Telehealth continues to play a significant role in the health care industry. However, psychologists who offer both in-person and virtual services are poised to meet increased demand for flexible, accessible mental health care.
In 2020, psychologists responded to the onset of the Covid-19 pandemic by making a nearly universal pivot to telehealth. This rapid and widespread adoption was largely enabled by the federal government’s declaration of a public health emergency (PHE), which prompted several significant policy changes that made telehealth more feasible for both patients and providers.
Yet in the following year, an APA survey found that 50% of psychologists had moved to offering both in-person and virtual services to their patients, up from 30% in 2020. Additionally, Pew Research Center data showed that 25% of adults with low incomes do not own smartphones, and 40% of this group do not have broadband internet or computers at home, signaling significant concerns about telehealth equity.
This means that psychologists should prepare for a hybrid future in which they deliver services via both modalities.
“Telehealth is here to stay. In-person isn’t going away,” said Robin McLeod, PhD, a licensed psychologist and president and chief business development officer at Natalis Psychology in St. Paul, Minnesota. “I believe it is vital for most psychologists to be able and willing to provide both options for patients. It just makes good business sense.”
Meeting demand for telehealth
Like many other providers, those at McLeod’s large practice made a quick pivot to virtual care during the pandemic and now offer hybrid options.
“[Our] providers have returned to providing in-person care, which many of our patients welcomed,” said McLeod. “However, most every provider in our organization continues to provide telehealth services for those clients who prefer that.”
Similarly, Zixuan Wang, PsyD, of Encounter Psychotherapy in Gaithersburg, Maryland, also has a robust hybrid practice. However, prior to spring 2020, she had never seriously considered offering telehealth.
“I am so appreciative that technology has enabled us to provide telehealth services, as they have been proven to be effective and beneficial for so many people who need care,” she said.
Wang and McLeod’s stories are scaled-down versions of the broader narrative of telehealth during the pandemic: Rapid and sustained implementation out of necessity has led to a permanent change.
According to Diane Pedulla, JD, director of regulatory affairs in APA’s Office of Health Care Financing, policy changes at the federal and state levels made it easier for providers to offer telehealth.
“A key factor in providing services to patients across the country has been the flexibilities extended by both public and private payers,” Pedulla said. Many of these flexibilities in service delivery flow from the PHE declaration, which was issued on January 27, 2020, and has been renewed every 90 days since.
For one, the Centers for Medicare and Medicaid Services (CMS) removed restrictions on originating sites, which refers to the location of the patient during a telehealth encounter. Many state regulations and private payers have followed suit, said Deborah Baker, JD, director of legal and regulatory policy in APA’s Office of Legal and State Advocacy.
“Prior to the PHE, the patient was often required to be in a clinical setting, such as an office, skilled nursing facility, or clinic,” Baker said. “Now, many states have followed the lead of CMS and have either removed this restriction or are silent on it, which allows patients to receive care wherever they are, such as at home, work, or school.”
The PHE also gives providers substantial flexibility in the technology they use to deliver telehealth services. Providers currently have temporary flexibility to provide their services via non-public facing platforms like FaceTime, Zoom, and WhatsApp. These popular platforms are not Health Insurance Portability and Accountability Act (HIPAA) compliant, so providers faced penalties for using them to provide telehealth prior to the PHE.
Public and private payers have also allowed telehealth visits using audio-only devices, such as the phone, which is crucial to providing services to people who may not have access to videoconferencing platforms or reliable Wi-Fi, said Pedulla.
CMS has also made telehealth more financially viable for many providers. During the PHE, it has reimbursed providers for telehealth services at federally qualified health centers (FQHCs) and rural health clinics (RHCs), and it has reimbursed all psychologists for telehealth services at the non-facility rate.
“This was a favorable change, as previously telehealth services were reimbursed at the facility rate. Facility rates pay less due to lower practice expense values,” Pedulla explained.
These policy changes enabled psychologists to rapidly meet the demand for telehealth during the pandemic. However, many of these policies are temporary and will end either immediately or shortly after the PHE expires, said Pedulla.
Beyond the public health emergency
The PHE was most recently renewed on July 15, 2022, with an expiration date of October 13, 2022, if not renewed. Telehealth policies incorporated into federal law will strongly impact telehealth delivery for mental health services after the PHE ends, Pedulla said.
A federal appropriations law passed in 2021 extends several telehealth policies for 151 days after the PHE is no longer in effect. For example, patients can continue receiving telehealth services in their own homes, Pedulla said. Additionally, providers at FQHCs and RHCs will continue to be reimbursed for telehealth services during this grace period.
However, continued flexibility to use popular technology platforms that are not HIPAA compliant for telehealth will not be extended.
“[The Department of Health and Human Services] will resume its enforcement when the PHE ends, so psychologists should begin to incorporate technology that is HIPAA compliant into their telehealth practices,” Baker said. “My hope is that they’ve heard that messaging and are making the switch.”
Pedulla said that providers will need to see a patient for an in-person visit within 6 months of an initial telehealth visit and then conduct in-person visits with them at least every 12 months. However, this requirement will not apply until the end of the 151-day grace period after the PHE expires.
Unfortunately, CMS did not adopt an earlier recommendation by APA to permanently continue reimbursing telehealth services at the higher, non-facility rate, Pedulla said. However, APA will continue to advocate on this issue.
The impact of PSYPACT
Irrespective of federal and state policies in response to the pandemic, the Psychology Interjurisdictional Compact, or PSYPACT, is a major force behind increased momentum for telehealth among psychologists. This interstate licensing compact for psychologists facilitates the practice of telepsychology across state boundaries in participating states as well as temporary in-person practice. Introduced by the Association of State and Provincial Psychology Boards (ASPPB) in 2015, the compact became operational in 2020.
“With the increased need for telepsychology services during the pandemic, PSYPACT was viewed by many states to be a solution to increase access to care,” said Janet Orwig, MBA, who is the compact’s executive director.
The pandemic undoubtedly accelerated the expansion of the compact. When the pandemic began, there were 12 PSYPACT states; now, there are 34. Today, according to Orwig, more than 6,300 psychologists are authorized to practice under the compact.
“Member states have expressed gratitude in having additional providers that are available to provide mental health services to their citizens,” said Orwig.
While the PSYPACT map is filling in from coast to coast, some notable states have yet to join, such as California and Florida.
Some states are waiting until the compact has been operational for a certain amount of time before pursuing membership. Other states may have concerns that the licensure requirements of the compact do not align with their own regulations, or that most providers in their state would not be eligible to practice as part of PSYPACT due to the requirement that providers have completed an APA-accredited doctoral program.
Nonetheless, ASPPB “will continue to work with the remaining states in hopes of continuing to increase the PSYPACT member jurisdictions,” Orwig said.
An additional motivator for joining this compact is that PSYPACT is part of a bigger trend toward licensing compacts in health care, particularly since CMS has publicly endorsed them, said Baker.
“While we may struggle to see a silver lining in the pandemic, we can celebrate that CMS has officially sanctioned providers to lawfully deliver services through a recognized compact,” Baker said.
This may lead to increased adoption of telehealth across the health care sector. Orwig said that counselors, audiology and speech language therapists, and occupational therapists have introduced similar interjurisdictional licensing compacts that will enable greater ease of telehealth for those professions.
For this and other reasons, Orwig is optimistic that the eventual expiration of the PHE will not negatively impact PSYPACT’s continued growth.
“From the data we have seen, it seems that consumers of mental health services have appreciated the flexibility that telepsychology offers, so we are hopeful that advocacy for telepsychology and telehealth in general will continue,” she said.
Accessibility, privacy, and other challenges
Telehealth represents increased accessibility for many patients, but it still has equity challenges.
For example, McLeod shared that because her organization serves a large number of patients from immigrant and refugee populations or who have a lower socioeconomic status, they continued to provide some in-person care throughout the pandemic.
“Many of these patients simply did not have access to the technology needed to participate in telehealth services,” said McLeod.
This underscores the importance of providing audio-only options for people without access to videoconferencing services or Wi-Fi, which Pedulla previously noted, though sometimes the phone is not a viable option either. Notably, people with severe mental illness, neurodegenerative conditions, or other disabilities may not be able to receive services via telehealth.
While patients often appreciate the ability to receive services at home, this can also present some issues with privacy.
“Many times, patients had concerns about lack of privacy when receiving telehealth services from their homes—for example, teens with parents who might listen in,” said McLeod.
On the provider side, there are also some drawbacks. Wang said that not being able to see the patient’s whole body language through the screen can add a sense of psychological distance into the relationship.
“Also, you never know how stable the internet connection is. Pixelated images and choppy audio quality can certainly impact therapy progress as it interrupts the flow of the session,” she added.
Both the benefits and the drawbacks of telehealth add up to one clear conclusion: psychologists should remain nimble and equip themselves to offer care in both modalities as the pandemic evolves—and, eventually, ends.
