5-11-21 COVID19



NASMHPD via ExpressConnect Conferencing, LLCTuesday, May 12, 20212:15 – 4:00 p.m. ETCART CaptioningCommunication Access Realtime Translation (CART) captioning is provided to facilitate communication accessibility. CART captioning and this realtime file may not be a totally verbatim record of the proceedings. >> My name is Kelle Masten, and I would like to thank you for joining us today. Before we begin, I would like to go over a few housekeeping items. Today's Webinar is being recorded. The recording along with the PowerPoint presentation slides will be sent via email to everyone who registered. However, you may download the slides now at your convenience where it says files. For those who need to use closed captioning, please click the CC on the top of your screen and the transcription of the audio will be available to you. The caption box on your screen is customizable. Please adjust the display to your preference. Please know all lines are currently muted. If you have any technical difficulties during the Webinar, please type your comment in the chat and questions pod on your screen and someone will be able to assist you. Please also use the chat and questions pod to interact with each other and to ask questions. We will ask as many questions at the end of the presentation as we can. At the end of the Webinar, we would ask you to complete a quick survey for us. Please note, we do not offer CEU credit for the webinar, but we will send you a letter of attendance upon request. My email address will be available at the top of the screen during the evaluation. I would like to thank SAMHSA for allowing us to share this information with you today and thank you for joining us. Today's presenters are Dr.?Robin Meyers, managed care of the New York state’s office of men tale health. Dr.?Martin Rosenzweig, behavioral chief medical officer of behavior health and Dr.?Carolyn Rekerdres, psychiatrist, community psychiatry solutions. Thank you to all of our presenters and we'll now begin our presentation. >> Dr.?Carolyn: Hi guys! My name is Dr.?Carolyn Rekerdres. I'm a member of the medical director institute for the national council and also medical director of the northeast region of east Texas, behavioral health network which is a cooperative of tell psychiatry services here in Texas. We mainly serve communities, behavioral health centers across the state. I'm an expert in rural tele psychiatry and healthcare delivery for underserved populations. I'm going to represent the provider perspective when we talk about COVID19 and the future of the behavioral healthcare delivery. So, this is a disclaimer slide that we have in here. Just saying that the policies and opinions expressed are those of us and do not necessarily reflect those of SAMHSA or HHS. Goals and learning objectives. So, this session we're going to explore the experiences and implications of telehealth practice and policy during COVID19 and beyond from the provider, payer and state perspectives. The learning objectives are going to be discussing successive challenges and lessoned learned during the last year utilizing telehealth. Prepare for the future of telehealth post COVID, discuss positive and negative impacts including data to support the effectiveness of telehealth, discuss specifically the impact on children and families and discuss how to incentivize telehealth. So, from my perspective, which is the provider perspective, I want to begin by really honing in on something that has been happening for many years prior to COVID19 and that's mental health in America, the depths of disparity. As you look at this slide, it's going back to the 1900s and this data is probably spottier back then, but we had alcohol, suicide, and drug deaths which are not new. But what we have seen in 2010 is a real spike in influx point and some of them were driven by opioid deaths in particular that have started to trend off since 2016, but overall, if you look at the top curve, the deaths of despair are worrisome, starting in going 2010 and this is also occurring prior to COVID. Prior to COVID19, there were barriers, and they were worsened by inequity and we have studied that show this. A 2018NCQA report showed that half of patients discharged, made it in the clinic within 7 days for the outpatient visit. I don't know where you are in the United States of America, but you probably feel it resonates with what you have seen prior to COVID. So, telehealth emerged prior to COVID as a strategy to health increase access and newer rate provider shortages but this is mainly in areas that were rural. This was not being utilized at the same scale that it is now in urban areas. Data has showed efficacy for over a decade but the overall impression that was still not favorable for patients and providers. They just hadn't caught on yet. This is what I'm calling the COVID19 effect. So pre-COVID, fewer than 10 percent of all patients in the U.S. report seeing a provider telehealth. Only 18 percent of physicians reported using telehealth intervention and fewer than 50 percent of psychologists. Since COVID19, they are up by 50 percent in the first quarter of the 2020, according to the CDC. 53 percent all visits were depression, billed to Medicare done via tell medicine and so clearly, COVID19 has changed things. Just to clarify, as far as deaths of despair, this is a term that hit the mainstream media that is just kind of an encapsulation of the three causes of death. So, there was a paper kind of a central paper that was released and showed that certain populations, particularly Caucasian folks between the ages of 35 and 55 who live in non-urban areas without college degrees were done sooner than their parents or grandparents had done. When they dug into the data, they found there was three reasons people were dying, suicide, drug overdose and alcohol related deaths including liver deaths, and accidents. So, these three things were changing overall mortality for Americans. So, these were coined depths of despair and this hit the Nightly News and the newspapers, and they all reported on it. So, we were aware of this trend in mortality that particularly affected patients who had a lot of these social determinants of health, like poverty, lower education and lived in areas where there were fewer access to healthcare. That's what deaths of despair were referring to. So, this is a cartoon that says how it started and how it's going. For providers, we were in our offices and we thought in terms of bringing patients together with us, with clients so this psychiatrist says, schedule the lawyer and the exhibitionist for the same time. I want them to meet. That's kind of a cute joke but it's something you could do back in the old days when you had patients coming to your clinic. How’s it going, this guy says, I really want to thank for great sessions. That gives my anxiety and feelings of inadequacy for others. He's doing great. The doctor does not look like he's doing as well. He's sitting there in his little bunny slippers, looking like he needs a vacation. The question is, is there a difference between how patients are experiencing these sessions and how we are? And what really happening with telehealth in America. So first of all, what is tele-behavior health. The health resources and services administration defines telehealth as the use of electronic information and telecommunication, technologies to support long distance clinical healthcare. Patient and professional health related education, public health, and health administration. The way I see it, there are three main ways that we can enact tele-behavioral health in this country. One is direct consumer. Which could be crisis interventions or phone-based therapy where there is audio only. The doctor is sitting somewhere else. The patient is somewhere else, and we are communicating via audio only technology. Meaning the telephone. So that's one way that we can do tele-behavioral health. Another is more of a hub and spoke model. An integrated care model uses this, traditional behavioral health clinics use this. The patient is going to a brick and motor location, always operating to see the patients but the provider is not there. So, this modality is used to help extend when we have provider shortages or if you have a clinic system that covers large distances, but they are all providers on site like nurses checking vitals or a front desk checking patients in. This third modality is a newer kind of modality which is utilizing app-based technology for the patients who have smartphones and can download an app, and this is a direct-to-consumer model where patients are doing video streaming visits, similar to what we're doing now but both provider and the patient are located in a non-clinical setting. Usually, the patient is at home and they're able to connect with their provider right from their home. This is a blended service model. Using apps and be things like that, you can also, of course, incorporate things like sleep tracking. There's wearable technology where a doctor can see a patient's pulse or blood pressure, if the patient has an app or a watch or something like that, so they can get data from. Text based therapy is also in that categories and we have a lot less data on that application. So, the provider concerns that have emerged over the last year in particular, numerous studies show that although providers do like telehealth, the satisfaction rates are very high. They don't like it at the same rate as the patients do. It's complex and vague. So currently, we don't have practice guidelines give us guidelines on when we should use which three. So, technology frustrations wear out the providers. So, if they're not getting a good audio signal or tele video signal, that frustrating them by the end of the day. Telephone visits require different training and methodology. Providers feel unprepared. So, we wouldn't go work at AT&T at the service center, without undergoing two weeks of intensive training on how to have phone skills and answer the phone. We haven't done it for the providers but many of them especially in rural areas are doing a lot of these only audio visits and yet they have trained for in person therapeutic visits. So that's causing them some frustration. There's a lack of decor. And they miss people in the clinic. Patients are distracted during the visits or they're out in public. We have heard a lot of provider complaints that patients are out and about and this could violate HIPAA and there's some concerns about that. And of course, when we are not doing visits in a clinic, we have lack of vital signs, blood work and there's the inability to do AIMS if the patient is interested in audio only, for example. These concerns are heightened in populations of concern. So, in geriatric patients, for example, we have more risk for dementia or hearing problems and if those patients are at home without their caretaker there, then doing a kind of direct visit one second, it looks like I have lost the connection. Sorry, I don't know why I lost the connection because my internet So pediatric patients, so older patients who have dementia that's a very difficult visit, audio only or trying to connect via only technology if they have dementia and don't remember anything. We need the caretakers and the collateral information we need when someone drives them to the clinic. The same thing with pediatric patients. We have had concerns about providers that way. Let me go back. So, in the pediatric patients. If patients say, you can go to work, you can talk to them and prescribe a medicine, that's not the same quality. We're not going to do that. Patients with ACT programs have a history of being difficult be to engage. Those patients, the phone visits are cumbersome, and they get tired out. So sometimes we lost the engagement with the patients that way. Patients with intellectual and developmental disorders, they may have a harder time connecting even if it's through an app and relatively easily unless they have someone who is there to help them. Patients with co morbid, data they're not enjoying the video streaming visits as well as the ILP program or something like that as much as they got from going to an in-person AA or NA meeting. And patients with co morbid medical disorders, we want to monitor their weight and vital signs. So, when we lose that information, we're losing something at those visits. So, telephone services in particular, I think, present a challenge for medical visits. They should never be the first line for diagnostic assessments, even though we have to do it because it was a pandemic and an emergency. Movement disorders cannot be evaluated and descriptive style they be in person to those who have not trained it. Patient with low IQ or severe psychosis or patients with moderate or severe dementia should not be seen with a phone visit without a guardian or family member in the room. We need the extra information to make sure we're getting it. Patients cannot be driving when they are seeing us or in a public place due to HIPAA concerns and it's harder to ensure that with a phone visit. Provider burnout is one of the things that we have also looked into. Zoom fatigue, which is described almost immediately after a lock down, is a cognitive fatigue or distract ability. Hopefully, you're not experiencing Zoom fatigue by now. It's supposed to have real neural psychological underpinnings from a lack of cognitive award and oxytocin release. So, like the patient we got to see their face and we got to really feel like we're really connecting and interacting with them. When that has been removed, we're finding that providers are not feeling, that the visits are as rewarding as before. So, the show rates are higher than ever before. Patients are sicker than ever before. This is a tough time for providers so one of the things to think about, if you're in an institution that sees patients is providers need breaks from devices, from time to time, like fresh air, vacation time. They need to use it even if they're not traveling anywhere. Additional admin time for notes as they adjust for this service model. They need plain old encouragement, time to connect and aided guidelines that are more helpful. So, to recap, all of these things you can see here are part of the complex network and mesh that constitutes what we do in mental health. It's not just patients coming to a clinic to get prescription for medication. They have to interact with a pharmacy. We have case managers who come out to their home. We have therapists who do one on one in group therapies. We have in patient services. And we have really specialized services like, neuropsychological assessments and diagnostic assessments. All of these things are not able to be delivered in just one way. So, some of these things may be just fine to continue doing by telehealth and that will continue to increase the access to care which is what we hope happens, but we want to be careful from the provider perspective, that we're not pushing services that are not as effective as the face-to-face services were. So, on our end, we're going to continue to collect data and to get as much evidence as we can before we push forth some recommendations for how we can continue to expand access because that's not going to ever want to go backwards. But while also ensuring quality. If you need some references, here's some great references for the information provided. Now it's time for the next presentation. >> Thank you for that. I'm Martin Rosenzweig and I'm the chief medical officer for united healthcare that covers behavioral health services. What I would like to do is go through a slightly different perspective on what we saw under COVID. So OPTUM covers somewhat more than 35 million Americans for their behavioral benefits across the United States and we really do that in three different channels. There's the commercial channel, there is the Medicaid and then Medicare and the data I'm really going to share with you is based on some surveys that we did with our members to really understand their experience as well as looking at some of our claims experience. And really, the interesting thing, I think there's some surprises in this data around some of the assumption that we made around who benefits, who used and really, the willingness of various groups to adopt this as a form of care. So just to underscore what you saw already. One of the things from our payer perspective, you know, so I always talk about, you know, BC, before COVID and then, after COVID. So, when we look at our claims experience, BC, before COVID, only about 2 percent of our outpatient claims were for virtual care. We were really trying to promote, you know, adoption of this because it addresses some of the issues around access and also, some parts of the country where there are sort of relative deserts of providers. So, there may be a clustering of providers around larger urban areas. I live in the commonwealth of Pennsylvania, so there's parts of Pennsylvania where we have a relative shortage of providers that just don't exist. So, we saw this as a way to really kind of level the playing field so to speak. Where we are from now, after COVID, we have gone in the space really of a few months to more than 70 percent of our claims are for virtual care. So, if you think about how disruptive it has been, some of the things that Carolyn talked about from a buyer perspective. Certainly, from a payer perspective, we had to change rapidly to the change modality of the delivery of care. One of the things that is really interesting, that I think sort of underscores how things change. So, this graph here on the right is really looking at Google trend data. So, it's looking at how individuals go online. The red line shows people Googling for mental health services, you know, near them. And we see the trend which occurred obviously before COVID of increased demand for behavioral services. And you can see that sort of line, you know, trending, obviously there's noise. But you can see it sort of trending up. The blue line where individuals looking for how I can find virtual mental health near me. So, you can see towards the end of the graph, the complete disruption in the early part of 2020 when COVID hit how. Consumers really shifted their behavior to looking more for virtual care and then that sort of drop off as things are more stabilized but overall, individuals are still willing looking for how they can find sort of the virtual care. As you can imagine, this has been very disruptive, I think, for the payers as well, as we have had to reconfigure the systems to deal with this. One of the things we did, and this is a lot of data I want to share with you is, we wanted to understand the experience from the member point of view, the patient. So, we conducted a survey where we went out and sort of asked them directly around the experience. So, I am going to go to some of that. There’re some interesting differences between channels that actually were a surprise to me when I reviewed this study. So, one of the things that is really changed is, you know, less than half of consumers were really aware of virtual visits prior to, you know, BC, before COVID. And you can see the understanding of when this significantly increased. What is also significant is there seems to be border adoption or appreciation of getting behavioral services this way and we have seen almost twothirds of the individuals we surveyed were highly likely to continue to use virtual visits in the future. Important, obviously as we plan network development, how services are developed, it looks like from the consumer point of view that virtual care is probably likely to persist at a high level. The reasons, obviously that people wanted virtual care, I'm not going to go through them. A lot of them is reducing exposure by the convenience factor was significant. You know, both around the time of the appointment but also the convenience of being able to take it, sort of remotely with significant kind of factors in improving the adoption. So, this is a perspective of looking at the changes that we submitted. There’re some interesting trends here. This is looking at Medicaid claims. The blue line on the bottom which is pretty flat shows low adoption. You can see the rapid spike from 2 percent to, you know, over 50 percent of outpatient expenditure on telehealth. What is interesting, you know, and slightly decline is in October and I think it coincided with the summer and the numbers sort of declined somewhat in terms of the incidence of COVID19 and then went up as the United States went in the fall and the winter. We saw that concurrent claim or increase in sort of the claims as well. Obviously, the Medicaid population is probably more vulnerable to some of the detrimental effects of an infection and that may have driven the change there as well. So, this really was really looking by channels. The top one is commercial, the middle one is Medicaid, and the bottom is Medicare. The significant differences here because not all of the respondents experience the same degree of distress or need of support, they're using virtual services for. So, you know, I would have anticipated quite frankly that Medicare respondents, given the fact they were more likely to be isolated and cut off from sort of the usual social supports, would have actually requested more support. And we actually found that half are really getting the same amount and only under a third actually said they were receiving more support compared to previous years. When you look at the commercial numbers, so these are generally individuals who are employed and have employer sponsored benefits, significant increase in those using telehealth for support. Which is sort of interesting. In addition, 35 percent of them said they were seeking health due to increase stress due to COVID. So that's sort of the surprise as well. Even though that group in some ways may have had, you know, tended to be younger and may have had more support. They tended to be heavily impacted in terms of sort of the psychological, psychosocial impacts of the pandemic. So, one thing we did is try to understand why they were using behavioral health uses during the pandemic. These three, commercial, Medicaid, Medicare. You can start to see the differential in terms of the amount of support. So, you know, just to reiterate that as well. The overwhelming reason that people use telehealth is for therapy and secondary for sort of medication. So, you can see the difference here that I have, the previous slide underscored. Medicare was asking for more support. Most was really in the commercial sort of population which utilized services as well. I'm going to show you two slides as well that show the changes just to sort of highlight that. So first in commercial, we saw an overall increase in use of services, you know, prior to the pandemic. You can see that the graph over here goes to 2015. So, this is the overall trend that we're seeing increase utilization. Some of that has to do with what is available, greater access to services and you can see that dramatic increase from 19 to 20. What is interesting and unfortunately, I can't put up both slides at the same time. So, the 30 percent increase in telehealth and the 27 percent increase in medication services that really went on in terms of increase over all usage of tell psychiatry or telehealth. So, if you compare it to Medicaid, you can see the telehealth support went up by 47 percent and medication by 35. What was interesting about this is there had been some expression on what we have seen in the literature on how individuals with Medicaid would have had difficulty accessing telehealth because some of the technology barriers. Not having access to smart devices or broadband access to the internet. What is interesting is we saw this increase any way. So, it seems like despite the barriers, individuals were really able to sort of access behavioral care services and really significantly took advantage of them. What I found interesting about this is look at the slope on the yellow piece there. That's the kind of telehealth increase that you're seeing. So, I'm going to go to the last slide. You can obviously see some of that sharp increase, but it was most marked for the Medicaid population. So, we're really able to take advantage of the rapid change in our network capability for this and access to assess that way. This is encouraging. We have noted concern particularly around highest risk members because they were showing some increase presentation in emergency rooms which is a concern. That did happen but they were accessing telehealth as well. The concern as was mentioned, there may be some populations that are particularly vulnerable and have a hard time with telehealth, particularly those who are experiencing more severe illness or psychotic illness. So, this after all showed there's a benefit. It may not be able to help all diagnostic groups equally. So, we also took a look at why, from a respondent point of view, why that had an increased need. So, this is looking at the commercial group that showed the 60 percent increase. A lot of it really has to do with the increase symptoms of depression and anxiety. The graph on the right-hand side there is really putting it in the words of a member, you know, needing help, not coping well. One of the other significant drivers of utilization is many of the payers in some states really waived any copayments. So, this care could occur at no cost to individuals, and we believe that's another factor as well. We could access behavioral care without having to front any of their dollars in terms of being able to sort of schedule. That's also a significant factor to understand how this is a barrier to accessing services going forward. So, I think lastly, I just wanted to focus a little bit on the sort of Medicaid population. When we looked at them and asked what is it really around accessing this as making it easier for them. One of about a third of them got a response really conversing to the virtual care environment made it much easier for them to access care compared to before. The care may have occurred in a clinical fitting. It may have been the barriers were impediments to access, like transportation, childcare, getting time for work. It really goes away when they were able to access care by this platform. However, about one fifth of the respondents said they still refer in person support and that telehealth made it more difficult for them. In spite of the access, more accessibility is more difficult in the Medicaid population compared to commercial. Even though there was a broader adoption, the technology barriers really need to be addressed if this is going to be a modality of providing care going forward. The other piece here, which I think is difficult as well is in some situations, the surveys showed that in this demographic, it may be a little bit more difficult to find privacy at home where they could, you know, have a confidential conversation with a therapist. That is one of the things that came out of this. But overall, just to summarize, we were really encouraged by the national view of how we all sort of pair channels if you will, kind of took to virtual care. This is obviously a planned adoption. This had occurred rapidly, and providers were unprepared and quite frankly so were our members and patients. It really shows adaptability. What this means going forward from our perspective as the payer is, we believe this is going to be the predominantly way that care gets delivered in settings. I don't have the data here but some anecdotal experience about providers and delivering care for intensive outpatient care programs seems to have been successful. As Carolyn underscored, I think the substance use can be challenging. On the one hand, it does make access a little easier. On the other hand, patients seem to struggle more with engagement which may not lead to an outcome we would hope. There's a lot to be learned from this and obviously as an organization, we're continuing to track and train the data to see what it is we can learn and how do we sort of shape our network and the experience to meet the needs of our members. I think that's pretty much what I feel. I'll hand it over to the next speaker, thank you! >> Bob Meyers: Thank you! I'm senior commissioner at the national health and I'm going to talk about this from the perspective of the state mental health authority. A large percentage of the people that we provide services to are local provider networks, so most of the day, I'm going to be presenting is based upon Medicaid claims. This is just a quick overview. New York is a very large and diverse state. In the system, there's about 800 thousand people served a year. The state itself running 24 hospitals and servings about 45 thousand outpatients but overall, about 800 thousand are served. There’re about 200 licensed programs and about 2600 unlicensed programs and the diversity goes from urban areas in New York City, to rural areas. We do have some frontier areas. It's also very ethnically diverse, especially down state. Besides everything else, it's really exposed an issue with the social determinants that we're working on along with everything else. It's actually heightened the focus on trying to address that going forward along with all of the other issues that I'll be discussing. So mental health, this dips our toe in the water of mental health prior to the pandemic. In 2005, we actually allowed psychiatry to provide telehealth services. At that point, both the provider and the patient had to be in a physical location in a clinic. So, if you're in a rural clinic and you're having access problems with psychiatrist, that person could be in another clinical setting. In 2015, we started issues regulations on telehealth, and we started to move beyond the clinic settings. Carolyn mentioned the hub and spoke model. We had a hub setting which is where people would be located in another setting other than clinic and then prior to the pandemic, we started to use the term tele mental health. There was some confusion about these, so we started to use that. So, at the same time, we expanded practitioners to the people who provided therapeutic services besides the psychiatrist, psychologist social workers and counselors and we up and downed again, where they could be working from the home settings. And we expanded licensed practitioners, but they still had to hold a license in New York City, even if they were coming from out of state. And very importantly, we said that recipients could start to receive the service in their home location. We started to use tell psychiatry modestly in settings other than clinics. Like, personal oriented rehabilitation services. And then the pandemic hit, and I think, many of you on the call, no matter where you live, you probably remember. New York got hit very hard in the beginning, especially New York City. It was on the news every night. The situation was getting worse and worse. The crowding in the hospital. There was a lot of concern that the hospital beds were going to be overwhelmed. The state went into a pretty hard lock down and we started to quarantine. So, from the mental health perspective, we said we have a range of concerns. One was from the provider perspective, sorry, we skipped a slide. From the recipient perspective, what are challenges and how can we initiate treatment in a remote environment? How would they be able to remain engaged? And we would have to be very careful about reducing COVID exposure. We would have to make sure we did this in a way where people didn't have to be out and about. And as both Martin and Carolyn mentioned, there were technology issues. With the patient population of access to video technology or phone technology, and whether they are familiar with using that technology. These were questions that we discussed once the pandemic hit. We quickly surveyed providers to our own conclusions to but from the provider perspective, there's many operational issues. You have the same length of stay in a remote type of environment? How do the people remain engaged? And also, with group work, how do you approach group work? Do you shift the individual? Can you still do group work in this day? From a staff perspective, we knew there was going to be increased outages. Staff would become infected. Staff were exposed and had to be quarantined and some staff were reluctant to come in or even if they're working from home and they were ill. So, there was a significant staffing concern and you had to prepare your staff to work in a telehealth setting. Besides patient access, we were concerned with the financial stability of the provide every safety net. So, most providers are non for profits and the margin is very tight. They don't have a lot of reserves to keep going forward and we didn't want to have that whole system collapse in the circumstance and create an access problem. And then a liability problem going forward. And besides generating the revenue, they need to operate like they did in the past. There was additional cost like telehealth technology, ventilation systems, space issues, etc. So, it was very concerning. So, we quickly made some rapid changes from a regulatory and flexibility perspective. We went into a waiver environment. The governor declared a state of emergency which gave extraordinary powers and that translated down to mental health. We were able to waive a lot of requirements and a lot of regulations quickly and we use that to the maximum. So, we had a pretty rigorous process to designate providers who do telehealth and they had to designate each of that. We changed it to a process they can do over phone and designate the locations so you can make it available very rapidly. Sign consent could be done verbally with documentation in the record. We had required an initial face to face visit before the decision was made to go to telehealth and we waived it so we could start treatment directly to telehealth. We expanded the type of providers that could use it and were even able to use it for inpatient evaluations and most importantly, we expand it to be telephone. We looked at that pretty quickly. We talked to the counselor's office. We looked at HIPAA and security issues and we decided that it was the way to go. So, we very quickly looked at our regulatory flexibility. We look at relax time frames around treatment planning and service planning. Again, when we removed the signature requirements, we had an external utilization in this period. In some of the services, there has to be background checks to protect the patients etc., and that used to be done by programmers. What we did is when someone went through that process in one program, or one agency and they also wanted to work with another one, we could expand that. That was an effort to make the workforce more available and it's based upon the provider feedback. And we also provided a lot of flexibility on billing. We provide deficit fundings to a lot of these organizations too. They became very flexible and aware of cash flow. We reduced the duration of some of the visits of billing requirements and then when the federal payroll protection plan came along, we really provided a lot of assistance to providers in applying for that and then in terms of when they got those dollars, we changed our claiming, our reconciliation process so that money could roll over to a couple of years and it wouldn't affect the reduction in the funding they got from the office of mental health. So, we did everything we possibly could to maintain access and make it easier to care but also to try to help with the financial viability of the provider organization. What happened is we had the Medicaid claims data on the March to April in 2002. And it went from 35 percent to 91 percent. This is mostly our clinic data, but it also went up in other slides. It was a dramatic increase, and we were very pleased from the access perspective and from the financial viability perspective, but we were also surprised even with the flexibility and the technical assistance that we gave, that the provider community was able to pivot that quickly and that the client population was able to be reached and accessed that way. I will be showing some billing data next to talk about that in more detail. So, we looked at the various service lines and we compared the whole billing volume translated to dollars. If you look at the clinic which is our main basic service where medication and therapy is provided among other things, that, during the period from when they started into February this year so it's almost a year. Our clinic billing actually grew by 12 percent. We're a state that went from the model and we have 13 agencies that got the enhanced reimbursement for that and that billing went up 26 percent. Even our where we did see the decline is day treatment services, like the place stay services went down. That's a smaller piece of the business so on top of this, a lot of the providers were able to access the protection. So, we realized that from a financial perspective, they were being held okay. We didn't have the crisis that we thought we would have with providers in terms of financing and access. So, we were able to have access and work with the providers financially whole. So, this looks at support of housing. New York state is a state that provides a lot of supported housing and providers visit them on a monthly basis and enter the clinic. The red is telephone, the blue is video and the green is in person. You'll see quickly, all of the settings give in quickly to virtual and by far, phone was the service that we use. But within that, with the work that we did, the clinic utilization in person is way down. It's about 7 percent or so whereas, supportive housing is a bit higher. There were people who needed to be seen face to face and given that, you know, with the asserted community treatment and the type of individuals they serve and some of those individuals are on medications, et cetera, about 30 percent of that volume was still in person. But even that, it led to virtual in a significant way. This is a busy slide. I won't spend a lot of time on it but again, we certainly did a range of surveys and we asked those clients and providers questions, and the question here is what are the barriers to video-based telehealth and what this shows is significant is that the clients were knowledgeable about how to use it. Consumers also had a concern about the myths. A high percent of the population has a phone, but a lot of people have like phone cords rather than a monthly account because they really can't afford that amount of money. And you know, when they were on the phone with their clinician, they would be doing that. So that's a significant issue that we had to take into account. When you go down to the bottom, you don't think video is better, a lot of people thought it was fine. We have more data to show about it in a minute. But we did satisfaction surveys for the client population. Almost 85 percent of the folks thought it was easy and effective to access. About 85 percent thought they were receiving enough support. Only 13 percent were uncomfortable. I think this is very consistent with what Martin was saying in terms of the survey that they did. In terms of the descriptions, it says it did really eliminate barriers to access like transportation issues, for example. Some people's transportation, during the pandemic when we had the lock down and there was quarantining, people wouldn't have been able to travel. So, this made it a huge difference. So, this is a routine visit. So again, we have some concern about the high need population which I'll talk about a little bit and Martin expressed the same concern with the data he presented. It did reduce no shows. When you go back to the billing data that I showed later, there's two things that happened there. There was a lot of people seen, but there was a reduction in no shows. People were being seen more frequently than because of the high no show rate. But in some cases, there was increases in frequency. And in fact, not very often, but we have a couple of providers that we're looking at closely because they're with residential settings. We are looking at access there. But this is mostly reduction in no shows or people being seen more frequently, given the circumstances. This is interesting. Engagement service over the life span. So, the yellow is an increase. Gray is no change, and the blue is decrease. So, it starts from early childhood and it goes to the elderly. As I was looking at it earlier, you can almost look at it. If you look at the yellow line which is the increase and it goes from a decrease in younger kids, all the way up to a significant increase in adults and then a slight decline, but a significant increase in older adults. When you go to the decrease, it's the opposite way. There's a decrease in services, very young kids and still a decrease in adolescent, in 6- to 12-year-olds and then significantly less. So, this is an area that we are really going to need to continue to look at. We have a lot of school-based clinics. So, there's usually satellites and how do you provide a school-based clinic when all of the kids are home with their families. So those providers actually tried to do group work over the phone with these kids and again, Carolyn mentioned. Even for the younger kids when you're trying to get their attention, how can you engage the younger kids in group or individual work from home, when they're doing their homework, et cetera. So that's going to be a challenge going forward. And as schools reopen again, especially in the fall, we're expecting there to be a lot of behavioral health issues coming out of the school-based clinics. Just today, we had a monitoring dashboard to put in place to keep our eye on that and make sure that we keep ahead of that when that happens. And then we start rolling back the virtual flexibility when the kids go back to school. But the school clinics, we made modifications over time. We didn't just make one change. Just about two months ago, we reduced it in a short amount of time because we wanted to engage in the kids at all. So, what are we going to do post pandemic with this? As was said, you know, this told us a lot. We think this is a viable service option going forward. That's the position we're taking about it. Obviously, we're going to roll back some of the flexibilities when the pandemic ends and some of these that we have through the effectiveness, we will put in regulation if we're going to continue them. We can't continue to operate with them virtually. So, between what health is done and at the governor's office, this was for the legislature and now it's passed. So, I will talk about what actually passed between most of it. We're going to permitting telephonic equal to video, going forward. For example, we're going to allow certain unlicensed people to do this like prevention alcohol and counselors. We're going to look at the obsolete clients and patients are in their home going forward. And going down to some of this. We're going to require telehealth in commercial insurance too. And we're expanding access. The more things when the governor passed, there's some dollars available for training and education opportunities. In terms of the commercial side or the managed care side, can some care management be done in a virtual way? We are fairly positive experiences with care management and virtual, although there's some situations that we're in now. Working with the care management agencies, we get back to the field where there's some people that need the direct contact. As the infection rate goes down and the vaccination rate goes up and the economy will start to open back up, we're going to be working with a challenge of deciding with, who will be seen face to face, whether it's all of the time or part of the COVID. So, in terms of what is in the budget, and there was very strong legislative support for this, we also know how, this is now going to expand telehealth, expand the range of practitioner types. We're going to remove the first visit, face to face visit requirement. You'll be able to engage someone directly through telehealth from the beginning. The streamline application process to be put in place to get approval for telehealth, we're going to maintain that. Importantly, the legislation and the governor signed it and the public health is all telephonic contact, will be allowed. And we have been trying to work with Medicare to promote that. My understanding is they have, you know, said that telephonic is okay in certain circumstances. So, from our perspective, what have we learned here? What do we want to go going forward? We're looking at the best versus in person and our position is it has to be individualized. In some settings, you will see a high percentage telehealth like in the clinics, like community treatment teams. But even there, we want to individualize it. The person has to want it and their circumstances have to be such that the care would be as good. And in some cases, there's the engagement. This is along with the vital signs etc., but just that. And then for the people who are hard to engage or need care, we want to make sure that the license provider is still engaged with the individuals. We're looking at different reimbursement methodologies for that population. Is there a fee to service approach the best way to do it or is a bundle payment for that population at the back end for outcomes, a better way to do it? So, we are looking at reimbursement methodologies for this populations that address that. But we don't want a licensed clinic to become a completely virtual clinic that we need to have play stay services. Along those lines, in order to do that, the providers will still have fixed cost for the bricks and motor, we need to make sure that the rates that are established are adequate. And fifty percent of the provider's volume goes to virtual, and that's the lower rate, how can you spread that overhead with the in-person visits. So, at this point, we're still requiring that the clinic rate is the same through Medicaid, whether it's in person or virtual and over time, will be examining to see if that's still the best approach to take. We are allowing some virtual. We have a bundle rate with you get a full payment, and some can be collateral but we're going to be allowing a percentage of them virtual and it will allow the psychiatrist to video in when necessary. And we're also going to be allowing it in our psychiatric rehab programs but we're going to look at how we can really provide high quality psychiatric rehabilitation in a virtual way and probably do that next. And then finally, we talked a little earlier about school-based services. We really are going to be watching that very closely about the best way to approach that going forward. You know, we're seeing a spike now inpatient admissions with the kids in hospitals and we expect that especially this summer when the people come back, we'll have a high demand there. We think that virtual will help but a lot of the people in the school the, the kids and the teachers are going to need support of the clinicians on site, and we'll be working on that. So, with that, that's the information that I have to present from a state perspective. I don't know with the host, how you want to proceed from here. >> Moderator: So, to begin with, we have a comment that was made during Robert's presentation from Samuel which is, the backgrounds are really interesting. We're seeing extremely long rates from background checks in Florida. But having the background checks can seem like a tough sale. >> We did two things. We use today do individual background checks with each program and if someone had one, even if they're working with a different agency. Like, we have some people employed in one agency, but they might be moonlighting or working on the weekends in another and we're extending those. With checks, we do take a look and we make a distinction about whether it's okay to proceed with an individual. So, we're being very careful there. If anybody wants to get more information about how they're doing it, you know, you can send me a note and we can connect you with the people on that. Again, I don't think this is something we'll continue. Again, every state is somewhat different. In the beginning, New York is so hard hit, we're having terrible workforce issues. Staff is getting sick. Staff had to be quarantined and providers were having significant staffing shortages. Especially in our residential programs where you did have to have on site presence. We had situations where somebody in the residence would be infected, whether it was a resident or staff person and then everybody had to be quarantined. And how can you quarantine people in those settings. So, we had to be as creative as we possibly could to provide staff. That's where we mainly need the flexibility. >> Moderator: Thank you! The next question comes from Tim. Do you think telehealth will continue to be this way even after the pandemic? Will payment reform model address these types of services as well and in this model? >> So, I can address that from the payer perspective. We have continued to see broad adoption. On tell health and we're really anticipating that will continue. From a payment point of view, you know, we're actively sort of looking at continuing to support this going forward. But part of this is, I think, Carolyn mentioned we're looking at the guidelines to be established nationally that I think would make this more consistent. So, I don't think there's any plan at least in the short term to change the way that care is sort of being delivered. What is interesting too, when you look at virtual care, with some of the digital expansion of care delivery, we're seeing this care delivered for some disorders that I wouldn't have believed is possible before. So, in home, you know, to care for substance use for eating disorders. We're looking at the providers to look at the outcomes and make an informed decision going forward. >> I was just going to add, to point out, when we talk ant telehealth, remember again, that about the three different broad categories. Telehealth that is provided in a clinic with a provider off site, is definitely going to be part of the future and I think, both Bob and Martin pointed to things like, removing restrictions for providers to be able to do in patient. In patient psychiatric units have been so limited by provider shortages because they have required people to be in person. That's where I see some real low hanging fruit for provider shortages and things like that on the medication side of things. I definitely think we have seen broad adoption for the tele applications for therapy with users in their home and things like that. I do think that patients and providers have really enjoyed that modality where there weren't as many restrictions as far as needing vital signs and things like that. I think we'll see it continue to grow and expand. Where I think we will have a lot of hang ups is what we saw in this, is the widespread of audio only. Way more than any would expect. And I think that's data we have to parse through the most. Obviously, the easiest way to get ahold of patients is to call them. And the real question there is, are we missing something? We need some more data to say, especially from the medical visits, that they were as effective as anything you have a visual component as well. >> And I would also like to add, there's the tele mental health in general, where you're providing what would have been the traditional mental health services in a virtual way, therapy, medication, etc. But we're also looking at what is happening with technology in general with that based care and checks in and chat. Most of that what I can tell is private equity going into either the direct market. You're starting to see ads on the TV now or on the commercial side, the selfensured large corporations. But we do have some providers that with grants, are using chats to remind people of appointments and if they have a pressing concern, we can deal with it. And how does it get pushed into an overall reimbursement. If we go to a payment model, how will that technology link to both tell and in person including, you know, boots on the ground for some people. We want to make sure that the public system stays open for what is happening with these technologies just beyond the phone therapy and how they could be used in an effective way with different reimbursement models. >> Yeah, just to follow up with that as well. One of the things that is interesting about telehealth is how it may actually further some of the goal around sort of getting better outcome measurements. So really, the whole sort of endeavor to drive broader adoption of models. So having a platform is a really enable that because you can thin out your sort of instruments to the patient before the session. You can actually get feedback, you know, in realtime. So, before you see the patient, you know that the more depressed, they may be more suicidal and also, they don't feel like you're helping them. You can get that. So, we actually from a payer perspective, see telehealth as enabling some things that I think will better enable us to sort of show, you know, outcomes and improve the care being delivered. >> I totally agree with that. We will see another way emerge from the app-based care is the AI enabled applications with mental health. Meaning your phone is prompting you to chat, to log in a PHQ2. Are you feeling sad? All of the scales, the rating scales you're formally filling out when you go in the clinic. These could easily be pushed through an app interface and most patients these days have phones and they're always on them. So as far as keeping engagement when you leave the ER or your outpatient clinic, incorporate rating peer support and other things, you just haven't done cohesively before. That's where you will see the real gains through technology as long as technology is facilitating communication and not enacting barriers to it. So,?facilitating connection. When they feel there's a barrier between them being connected, whether it's the they don't have enough internet or they can't download the right thing, that's where it's frustrating. >> Moderator: Given the anticipated sorry. What suggestions do you have to help agents pivot to a hybrid model in person with video? >> That shouldn't be too hard. That's what I have been doing for five years in rural clinic. Rural clinics have had it for a long time. All the clinics need to do, with their providers working for them during the pandemic that didn't live nearby, you just need to purchase the right equipment. Cameras and we have to watch Congress to see what gets passed as far as continuing reimbursement on that. That remains to be seen. >> At least from the state's perspective in New York, we do?maintain phone contact and Medicaid and it seems like Medicare is going that way for some. Both Carolyn and Martin pointed out, we're going to have to look at what is appropriate. What appropriate circumstances are. But we have enough positive feedback during this period where we're not going to preclude it going forward. >> Honestly to put a point here, with that 20 to 30 percent no show that changed from the pandemic to now, that shows that our patients didn't want to miss their appointments. They didn't want to not come see us, but they had a barrier to getting there. So, we, all three of us, recognize that from our different perspectives and we really want to make sure that moving forward, whatever we do, we keep quality high, and we make sure we're addressing what the barriers were in the first place. Because as providers, a lot of us thought, oh, this person didn't bother to show up today, before, and now what we have realized is they want to talk to us. Obviously, if the no show rate is virtually zero, people were missing out and we want to make sure they don't fall through the cracks moving forward. >> Thank you, the next question is from Bob. What about the continuous use of article nine post-pandemic? >> Well, that seems like something we're looking at and we can talk offline about it a bit more. So, there's the big hospital associations so we're looking at it. >> Next question from John, when implementing telephonic care, is there a distinction from video such as diagnostic assessment and treatment planning? >> From a payer perspective, we cover telephonic as well. I think it has to do with the access issue. Because there is a large part of the United States where it's difficult and challenging to see a provider. I think we mentioned during the presentation, access to broadband may also be a problem. The issue again is, we probably need more research in this area because it's very hard to sort of say, that it does or doesn't work in all circumstances. My team, when we were looking at this, did an extensive literature review about what do we know about the efficacy of sort of the virtual care and the literature was pretty clear about, you know, tele-mental health being just as effective in most instances as well as face to face and also, telephonic which I was quite frankly taken back by. I know that there's a requirement, you know, if you provide telephonic care, you have to have a face-to-face peer visit every six months. Which may create actually, access issues. I think this is an area where we really need to have more research and understanding. So, we can make informed choices about what should or shouldn't get care this way. >> I think that's a good point! We have done it for about nine months. I was surprised at my own clinical skills some days but there were other days where it's clearly impossible. When you're doing a new evaluation and a medical visit this way. I had a patient once with Huntington's disorder who had a history of meth visit and his sister was there who had Huntingtons, and she was slurring her speech and it was hard to understand her on the phone. This is a phone only visit. There's no way for me as a provider to know what I'm going to get until I encounter someone. That was not a visit where I was going to be able to come up with a correct diagnosis or even fully assess the level of movements and the level of impairments she physically had. What we had to do is get through the basics and then bring her in for more information. Because there are situations like that clinically, all of the time in a community behavioral health center. I don't think I would have as many of them if I were doing like a pure insurance base cash only type of practice. We would probably have fewer types of those situations, but I was surprised how many cases there were. I was longing to see the person and be able to see, are they tracking? Are they moving? What is happening right now? >> Moderator: The next question is from Glenn, what is an emergency department? >> So, there are providers that we have worked with around doing virtual care in an ED. I think tell mental health may make it possible. Obviously, you know, as Carolyn mentioned, having the patient going to a clinic setting where there's other staff around and they do have the video component, honestly could be quite successful. We certainly have seen it in various parts of the country. So again, I think it's really on how you define where it is or isn't. And also, there's a back-up plan because if you get a patient that is for whatever reason, impossible to assess like that, you know, what is the alternative to get the psychiatric assessment done? >> Shawn: Do we expect the telehealth to be reimbursed at the same rate as the in person for the future? >> I guess that's directed to me as the payer, right? This is perceived for the foreseeable future. I believe this year, that's probably the plan under the state of emergency. You know, part of it is really understanding the efficacy and tracking more of the sort of data. So, I think beyond this year, I think it's a little unclear on what direction payers will take one way or another. >> Bob: I would agree. Actually, during a legislative session this year, the legislature had some language in a you have to pay the same unless there's clear documentation. The cost is less and then when we work with them, we said for now, for the Medicaid population, the rate will be the same. The in person and virtual rate will be the same. We agreed we would monitor it over the next year or two. If the virtual volume gets very high and it's clear that the overhead is less and providers start to shed office space or the volume on the higher cost services, we may have to visit it. So, for now, in the Medicaid population in New York, we're going to have it the same but we're going to be watching it closely to make sure that it's an appropriate rate going forward. >> Next question from Tracy. Any chance that Medicare will start accepting other credentials than just at the SAW. >> There is a bill in Congress that would allow for Medicare funding for those specialties and as of today, I do not know what the status is. But I know there's a push for a long time for it to happen. I fully support that, but I don't know the status in the legislature right now. >> Next question, will there be requirements for providers to have telehealth certifications for state boards or federally? >> I haven't heard of anything like that. I can tell you in Texas, there's a new categories on the Texas medical board that is a telehealth only permit for people who are out of state and that's in response to COVID and their dire need of providers for just regular primary care and things like that. But I haven't heard of any type of requirement national for that. >> Do you recognize generational differences in preferences, and do you design services accordingly? >> From a pay perspective, we bill the network. We obviously look at what the preference is. If you went to a payer provided direct field, you will see they may designate the face to face or telehealth. Some only do virtual care. So, the choice rests with the patient in terms of they want to get their care. So, there's really no plan to sort of change that. And I think even that earlier question of the hybrid model. I suspect that it's a piece of the way that care will be delivered. Some of it may be in person. Some of it may be done virtually. I think there is some legitimate concerns clinically about the initial assessment being done virtually. Although it can be done quite successfully but for some patients, you may also have, you know, sort of the co-occurring medical conditions that may be a bit of a challenge. So, we're providing a structure that will allow a choice for how the individual wants to really get their care. >> We probably have time for one more question from Diane. Wondering how I receive care from anywhere I imagine providers in other areas would not cover by insurance or covered the same percentage? >> So, the way from a payer perspective, the way that the network works, is you have it with the payer. So, you're going to provide care. You're in network irrespective of where the actual patient is. So, the network status is between the provider and payer. That doesn't change. What has happened, as was mentioned with the restrictions is, you may have a provider that is in an adjacent stake that is able to see it and elsewhere. But they're still in network. It doesn't really make a difference. And you know, geographically, it also helps. I can take New York as well, for example. So, you know, they may be relatively more providers in Manhattan versus up state. You know, some of those providers can see patients in more rural areas where access was an issue. And it's all done in New York so there's no issue with it. >> Moderator: Thank you! I probably can ask one more question from Tonya. Is there a work being done on messaging and chatting with the population and if so, where is it happening at? >> So, I think from our point of view, there's a number of sorts of technology-enabled solutions that we have looked at that use the hybrid model of having a therapist plus a coach, plus allowing for texting as a way of supporting engagement. Which you know, we do support, really based on the ability to show they meet sort of, you know, standard of care or acceptable practice. That is really the upside of shifting to a virtual environment. I think it's been well adapted for patients. Even in the sub population. How do we leverage it as a way of getting better adherence to treatment both from engagement if you missed appointments and obviously, some other things we can add around the sort of live treatment that would really support them. So that is one area we're interested in and we have a couple of providers that provide support that way that we're tracking. And even from a provider point of view, I would be interested to hear, you know, if that works in a population as well. >> I'm looking at some interesting apps of looking at the peer support model. Really, what is ideal is having inter op I think peer support is just right for something to come along and make a really nice app on that. That could then tie into the care team wherever you are. So that is kind of the stuff that I'm looking forward to hearing more about in the coming year. >> I think we'll hand it over to you Kelle. >> Kelle: Great, thank you! I would like to thank you for your questions and the presenters for presenting today and taking the time to answer as many questions as possible. For the ones we weren't able to ask out loud, I would send the questions to the presenters and ask them to respond to you directly via email. I would like to take this time to transfer to our evaluation and ask that you take a few moments to fill this out for us. Thank you again for joining us today! Thank you, SAMHSA, for allowing us to share this information with you today. And enjoy the rest of your afternoon! ................
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