Telemedicine has long been touted as a way of reaching rural corners of this country and elderly shut-ins who have no easy way to get themselves to a doctor’s office, as well as others who just like the convenience of visiting a doctor from home. Telemedicine can be good for discussing symptoms or doing follow up after an in-person procedure where no complications would be expected anyway, yet the main weaknesses of telehealth have always been clear – no lab tests or X-rays, no personal touch, possibly no privacy for the patient if he or she is not home alone at the time. After all, how is a woman, for example, to talk about physical abuse if the husband or boyfriend insists on monitoring the televisit?
But the Covid-19 pandemic has brought a renewed interest in telehealth, especially for mental health therapy. Most such treatment is still “talk therapy,” which can be done online, and assessments can easily be made online or via video connection, at least after a fashion – the therapist asks questions, you answer, and some score is derived according to some rubric.
Throughout the Covid-19 pandemic media reports ceaselessly pointed out that the demand for mental health services far exceeded supply, following a standard media dramatic story line – identify a problem, interview both ordinary citizens in need and experts who concur it’s a big problem, and then point the way to a better, brighter future, albeit while lamenting that we’re not there yet.
That better, brighter future for better mental health? That would be online and video consultations with therapists, or so it’s implied.
But think about this for a moment. If there was a shortage of therapists before the surge in online therapy options, then who are these people we’re willing to call therapists who are suddenly available at the other end of a computer screen? Will a prospective patient or client be connected with a medically trained psychiatrist; a Ph.D. psychologist; or someone with a master’s degree and some sort of certification, perhaps a “social worker” with some advanced accreditation? And how are these people vetted by the companies who advertise on TV, the middlemen who make the therapists available to you? Oh, in almost all cases they will be independent contractors, especially if they work for monthly subscription services.
I do not dispute that people felt anxious and depressed throughout the pandemic, nor that therapy and counseling might be of great benefit to them. I get a daily feed from WebMD that includes various mental health topics, including Depression, and I’ve engaged in my own “bibliotherapy” in the last couple of years, reading well-known authors such as Irvin Yalom, Steven Hayes, and others. Whether one thinks of therapy, reflection, introspection, wisdom or anything else that touches on what we usually think of as our psyche, our soul, or our mood, you can learn a lot from others. As different people have different learning styles, it may be that talk therapy with a credentialed mental health provider is a good thing.
But there are problems with the online mental health therapy model. Many of the people you’ll find via these new online platforms are at the lower end of the training scale, and I doubt the advice they offer will deviate much from the standard slideshow you can get from WebMD. And then there is the problem of reading body language and subtle face expressions. Unless both the provider and patient know how to properly light a room before turning on the camera I suspect such important subtleties will just be lost. I worked with professional photographers in journalism for 25 years and know that it takes real skill, plus pretty good lighting equipment, to make something look right on camera.
I did some checking before writing this post. Among the things I investigated was who takes insurance. Many mental health therapists do not, and this was a glaring problem during the worst of Covid. Why? Well, why accept insurance, which almost always pays less than a provider’s list price, when there are plenty of people who will pay full price. Think about that for a moment. These providers are in the helping professions, yet many, many appear to have changed their business practices to reject any insurance because they knew they could fill their dance cards (as it were) with full-pay clients.
I tried emailing a couple of these new telehealth therapy companies about their policies vis a vis insurance. Here was the response from Talkspace: “We now partner with a number of U.S. health plans to provide online therapy to employees through employee assistance programs (EAP) and behavioral health benefits; go to https://www.talkspace.com/partners to see a full list. We also recommend contacting your benefits department or calling the member services phone number on the back of your insurance card to see if you qualify for this benefit.”
Employee Assistance Programs get the group discount, I guess. But that may just mean employers are channeling staff to online services in lieu of in-person consultations. Other companies? Some accept insurance, some don’t.
You know, there is a difference between regular medicine (for a cold, for a broken bone, for cancer) and mental health therapy. The difference is that in the former we trust that we can count on empirically valid treatments and real expertise, proven technology and reliable test results and so on, while in the latter the most important thing is that the person you’re spilling your guts to really cares, a very old-fashioned model that hasn’t changed much over the years.
Most of the reporting I’ve seen in the last couple of years about the great shortage of mental health providers completely ignored the issue of payment. Psychology Today magazine has a nice portal to identify various local therapists and those who will see people in person and/or “remote,” as well as who takes insurance (you may need a little fiddling with the site to get the results you’re seeking). If you’re on Medicare, though, you can go suck on a fig in most cases – most therapists will not take Medicare. The reason (they’ll almost never tell you why, but some other media outlets have investigated this) is allegedly because of low reimbursement rates. Write you’re Congressman or Congresswoman, I guess, but I think it’s immoral for someone in the medical arts and health professions to not accept Medicare assignment (that means the providers won’t agree to the patient “assigning” the bill to Medicare). Medicare is the major insurance program for elderly Americans, established by Congress decades ago and representing the will of the people, and yet many, many providers won’t accept it for mental health services. What would we think of a Primary Care Physician who said “no” to Medicare?
I’m going to link you to a recent Time Magazine report, “The Online Therapy Bubble is Bursting,” that looked at several mental health therapy providers and their contract employees and/or subcontractors. The reporting team saw a lot of what I saw – limited oversight and/or support for therapists; issues with insurance acceptance; high commissions and/or low reimbursement by the platform for the therapists (that was news to me at first but, ultimately, not a surprise as the investors in the online platforms want to get their profits out as fast as possible); and the tenuous future that these platforms actually face going forward.
No, telehealth for mental health therapy is not likely to be the wave of the future. As soon as demand goes down (i.e., we get past the pandemic, both physically and psychologically) consumers might realize they’re getting a better deal by seeing a therapist in person, and the investors might see their return on investment go so low that they just close up shop anyway. Will this be a loss for the public, a return to limited access for rural populations and elderly shut-ins? There will be pain, I’m sure, people at the margins still by the wayside, but shopping for a therapist cannot be like shopping online for new clothing or a computer or whatever. Telemedicine is not a “product” you can return if it’s no good, and the relationship one might build with a therapist will always be more promising in a live setting than via a badly lit, two-dimensional screen.