Using Telehealth to Support Opioid Use Disorder Treatment Issue Brief

11/01/2018

Laura Dunlap, Saira Haque, and Erin Mallonee
RTI International

Joel Dubenitz, Laurel Fuller, and Daniel Schwartz
U.S. Department of Health and Human Services

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ABSTRACT

This Issue Brief was informed by an ASPE-funded study conducted by RTI International that assessed the use of telehealth to identify and manage SUDs in rural areas. The final research brief included an environmental scan and site visits with participants that represented a wide range of telehealth experiences throughout the country.

DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization.


 

The opioid epidemic has increased demand for behavioral health services and exacerbated the behavioral health workforce shortage, which disproportionately burdens rural and underserved areas. Reasons for access limitations may include lack of specialty substance use disorder (SUD) treatment providers and lack of primary care physicians (PCPs) with experience in behavioral health treatment. In addition, privacy and stigma concerns remain pervasive.

Telehealth can connect geographically dispersed patients and providers and is a promising approach to expand access and enhance quality of Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD).

"If you read about the [opioid] epidemic, every national and state organization talks about improving access. I think telehealth is a simple way to do it... Also, you can use it to train and do consultations with physicians that may not feel as comfortable with [MAT]. That's huge for expanding access." ~ Physician Discussant

 

Key Findings

Financing and sustainability influence which services organizations chose to implement. One of the key challenges of using telehealth noted by discussants is financing for ongoing delivery and sustainability. As shown in Table 1, Medicare covers services related to assessment, diagnosis, and brief interventions, but limits eligible originating sites to those located outside of a Metropolitan Statistical Area or within a rural Health Professional Shortage Area (HPSA) in a rural census track.[1][a]

Forty-eight states and the District of Columbia (DC) allow for reimbursement of some behavioral health services delivered via telehealth through Medicaid. Each state has its own unique set of requirements around the types of services, locations, and settings that are eligible. Twenty-three states and DC require private insurers to have full parity between their coverage of telehealth and in-person services.[2] Yet, although telehealth may be covered, reimbursement rates may be lower than similar services provided in person to the patient.[3]

TABLE 1. Reimbursement for Telehealth Services, by Payer Type
Payer Reimburses for Types of Behavioral Health Services Covered Requirements
Telehealth? Medical/Surgical Services via Telehealth? Behavioral Health via Telehealth?
Medicare Yes Yes Yes Included: Mental health services, medication management, SUD assessment, diagnosis, and brief interventions

Excluded: Psychiatric diagnostic interviews or medical evaluation/ management services

Originating site in rural HPSA; limitations on eligible providers
Medicaid Yes; in 48 states and DC (excludes CT and RI) Yes; in 48 states and DC (excludes CT and RI) Yes; in 48 states and DC (excludes CT and RI) No noted specific inclusions or exclusions 24 states and DC have no restric-tions on location and setting; 15 of these states also place no restrictions on the type of provider
Private payer Dependent on payer Dependent on payer Dependent on payer Dependent on payer 23 states and DC require private payers to have full parity with respect to telehealth services

 

Implications for MAT: Financing and Sustainability
  • Use of telehealth to provide MAT has lagged behind use of telehealth to provide other behavioral health services. Specific expansion of MAT could leverage the existing behavioral telehealth infrastructure.
  • Discussants noted that renegotiations of existing private payer contracts with providers could include modifications to billing codes to support telehealth services, including MAT to address challenges.
  • To incentivize quality telehealth MAT services, providers emphasized that value-based purchasing approaches could be considered as an alternative to fee-for-service reimbursement.

Telehealth is used to facilitate a variety of provider-to-patient and provider-to-provider interactions. Provider-to-patient interactions include real-time live video, remote monitoring, and store and forward (asynchronous) communication. Examples of provider-to-patient use of telehealth include clinical appointments, group therapy sessions, follow-up care, and monitoring. Provider-to-provider interactions included education and consultation. One provider-to-provider program is Project ECHO's (Extension for Community Healthcare Outcomes) Opioid Addiction Treatment (OAT) program, which connects PCPs with specialists to review and discuss de-identified cases, obtain OUD treatment training(including management of naloxone/buprenorphine and injectable naltrexone) and access tools and resources.

Implications for MAT: Use Cases
  • Successful use of live video for other behavioral health services suggests that these telehealth services should be transferrable to MAT with appropriate training and implementation planning.
  • Existing education approaches such as Project ECHO's OAT could be leveraged and expanded to reach target clinicians such as PCPs and integrated care teams.
  • Provider-to-provider communication may assist PCPs in guiding patients through MAT. Consultations with specialists can increase PCPs' competency or confidence, allowing them to progressively handle more complex cases or practice MAT without frequent consultation.

Organizations vary in how they implement telehealth services. Advance planning is essential to both technical and non-technical aspects of the process. Many organizations extensively planned the technical infrastructure to minimize the start-up costs of telehealth (e.g., videoconferencing equipment, increased Internet bandwidth, electronic health records software) by considering the availability of existing technology and seeking grants or demonstration programs to fund new technology. Non-technical aspects of planning include integrating telehealth into the workflow of organizations, ensuring sufficient trained staffing, and planning for things that might go wrong. This involves staff time for coordinating telehealth services and for providing training, troubleshooting, and technical support. Some sites enhanced the telehealth experience by incorporating tele-presenters--health care professionals at the originating site who may remain in the exam room with patients during their telehealth sessions and provide support.

Implications for MAT: Implementation
  • Telehealth requires a robust technological infrastructure, including sufficient Internet bandwidth to support each element.
  • Organizations were able to minimize costs by extensively planning the technological infrastructure, using existing technology, and seeking grant or demonstration program funding to subsidize their start-up costs.
  • Planning for workflow integration and staff training are integral to successful implementation.

 

Conclusion

The findings from this study suggest that use of telehealth can greatly improve access to and delivery of behavioral health services, including MAT, but this full potential has not yet been realized. Several barriers to broader use of telehealth remain, including technological requirements (e.g., interoperability, standards), funding mechanisms, and workforce licensing and training needs.[4,5,6,7] Overall, results from this study show that policies and innovative programs are successfully addressing some of these challenges, but more needs to be done to understand the opportunities and barriers for telehealth in behavioral health. Moreover, further evaluation should be conducted to measure the impacts of existing telehealth services and programs on behavioral health.

 

References

  1. Medicare Learning Network. Telehealth services: Rural health services [Internet]. Centers for Medicare & Medicaid Services; 2016 [cited 19 July 2018]. Available from: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf.

  2. Thomas L, Capistrant G. State Telemedicine Gaps Analysis: Coverage & Reimbursement. Arlington (VA): American Telemedicine Association; May 2015 [cited 19 July 2018]. Available from: http://cdn2.hubspot.net/hubfs/1775981/omada-pdf/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?t=1461875181706.

  3. Campbell ANC, Miele GM, Nunes EV, McCrimmon S, Ghitza UE. Web-based, psychosocial treatment for substance use disorders in community treatment settings. Psychol Serv. May 2012; 9(2).

  4. Hilty DM, Cobb HC, Neufeld JD, Bourgeois JA, Yellowlees PM. Telepsychiatry reduces geographic physician disparity in rural settings, but is it financially feasible because of reimbursement? Psychiatr Clin North Am [Internet]. Mar 2008 [cited 16 July 2018]; 31(1):85-94. Available from: https://www.sciencedirect.com/science/article/pii/S0193953X07001219?via%3Dihub.

  5. Larsen ME, Farmer A, Weaver A, Young A, Tarassenko L. Mobile Health for Drug Dose Optimization [Internet]. 2011 Annual International Conference of the IEEE Engineering in Medicine and Biology Society; 1 Dec 2011 [cited 16 July 2018]. Available from: https://ieeexplore.ieee.org/document/6090449/.

  6. Benavides-Vaello S, Strode A, Sheeran BC. Using technology in the delivery of mental health and substance abuse treatment in rural communities: A review. J Behav Health Serv Res [Internet]. Jan 2013 [cited 16 July 2018]; 40(1):111-120. Available from: https://link.springer.com/article/10.1007%2Fs11414-012-9299-6.

  7. Report to Congress: E-health and telemedicine [Internet]. Office of the Assistant Secretary for Planning and Evaluation; 12 Aug 2016 [cited 16 July 2018]. Available from: https://aspe.hhs.gov/pdf-report/report-congress-e-health-and-telemedicine.

 

NOTES

  1. This study was conducted prior to the passage of the SUPPORT for Patients and Communities (P.L. 115-271), which eliminates certain Medicare originating site requirements for the treatment SUD and co-occurring mental disorders (Section 2001).

 


USING TELEHEALTH TO IDENTIFY AND MANAGE MENTAL HEALTH AND SUBSTANCE USE DISORDER CONDITIONS IN RURAL AREAS

This report was prepared under contract #HHSP233201600021I between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Research Triangle Institute. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officers, Joel Dubenitz and Laurel Fuller, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201; Joel.Dubenitz@hhs.gov, Laurel.Fuller@hhs.gov.

Reports Available

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Using Telehealth to Support Opioid Use Disorder Treatment Issue Brief