John Peloquin, PhD, MBA, is president and CEO of Discovery Behavioral Health treatment centers for mental health, substance use and eating disorders.
Over the past two years, we’ve witnessed a tumultuous shift in behavioral health care — including mental illness treatment and substance use — that no one could have predicted. The ongoing tragedy of the Covid-19 pandemic has set in motion an unparalleled real-time experiment in the effectiveness of telehealth. It also provided a glimpse of what healthcare will look like in the next decade.
But first, let’s go back to the start of the pandemic in 2020. When doctor’s offices across the country were closed for fear of spreading the infection, the federal government decided to rethink its drug policy, requiring patients to go through a prescription before a prescription. doctors had to be examined would be issued. Under the circumstances, of course, that was not possible.
So the rule was suspended† No longer would potentially addictive drugs, including amphetamines such as Adderall and benzodiazepines, such as Xanax, Ativan, Valium and Klonopin, require a personal visit. Each of these drugs is highly effective in the short term, but has enormous potential for abuse without medical supervision.
Dispensing drugs without direct medical supervision… what could go wrong? Needless to say, enough, but more on that later.
On the bright side, the meteoric rise of telehealth during the pandemic has given Americans unprecedented access to mental health care that was previously difficult or impossible to obtain due to a lack of insurance, geography, or family and work commitments. Unfortunately, it has also opened the door to the possibility of another addiction crisis.
Opioid Crisis, Redux
It may seem like another century, but just three years ago, America’s biggest health problem was the opioid crisis, which ravaged large swathes of America, regardless of age, income, race, ethnicity, or geography. For the first time, the average lifespan of American adults was shorter than that of their parents, what sociologists called “die of despair”, and was fueled by addiction to legal and illegal opioid painkillers.
The opioid crisis has not gone away; it was just overshadowed by the Covid-19 pandemic. To be clear, according to the Centers for Disease Control and Prevention’s latest statsIn 2021, more Americans died from drug overdoses than ever before. There were more than 100,000 drug overdose deaths, up 28.5% from 2020.
Despite this grim backdrop, too many venture capitalists viewed the pandemic as just another opportunity to monetize telehealth apps. I noticed that many of these apps overprescribed drugs at the expense of the necessary but time-consuming work of counseling. The economy of scale model may work for taxi transportation, food delivery, or vacation rentals, but behavioral health is a very different proposition. The same “fake it till you make” mantra falls short when dealing with individuals’ mental well-being.
Unsurprisingly, the rapid growth of telehealth in the past two years attracted the attention of the federal police because of possible violations of the Controlled Substances Act.
The Ministry of Justice now has a formal inquiry and will stop prescribing Adderall by telehealth companies. Whistleblowers are starting to surface with accusations of telehealth managers putting profits for patient health.
Suddenly this all sounds eerily familiar.
The future of telehealth
So, where does telehealth fit into the future of healthcare?
Telehealth is a tool in the patient care toolbox that is of immense value. However, one thing is certain after the unintended experiment of the past two years: telehealth is not the all-encompassing answer to the problems that persist in the national health care system. Still, it plays an important role in the post-pandemic era, although the picture is still foggy.
In 2022, as we move to a more mixed model of telecare and in-person visits, there will be many questions to be answered. How do we know when to switch a patient’s care from telecare to inpatient treatment? How do we monitor remote audit quality? How many patients are too many for a telehealth provider? And who determines the answers to these questions?
A recent NIH study sheds new light on the phenomenon of telecare and answers one question about the effectiveness of telecare. The study looked at the cancellation rate of counseling sessions as a measure of the effectiveness of telecare. The number of cancellations dropped dramatically during the pandemic, when telehealth was the only option available. It appears that telecare improves adherence by removing some of the obstacles patients encounter when making in-person visits, such as transportation, childcare and other logistical barriers. However, it is also critical to consider that the decline in cancellations may be related to the increased need for behavioral health services during the Covid-19 pandemic.
Towards behavioral health integration
Rather than seeing the future of behavioral health as a choice between mental telecare and clinical care, the focus should be on integrating the two. Telehealth can play a valuable role in providing basic access for everyone who needs care. It’s the doctor’s office that never closes, with informed, fact-based advice from qualified medical professionals such as nurses, physician assistants, and trained therapists.
Telehealth’s reliance on technology is both an advantage and a disadvantage. Technology is fast, efficient and elegantly uniform. It may help reduce some of the unintended variability and even errors in patient care, the kind of unintended consequences described in the popular new book Noise: An Error in Human Judgment†
Telehealth cannot replace the level of care that clinical visits alone can provide. And while human judgment is inherently imperfect, technology has its own flaws. Algorithms can eliminate human-directed variability, but they can produce their own biases or systemic errors that produce negative results. Also, not everyone in our country has access to fast internet or devices with smartphones, which limits the effectiveness of telecare.
The future of behavioral health care is not telecare versus clinical visits. An integrated model that combines technology and personal care can offer the best of both worlds.