Technical requirements and costs
In order to perform telepsychiatry, one needs Internet access, appropriate hardware such as a desktop or laptop computer or tablet, and a video conferencing application. Software must be HIPAA-compliant, although this requirement is not being enforced during the COVID-19 pandemic. Several popular video conferencing platforms were designed for or have versions suitable for telemedicine, including Zoom, Doxy.me, Vidyo, and Skype.
The use of different electronic health record (EHR) systems by various health care systems is a barrier to using telepsychiatry. One potential solution is to use a web portal, such as the one developed by East Carolina University’s North Carolina Statewide Telepsychiatry Program (NC-STeP), which connects hospital EDs and community-based primary care sites with remote psychiatric clinicians, allowing them to share secure electronic health information across different EHRs.27Box 2 provides more details about this program.
Box 2
NC-STeP: A statewide telepsychiatry program
The North Carolina Statewide Telepsychiatry Program (NC-STeP) began in 2013 by providing telepsychiatry services in hospital emergency departments (EDs) to individuals experiencing an acute behavioral health crisis. In 2018, the program expanded to include community-based primary care sites using a “hybrid” collaborative-care model. This model benefits patients by improving access to mental health specialty care; reducing the need for trips to the ED and inpatient admissions, thus decompressing EDs; improving compliance with treatment; reducing delays in care; reducing stigma; and improving continuity of care and follow-up. East Carolina University’s Center for Telepsychiatry and E-Behavioral Health is the home for this program, which is connecting hospital EDs and community-based primary care sites across North Carolina.
NC-STeP provides patients with a faceto-face interaction with a clinician through real-time video conferencing that is facilitated using mobile carts and desktop units. A web portal combines scheduling, electronic medical records, health information exchange functions, and data management systems.
NC-STeP has significantly reduced patient length of stay in EDs, provided cost savings to the health care delivery system through overturned involuntary commitments, improved ED throughout, and reduced patient boarding time; and has achieved high rates of patient, staff, and clinician satisfaction. Highlights of the program include:
- 57 hospitals and 8 communitybased sites in the network (as of January 1, 2020)
- 8 clinical hubs are operational, with 53 consultant clinicians
- 40,573 telepsychiatry assessments (as of January 1, 2020)
- 5,631 involuntary commitments overturned, thus preventing unnecessary hospitalizations representing a saving of $30,407,400 to the state
- Since program inception, >40% of ED patients who received telepsychiatry services were discharged to home
- 32% of the patients served had no insurance coverage
- Currently, the average consult elapsed time (in queue to consult complete) is 3 hours 9 minutes.
For more information about this program, see www.ecu.edu/cs-dhs/ncstep.
Our practice has extensive experience with telepsychiatry (Box 3), and for us, the specific costs associated with providing telepsychiatry services include maintenance of infrastructure and the purchase of hardware (eg, computers, smartphones, tablets), a video conferencing application (some free versions are available), EHR systems, and Internet access.
Box 3
Our practice’s use of telepsychiatry
Our practice (Rural Psychiatry Associates, Grand Forks, North Dakota) and our close associates have provided telepsychiatry services to >200 mental health clinics, hospitals, Native American villages, prisons, and nursing homes, mostly in rural and underserved areas. To provide these services, in addition to physicians, we also utilize nurse practitioners and physician assistants, for whom we provide extensive education, training, and supervision. We also provide education to the staff at the facilities where we provide services.
For nursing homes, we often use what is referred to as a “blended mode,” where we combine telepsychiatry visits with in-person, on-site visits, alternating monthly. In this model, we also typically alternate one physician with one nonphysician clinician at each facility. For continuity of care, the same clinicians service the same facilities. For very distant facilities with only a few patients, only telepsychiatry is utilized. However, initial services are always provided by a physician to establish a relationship, discuss policies and procedures, and evaluate patients face-to-face.
Telepsychiatry is increasingly used for education and mentoring. We have found telepsychiatry to be especially useful when working with psychiatric residents on a realtime basis as they evaluate and treat patients at a different location.
Reimbursement for telepsychiatry
Private insurance reimbursement for treatment delivered via telepsychiatry obviously depends on the specific insurance company. Some facilities, such as nursing homes, hospitals, medical clinics, and correctional facilities, offer lump-sum fees to clinicians for providing contracted services. Some clinicians are providing telepsychiatry as direct-bill or concierge services, which require direct payment from the patient without any reimbursement from insurance.
Medicare Part B covers some telepsychiatry services, but only under certain conditions.28 Previously, reimbursement was limited to services provided to patients who live in rural areas. However, on November 1, 2019, eligibility for telehealth services for Medicare Advantage (MA) recipients was expanded to include patients in both urban and rural locations. Patients covered by MA also can receive telehealth services from their home, instead of having to drive to a Centers for Medicare and Medicaid Services–qualified telehealth service center.
Continue to: Medicaid is the single...