perspectives. Was the accelerated shift to online delivery of mental and behavioral health interventions a good move? Latoya, Let’s hear from you first.

LATOYA THOMAS: Yeah. Happy to start. You know, I think that the multi-demics of the past year — and I labeled the multi-demics as COVID-19, violent trauma, bigotry, some of the health care resource and financial insecurities that many have faced — but those multi-demics of the past year have certainly drastically impacted the demand for mental health supports. We know that more than one-third of Americans live in a community that lacks a mental health provider, according to HRSA [the federal Health Resources and Services Administration], and the number of providers available in those areas will only meet about 27 percent of the demand for mental health.

We also knew that, you know, through reports from the Kaiser Family Foundation that nearly four in 10 adults reported symptoms of anxiety or depression during the pandemic, in contrast to only one in 10 the previous year. And 12 percent reported increased alcohol or substance use. And just to top it all off, you’ve got 12 percent reporting worsening chronic health conditions, especially those who are comorbid, all due to stress and worry over the multi-demics that we’ve experienced over the past year. So we were happy to be in a position with virtual tools and certainly meet the need for those who were seeking care.

SHANOOR SEERVAI: So at some level, this was sort of an inevitable shift. Solome, what do you think?

SOLOME TIBEBU: I couldn’t agree more with everything that was just said. Latoya, you know, we focus on youth at the Upswing Fund for Adolescent Mental Health. And just looking back at how COVID has impacted them. I mean, adolescent mental health has been an area that has been underserved for so long already, but then just the impacts of COVID, everything from the school shutdowns to the financial strain on the providers who serve them.

This was just an important place for us to focus. And so the ability for a lot of our grant recipients to be able to offer teletherapy while students weren’t able to go to school, which was frequently one of the main places for them to get emotional support, was hugely important.

SHANOOR SEERVAI: What were some of the attitudes about providing behavioral health support in a digital space before the pandemic?

LATOYA THOMAS: During the heart of the pandemic, I feel like ourselves, other behavioral health and virtual care companies, but also many brick-and-mortar hospital systems and traditional providers were in a provider crunch, really looking for capacity. Somehow we managed to have consistently high patient satisfaction scores. So it’s just nice to know that we didn’t diminish the care that we were providing to our patients. Nor did we diminish the virtual care tools that they were using to enable access to the care that they were seeking.

I think what we are learning from the past year, at the very least, is that COVID makes the use case stronger for the use of virtual care tools. I don’t think it created that use case, as we highlight just the plethora of health care inefficiencies, health care inequities, and the gross disparities between many groups, especially those who are marginalized. And I think that there is, unfortunately now, well-intended or not, a lot more attention to those virtual care providers who have still an access gap, and not necessarily a more holistic view of all licensed and certified providers who should be serving access gaps. So taking account of what was wrong prior to the pandemic to put us in such dire straits, how can we create a truly coordinated care system that includes both virtual care with a hybrid in-person model that keeps the patient and the family caregiver at the second?

And a lot the focus is just on volume, not what happened within the visit. We should be having conversations of, let’s look at the outcomes those visits, regardless of whether or not a virtual care tool was used. And what are some of those best practices that can be widely shared across the spectrum so that no patient or consumer is left behind?

SHANOOR SEERVAI: What about you, Solome? Did you see gaps particularly for adolescents?

SOLOME TIBEBU: Totally. So, you know, a lot of the grant recipients within our Upswing Fund portfolio are community-based organizations, and the quick pivot to telehealth was a little rough, but then there were a few examples of some digital-first nonprofits that we worked with that really were quite ready to go, in fact. The Trevor Project being one of them. They’ve been offering crisis support for LGBTQ teens, ongoing, virtually for quite some time. So, that learning curve or pivot was maybe a little less so for some of our applicants than others.

SHANOOR SEERVAI: And how do you think the communities with the greatest needs were served?

SOLOME TIBEBU: I really love this question because there aren’t a ton of philanthropic funders that have focused on mental health, period, despite the huge need, but specifically our focus, LGBTQ adolescents, adolescents of color. They have some unique needs in terms of providers who want to serve them. So everything from the fact that we don’t have enough providers, period, much less ones that reflect the populations we’re looking to serve, is a huge issue.

Similarly, a lot of youth have access to a smartphone, but might not have the internet access or privacy to engage in video therapy, even if we’re able to make that available to them. So I use the example of an LGBTQ teen might not want to embrace a video therapy session while they’re stuck at home during COVID because they just don’t have that privacy from parents listening next door. And so they were embracing text-based solutions as a result. So it really does need to be tailored to the communities that we want to work with and, everything from the actual intervention, but also the support for those providers.

We can talk a little bit about this later. Like, how do we empower organizations who serve these communities to get the general ops funding they need to really deliver the right care? One example that comes up frequently is, it’s not just about getting reimbursement for that therapy session for this youth. If that youth does not have transportation, or has not had lunch, we need to be able to support them with those pieces before they’ll ever engage meaningfully in a therapy session. So that’s important to keep in mind when working with providers who serve those populations as well.

SHANOOR SEERVAI: On the one hand, therapy is moving into virtual spaces, on the other, you know, the example you gave, that might not be the best place for an LGBTQ teenager to be in a virtual therapy session at home. So in your work, how are you thinking about efficacy?

SOLOME TIBEBU: First let me say, just as the American Psychological Association has said recently, online therapy is here to stay. As Latoya pointed to, there’s a lot of evidence and several studies that prove telepsychology’s effectiveness, teletherapy’s effectiveness. And so I don’t think we’re going back. COVID has been a catalyzing event.

So now back to culturally sensitive care, a lot of the organizations that we partnered with, amazing organizations led by BIPOC and LGBTQ and lived-experience leaders, they’ve recognized that a lot of the standard assessments and measurement tools that we’ve been using and have been generally accepted by payers and philanthropic funders are really not tailored for the populations we’re looking to serve: LGBTQ youth and adolescents of color. And so they have to find some other proxies that can help them demonstrate outcomes. Just the fact that youth keep coming back again and again, and turning to them as their source of refuge and emotional support alone, is one example of how many have done that.

SHANOOR SEERVAI: Latoya, what do you think?

LATOYA THOMAS: Yeah, I’ll start with the patient surveys because I do think, in our assessment of virtual care writ large, patient feedback is crucial. And I don’t think it’s being given the kind of credence that it should be, you know, how to close gaps in care, how to improve care overall, ways in which we can look at some of that data, perhaps disaggregate some of that data when you’re looking at patient feedback about virtual care specifically, and really trying to figure out the why.

We at Doctor on Demand and Grand Rounds Health, we published a study with Mayo Clinic, ironically the year before, year prior to COVID, we essentially looked at our own patient feedback and you can, you can imagine this is millions of patient anecdotes, and we just did essentially a qualitative study because we wanted to understand really what the drivers of that patient satisfaction was. You know, it’s nice to say that a patient is, you know, rating us on a scale of 4.9 out of five stars, but we really wanted to get a better sense of why. And essentially our research showed us that what really drives the patient satisfaction for our virtual care tools and our virtual platform, which uses primarily video, but also augments with audio-only tools like the phone, but also text-based tools, too. But the drivers for that patient satisfaction, no surprise, are good communication, trust, and building that relationship with the providers, that patient–provider relationship, no surprise is that is exactly what one should expect in the in-person world, and emphasizing similar principles that any patient should experience in the brick-and-mortar world.

SHANOOR SEERVAI: You’re both saying that it works, virtual care works. But there are still barriers to this. So tell me which ones are the most stubborn.

LATOYA THOMAS: I’ll let you begin.

SOLOME TIBEBU: Sure, absolutely. In terms of barriers, COVID has allowed us to loosen a lot of those restrictions that have been in place, namely around telehealth practice across state lines. We are seeing states now rolling back those telehealth waivers, which is unfortunate, but I think there’s quite a few groups that are doing work to ensure that that can be the case indefinitely, to be able to practice across state lines, on the substance-use front as well. Different barriers in terms of having to have that in-person initial intake assessment in order to prescribe medication-assisted treatments like Buprenorphine, those have been waived, but we hope that continues. In addition to that, just being able to make sure that we can support all patients’ access to internet and private spaces, if they’re going to be able to be successful in teletherapy. And in a lot of times, you know, in underserved communities, that’s really not the case.

SHANOOR SEERVAI: Coming back to the point you made about being able to deliver care across state lines, specifically who is being impacted by the fact that this is being rolled back?

SOLOME TIBEBU: I mean, rural communities, even more urban communities, where just the providers are not prevalent. If we have providers available to support individuals, wherever they may be, my position is we should do everything we can to support those interactions.

LATOYA THOMAS: You know, I would say a lot of these regulatory frameworks, whether they’re dealing with where a patient can receive care or some of those in-person requirements that we’ve seen, come back after 10 to 15 years of being absent, specifically for mental health. You know, they harm the patient, they harm every patient, especially those with access challenges. You can imagine someone who might be homebound, someone who may have a disability, perhaps someone with a transportation issue, or someone who’s living in an underserved area, whether it be rural or urban.

And let’s not forget the impact on 53 million caregivers, folks who care for those who are seeking care themselves. And the impact that caregiving can take on one’s mind and one’s body. Present administration and numerous lawmakers are certainly, and rightfully, taken the mantle of trying to address health inequities and further looking at the disparities between key groups. But it baffles me that when you understand that there continues to be persistent provider shortages and access challenges, but also you recognize that patients have chosen a means of which to access quality care that doesn’t diminish their quality of life, it values their time, and it values the relationships that they have with the provider. It baffles me why any lawmaker would endorse a policy that impedes a patient’s agency to choose who they’d like to see, how they’d like care to be provided, and from where they’d like to seek care.

And so the in-person requirements specifically that we’re seeing in areas like telemental health within Medicare should be struck down. Luckily there are some champions out there and some pieces of legislation that intend to repeal that in-person requirement. But without any action, essentially what you’re going to have are health care providers around the country who have been using these virtual care tools to communicate with their patients. They’re gonna be forced to have uncomfortable conversations with their patients about why they can no longer accept their insurance coverage, and how they may have to arrange for other ways of paying for visits that was otherwise covered, efficacious, and meaningful to that patient.

So, I’d like to just call out the Telemental Health Care Access Act. There’s a bill introduced in the Senate, Senate bill 2061, a continuum bill, introduced on the House side as HR 4058. And it essentially would remove those in-person requirements for telemental health services for Medicare beneficiaries, essentially seniors and those who are disabled receiving Medicare services.

SHANOOR SEERVAI: So there’s both resistance at the policy level, but there’s also a lot of support for it is what I’m hearing.

LATOYA THOMAS: You know, I can’t stress this enough. There were many virtual care programs that existed within hospitals and health systems, and also programs that were created prior to COVID because we recognized that there was a sharp need.

But a policy that arbitrarily terminates the provider–patient relationship and forces someone to go seek care elsewhere for no other reason that someone just thinks it’s the right thing to do, I think are policies that should be examined and repealed. And I think that we should be really moving away from this paradigm of either/or, it’s either virtual care or it’s in-person. I think what we’ve realized over the past year, and we certainly are hearing from our patients and clients and stakeholders, is that they want access and are prepared to use any tool to connect with quality health care providers in a secure fashion.

SHANOOR SEERVAI: What are the viable strategies, in your mind, that could really help overcome this resistance and dismantle some of the arbitrary barriers you just laid out?

LATOYA THOMAS: Listening to patients, but also listening to providers too, because when you have a team of health care providers that reflects your population by and large, that you’re going to see improvements. As a caregiver by proxy for my parents, as I’m helping them navigate their own health care coverage of them being over the age of 65, if we can work with the payers who are responsible for ensuring consumer protections to ensure coverage specifically for behavioral health. And by creative I mean, coming up with ways in which you are lowering out-of-pocket costs, ways in which you are expanding access to a greater network, but also ensuring quality and holding that employer and perhaps a clinical partner accountable for measuring efficacy, I think that that’s also a strategy.

We’ve been working with folks on the Hill. There’s a lot of conversation around Medicare and ways we can improve coverage and reimbursement for those over 65 and those who are disabled. But when you are looking at patients in consumer, across the life cycle, as Solome continues to do, 50 percent of employees who have a high-deductible health plan, presently, because of CARES Act policies, have the ability to get access to low or no-cost virtual behavioral health services before meeting their deductible. But come January 1, 2022, that is likely to go away because it’s got a sunset, right? And so really looking at a variety of ways that we can increase flexibility for those not full-time eligible — I’m thinking of the janitorial staff and food prep staff in hospitals and health systems. I’m thinking of retail health workers, hostesses and waiters, I mean, school bus drivers. Employers are trying their best to extend health care services specifically for behavioral health in a low or no-cost capacity but continue to run up against certain barriers with lawmakers who don’t understand that they too have some flexibilities that they can work with and build in some of those lawmaking changes over the next few months before those policies sunset.

SHANOOR SEERVAI: And Solome, from where you’re sitting, let’s look ahead now to who this patient of the future is. What are the emerging digitally based behavioral health modalities and tools that really show promise for the future?

SOLOME TIBEBU: It’s been exciting to see so many new innovations and start-ups focus on expanding their behavioral health solutions, just given such an emphasis on it these last couple years. It’s been exciting to see a number of different organizations and companies home in on condition-specific solutions. Whether that might be a start-up focused exclusively on eating disorder, like Equip or, you know, NOCD specifically for obsessive-compulsive disorder.

Also youth. This is really the first year, the last 12 months, that I’ve had payers reach out and say, “Do you have a solution that’s specifically tailored for youth?” more than I ever have before.

And then finally seniors as well. Each of these groups have their own specific needs, and it’s exciting to see how technology and service delivery is being adopted and tailored just for them.

LATOYA THOMAS: You know, prior to the pandemic, you had to schedule an appointment based on your availability and the availability of the licensed care provider in your community. But, just given the sheer demand, we realized that patients shouldn’t have to wait for the types of services that they were looking for.

So making our virtual care platforms available same day was certainly a transition that we’ve made over the past year. We realized that there are folks who have lower acute needs, and they don’t necessarily need to see a therapist or need to see a psychiatrist, there’s no need for a prescription from the psychiatrist. And so making sure that we’re putting them in touch with some of our coaches is something that we’ve done. Making sure that those coaches are available through text-based means.

SHANOOR SEERVAI: When we think particularly about the future of young people and what we can offer them in the future by way of mental health services, you know, if you had to stare into a crystal ball or look at the organizations that are already on the cutting edge of this work, what’s happening in this space?

SOLOME TIBEBU: Really, mental health care, the mental health system was just not designed for our Upswing Fund recipients. BIPOC teens, LGBTQ adolescents, they’re used to technology and apps that are very well designed and convenient to use, being able to access resources on demand. And so, health care is already inching toward being more consumerized, but more so than ever for the next generation. They’re expecting that level of user experience and design that’s up to their standards.

SHANOOR SEERVAI: Solome Tibebu, Latoya Thomas. Thank you so much for joining me today.

SOLOME TIBEBU: Thanks so much for having us.

LATOYA THOMAS: Really appreciate it, Shanoor.

SHANOOR SEERVAI: This episode of The Dose was produced by Jody Becker, Karl T. Wright, Naomi Leibowitz, and Joshua Tallman. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. I’m Shanoor Seervai. Thanks for listening.