Virtual Behavioral Health Care: Let’s Not Forget the Lessons We’ve Learned

Disclosure: I am the founder and owner of Animo Sano Psychiatry, a hybrid virtual and in-person behavioral health group practice. I am also an advisor at Holmusk, a digital health organization aiming to improve the utilization of real-world evidence in research.

The past two years have been a whirlwind for everyone and certainly for the behavioral health world. Initial COVID-related public health risks led to the rapid adoption of telehealth care across multiple specialties, and the changes were most definitely felt in the world of behavioral health.

While many people and practices have begun shifting back to in-person care, the behavioral health industry continues to firmly utilize the virtual medium for care evaluations, which is unsurprising. Some can and do argue that the change from the in-person to the virtual medium does not impact behavioral health [cite]. In fact, my own experience has been that virtual evaluations present their own benefits.

As a provider who operates in a specialty that leverages the mental status exam, I find myself now benefiting from being able to extend that exam to the patients’ home environment (perhaps we will even adopt “environment” as a new MSE component). Furthermore, as a provider, I have been impressed by the extent of the impact this change has had on many of my patients. They no longer have to take half or full days off from school or work; instead, they can simply request an hour to step into a private space for their clinical visit.

Additionally, patients in towns with no behavioral health care presence can now see a provider without driving up to four hours to do so, and geography is no longer a barrier to patients being able to switch between providers. To me, the benefits of virtual behavioral health care are clear. Unfortunately, however, significant challenges remain in this space.

At the start of the pandemic, several drivers came together that eventually led us to successfully implement good telehealth care. Obviously, we needed to minimize person-to-person contact, which led us to adopt (and necessitated that we educate ourselves about) telehealth platforms. Moreover, the public health emergency (PHE) waivers lifted restrictive regulations, and new technology permitted a care medium frameshift. While the technology has improved, even more, making virtual care more accessible than ever, and stakeholders are now comfortable enough with telehealth to have cleared the “learning curve” hurdle, many of us are still holding our breath regarding regulation.

Most relevant to us at Animo Sano, given the large volume of patients we see for ADHD, is the role of the Ryan Haight Act as it relates to prescribing scheduled substances (in this case stimulants). I recall a late 2020 discussion around this topic being a non sequitur of sorts. Everyone believed that with the clear evidence demonstrating telehealth’s benefits, the Ryan Haight Act and restrictive CMS billing regulations would undoubtedly be addressed to promote telehealth care by the end of the PHE.

Nevertheless, here we are approaching what is likely one of the last PHE extensions, and the DEA has remained silent on the Act’s future as it pertains to telehealth.

Is their silence definitive proof that we should expect no change? Or should we expect change? We don’t know. The DEA and Administrator Milgram have reserved commenting on this topic. They’ve addressed the Act’s current language but not whether we should expect change or status quo, post PHE.

Therefore, those of us who understand the impact this Act has on telehealth care are collectively holding our breath and asking ourselves the questions: What’s next? What will we do for patient care? What will we do for clinical operations?

At Animo Sano, we have worked out an organizational plan to address the DEA’s requirement for a patient to be seen in person and transition back to virtual care, though frankly, it feels arbitrary and unnecessary. The plan is a reaction to regulation and not for the purpose of advancing our patients’ care, which I strongly believe is among the best behavioral healthcare a patient can receive in this state.

Of course, I don’t want to convey that I live in a vacuum absent of news relating to some of the virtual behavioral health organizations in this space. As those of you who have read this far are likely aware, virtual management of stimulant medication has come under fire recently. Certain reports state that some patients may have taken advantage of organizational disorganization to set up multiple accounts in order to pursue treatment and that some companies may have employed unlicensed providers for patient management. Both are deeply concerning allegations, though in my opinion, they should not forestall regulatory change around telehealth.

Patients who create multiple accounts to receive stimulant treatment are, in essence, “doctor shopping,” as they do in person. Frankly, even in such instances, requiring patients to show ID prior to clinical visits and medication dispensation (which is best practice whether the patient is being seen in person or virtually) should alleviate this concern. In fact, the drive toward virtual care promises to grow the resources that can address such issues. For instance, can we not incorporate a facial recognition model that identifies discrepancies between patient ID and the presenting patient at the time of visit?

The second issue—employment of unlicensed care providers—is an abhorrent practice that does not relate to the virtual nature of health care, but to organizational ethics. The reaction, then, should not be to restrict a patient’s access to care by retaining outdated regulation but to address organizational malpractice concerns whether the organization is virtual or not. Excellent clinical care IS being given virtually, and that’s a fact. We do it here at Animo Sano, and I know colleagues who are doing it elsewhere.

Before I make my appeals, I want to address one final element for anyone concerned that stimulant prescriptions have been soaring since the industry shift to telehealth.

You’re right; evidence strongly suggests that stimulant prescriptions are on the rise, but I would suggest that the upsurge is to be expected, given 1) the improved access to care, and 2) the nature of ADHD.

First, because telehealth has increased access to care, the world of behavioral health has seen a massive upturn in clinical volume. The reasons for that volume increase are beyond the scope of this opinion piece, but it’s reasonable to assume that when more patients participate in care, their involvement invariably leads to increased recognition and management of underlying illnesses.

Second, patients with ADHD generally do well with environmental agents that promote accountability. For students, that means teacher oversight; for working adults, it could look like the boss sitting in the office next to your cubicle. What happens, then, when those agents are no longer present? Influenced by their time blindness and the lack of accountability, ADHD patient procrastinates, loses focus, is distracted, and suffers. They’re not lazy or unmotivated; countless patients have sat in session with me, in tears about their desire to get things done. In many of these cases, the loss of an accountability agent was the straw that broke the camel’s back for them.

That loss took them from being able to get by despite their symptoms to failing, losing their jobs, or being under remarkable stress due to mounting responsibilities over which they had lost control. Why, then, have we seen increased prescription rates? Clearly, the numbers are a result of the ADHD sufferers out there who had previously found a way to get by and are no longer able to do so, and because those who didn’t have access to care are now able to get it.

To the public and behavioral health advocates:

I welcome your feedback, as long as it is positive and/or constructive. I also ask that you message your congressmen/women and appeal to Administrator Milgram to address this matter. We are coming to the end of the PHE, and I am afraid that we’re about to take a massive shift back in care as opposed to moving forward with the valuable lessons we’ve learned over the past two years.

To administrator Milgram:

I can only assume that this topic already has a major presence on your list of items to address and that an appeal from a provider at a small group practice is but a drop in the bucket. Still, I would like to throw my request in with the 70+ healthcare organizations and congressmen/women who have already made their appeals. My unwavering opinion (based on the evidence I would be happy to share) is that great behavioral healthcare can be practiced as effectively in the virtual medium as it can in person.  I also strongly believe that restrictions around the utilization of scheduled substances and the current Ryan Haight related in-person visit requirements can only hurt patient care.

I ask that you work with Congress to identify and communicate a clear plan for us, post PHE. Patient care has already begun to suffer because of the lack of clarity around what tomorrow will look like regarding this matter. If restrictions around patient management are not lifted, then I, like many others, implore we be given the option of a special registration process, as Congress has requested in 2018.