January 11, 2022, 8:46 a.m. — The SARS-CoV-2 pandemic has been accompanied by a significant rise in mental health problems as well as substance use disorders. At the same time, we have seen a welcome increase in telemedicine access to meet that need as a result of deregulation and increased insurance coverage for this service.
According to the CDC, as of June 2020, 13% of Americans reported having started or increased substance use as a way of coping with stress and related emotions related to COVID-19. Overdoses have also spiked since the onset of the pandemic. The Overdose Detection Mapping Application Program reporting system developed and managed by the Washington/Baltimore High Intensity Drug Trafficking Area shows that the early months of the pandemic saw an 18% increase nationwide in overdoses compared with the same period in 2019. That trend has continued throughout 2020, according to the AMA, which reported in December that the vast majority of U.S. states have seen increases in opioid-related mortality, along with ongoing concerns for those with substance use disorders.
Where I practice family and addiction medicine in rural southwest Missouri, we have seen the dire physical and mental health toll exacted by pandemic-related increases in unemployment, morbidity and mortality, hopelessness, and substance misuse. As of July 2021, our addiction recovery visits were up 53% compared to that point in the prior year, and we had already seen as many unique patients in half a year as we encountered during the entire previous year.
This increased growth in our addiction program has required us to seek the assistance of additional staff to help meet the needs of our patient population. For patients who are not able to make it to our facility for a face-to-face encounter, last year’s regulatory changes have allowed us to treat them via phone call or telemedicine visit. This has been a real game changer because it has enabled us to see patients who otherwise would not have received care.
In the words of my clinic manager, Michelle Kirby, “Telemedicine, with any visit type, greatly improves our patient’s access to care, and they do not have to rely on family, friends, or public transport to have a visit.”
It’s a sentiment our addiction recovery counselor, Dawnielle Robinson, LPC, shares: “There are patients with suspended driver’s licenses that without the telehealth option would otherwise illegally drive to their court- or probation/parole officer-mandated treatment visits, putting themselves and others at risk.
“The availability of telehealth to rural and/or disabled patients also allows them to seek and receive the help they need, which lowers the financial impact on our judicial system and, in turn, saves money for all taxpayers in the long run.”
In a cross-sectional analysis of data from telehealth visits early in the pandemic, CDC researchers found that the number of visits conducted during the first quarter of 2020 was 50% higher than the number conducted during the first three months of 2019. In the last week of March 2020 alone, there was a 154% increase in telehealth visits compared to the same period in 2019. The researchers attributed this rise as most likely being due to a combination of pandemic-related telehealth policy changes and need-driven public health guidance.
Similarly, a national study of outpatient care delivery and telemedicine trends conducted from Jan. 1 through June 16, 2020, found that weekly rates for telemedicine visits increased during the overall pandemic period, peaking in the week of April 15 before declining by the week of June 10.
Specifically, among 16,740,365 individuals with commercial or Medicare Advantage insurance included in the study, weekly telemedicine visit rates rose from 0.8 to 17.8 visits per 1,000 enrollees between Jan. 1 and June 16 — an overall increase of 2,013%. During the same period, the number of in-person visits dropped from 102.7 to 76.3 per 1,000 enrollees (−30.0%), while the number of total visits (telemedicine and in-person visits combined) decreased from 103.5 to 94.1 (−9.1%).
The researchers also examined geographic variation in the percentage of total visits delivered via telemedicine and the percentage change from baseline in total visit rates during the final four weeks of the study (May 20 through June 16). They found wide geographic variation in the percentage of visits delivered by telemedicine (from 8.4% in South Dakota to 47.6% in Massachusetts) and the percentage change from baseline in total visit rates (from −73.2% in Hawaii to −16.0% in Alaska).
Overall, growth in telemedicine use among those enrolled in this study offset roughly two-thirds of the decline in in-person visit volume during the first several months of the COVID-19 pandemic. Although geographic variation in the magnitude of changes was observed, every state experienced a drop in total visits, illustrating the broad scope of deferred care seen during this period. Despite the likelihood that some of this deferred care represented discretionary care that could be postponed without harm, these results substantiate concerns that patients may fall behind in chronic illness management or face complications from deferred acute medical issues.
It’s worth noting that an important limitation of this study is that results may not generalize to other populations (e.g., traditional Medicare or Medicaid beneficiaries).
My nurse practitioner, Kelly Watson N.P.-C, who sees the majority of patients in our addiction recovery clinic, readily acknowledges that telehealth is most appropriately used as an adjunct to in-person care.
“Typically, the telehealth option is used in our clinic when a face-to-face visit is not possible,” she notes. “With very few exceptions, I insist on seeing the patient in the clinic at least every three months. It is important to observe behavior, do a drug/alcohol screen, and do a more thorough assessment every few months.”
According to Watson, the “pros” of providing telehealth services include
Telehealth/phone access to care can be a lifeline for patients who otherwise may struggle to access services, she adds. Among the common barriers we see in our clinic are
To illustrate her point, Watson tells the story of a patient in our clinic who was taking care of her elderly mother, who was ill with dementia:
“She was unable to come to the clinic because it was unsafe to leave her mother by herself. She was able to do phone visits and was compliant to do so every month for follow-up. The patient told me that she looked forward to our monthly visits by phone. She was so thankful to have an opportunity to continue her treatment for opioid use disorder even with the responsibility of caring for her mother.”
In a Nov. 10, 2021, commentary in The Hill titled “Telehealth was a godsend during the pandemic; Congress should keep the innovation going,” opinion contributors Charlie Katebi and Arielle Kane offer insight into an evolving telehealth landscape in which prepandemic federal restrictions on providing these services have — for the time being — been relaxed.
“Lawmakers enacted these restrictions because they feared making telehealth widely accessible would lead to patients using unnecessary health care services,” the authors explain. “Many private insurers followed Medicare’s lead and similarly limited access to many telehealth services.”
That all changed with the advent of the coronavirus emergency, they note. With large sectors of the economy shut down and families forced to stay home to reduce the spread of infection, “state and federal lawmakers dropped those objections, rightly concluding that telehealth would help people access care during the emergency.”
HHS used its emergency powers to temporarily suspend various regulations, allowing Medicare recipients to access care remotely. Officials in all 50 states followed that example, expanding access to virtual care for people covered by private insurance.
The result has been an unequivocal success, say Katabi and Kane.
“Telehealth has proven a godsend for millions of Americans. It helped us navigate the treacherous months of the pandemic and brought millions safety and security,” they contend. “But when the COVID-19 crisis is officially declared over, the restrictions will snap back into place.
“To meet the needs of those patients now, and to ensure we are better prepared when the next emergency hits, Congress and state lawmakers should not let that happen.”
I couldn’t agree more, and as of this editorial’s publication date, Congress and CMS had temporarily extended telemedicine access until the end of calendar year 2023. Although this is a promising start, more needs to be done to make sure patients continue to have unrestricted remote access to their health care professionals after these provisions expire.
Kurt Bravata, M.D., is a family physician who practices primary care, geriatric medicine and addiction recovery in rural southwest Missouri.