Anna Whites, Owner, Anna Whites Law Office, speaks to Ty Borders, Professor at the University of Kentucky College of Nursing and Director of the University’s Rural Health Research Center, about the status of telebehavioral health and telemedicine in rural areas. They discuss how the expansion of telehealth may impact rural health care, prospects for continued use of expanded telehealth in rural areas, and current challenges related to mental health services. From AHLA’s Behavioral Health Task Force.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Anna Whites, Owner, Anna Whites Law Office, speaks to Ty Borders, Professor at the University of Kentucky College of Nursing and Director of the University’s Rural Health Research Center, about the status of telebehavioral health and telemedicine in rural areas. They discuss how the expansion of telehealth may impact rural health care, prospects for continued use of expanded telehealth in rural areas, and current challenges related to mental health services. From AHLA’s Behavioral Health Task Force.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Good morning. I'm Anna Whites. I am programming co-chair for the American Health Law Association's Behavioral Health Task Force. I'm a sole practitioner in our teeny weeny state capital of Frankfurt, Kentucky, and a huge rural health advocate and telehealth nerd. I'm here today to talk about rural healthcare and the state of the state and the nation with an expert from the University of Kentucky. Uh, Ty, would you like to introduce yourself?
Speaker 2:Yes, thanks, Anna. Yes. I'm a professor in the, actually in the College of Nursing at the University of Kentucky, although I've spent most of my career in the College of Public Health. And I'm also director of our federally funded rural health research center, which is only one of seven such centers nationally. And at a tour, the Journaler of Rural Health, which is sponsored by the, uh, national Rural Health Association.
Speaker 1:Well, it's great to have you. And I know even, um, before I knew of you, my co-chair and I were Googling Rural Health and you are a national expert, so we were excited to have somebody from right here at home. Sure. Um, let's jump right into it. What is the current status of rural health, particularly tele behavioral health and telemedicine, uh, today? Broad topic?
Speaker 2:Yes. Is it, it is a bit of a broad topic, um, in terms of the state of overall behavioral health, and if we think about this in terms of mental health services and also substance abuse treatment services, which I would put under this umbrella, the state of, um, rural of, of, of mental health and, and rural areas. It probably hasn't changed a lot over the past, you know, several decades except in terms of this rapid expansion of telemedicine and telehealth services that we've experienced as a result of the pandemic. And the reason I say there hasn't been a lot of change is that if we think about access to mental health services and substance abuse treatment services, accessibility remains a problem in many rural areas as well as in many urban areas. And perhaps we can talk more about this today in terms of telehealth, telehealth, um, has really in some ways made it easier for people in rural as well as urban areas to make contact with the healthcare system if they can just do this over their, their, their phone, their smartphone, and so forth. On the other hand, we need to make sure that we have an adequate availability of mental health services providers, and they need to be, they need to be located someplace. So if they're not located in a rural area, there needs to be an adequate availability in an urban area. And I'm not really sure that we have an adequate overall availability of mental health services providers to really maximize the effectiveness of telehealth services.
Speaker 1:And, um, I know when I deal with clients in small towns, and I have a lot of rural clients, a big concern, uh, is just that with those providers, they say, yeah, I have a lot of patients who could benefit from behavioral health, mental health, substance abuse treatment, but I don't know how to access that or where to find it. Um, I know on the state advisory committee and on the national level, we're trying to map telehealth and behavioral health providers, but, um, that looks like a big slow project. And so, um, what can we do locally or what are you seeing folks do to help expand that, um, knowledge of what the care is out there?
Speaker 2:Well, you, you raise one point in terms of, you know, many persons accessing the medical care system, um, in rural areas when they have mental health problems or substance use problems. And if we think about primary care, including family medicine or general internal medicine, um, multiple health problems such as depression, anxiety, as well as, um, alcohol use disorder and drug use disorders are among the more common, um, problems that persons, uh, visit primary care for. However, the reality is that many primary care professionals, whether they're physicians or a nurse practitioners or physician assistants, they don't receive a lot of education and training on how to diagnose and treat persons with mental health and substance use disorders. Um, now it has gotten better over time. Um, if we think about depression over the last 20 years, there's been a lot of effort to improve the quality of, um, care for depression. But if we look at things like alcohol use disorders and drug use disorders, it, it really has lagged behind with the exception of opioid use disorder. And the, the diff the, the difference with opioid use disorder is that there is a medication to treat it. Unlike for, for many other substance use disorders, there are no medications available for, for treatment. So then persons have, you know, per healthcare professionals have to think about where they would refer persons to for mental health services, such as from a psychologist or a social worker or a psychiatrist, or perhaps to an outpatient or residential, um, substance use treatment facility for, um, drug use disorders. And there's a shortage of those types of, um, services in rural areas as well as urban areas. And I, another thing I would, one of the reasons I'm bringing up urban areas is that, um, rural and urban healthcare systems are not totally distinct. They have to work together many times. Um, there are rural hospitals or affiliated urban hospitals and, and, and clinics and so forth. And the other fact is that many people who love rural areas go to urban areas for care, whether they drive there or, you know, these days, they may able to, um, receive services via telehealth, um, when, when virtually accessing an urban based healthcare professional.
Speaker 1:And I know when my husband's grandma who lived in a town of about 5,000 people, was very ill with cardiac and C O P D, we had to drive her from Louisa to Lexington, which is two and a half hours, three hours to see a doctor. So it was an all day event and very stressful for her. And I'm sure for us too, how is rural health and, um, more remote areas in the urban, uh, setting, because we look at some of these big hospitals and many of them are not an easy bus ride from a lot of our urban population. So how is telemedicine enhanced care for people in those areas, those accessibility struggling areas mm-hmm.
Speaker 2:<affirmative>? Well, if, if, if we think about telehealth, you know, very generally, um, we don't have a lot of information yet about what has transpired in terms of the expansion of it as, as really the result of, of the pan pandemic. If, if there's any positive effect of the, um, COVID 19 pandemic. It has been that it really forced the, um, federal government and ensures to relax their, um, restrictions on telehealth and, and, and, and in terms of reimbursement. And, you know, all of us, I'm sure, have in some way visited some sort of healthcare professional in the past year and a half and have done so via telehealth visit. And, you know, I think that for many decades there was this, um, reluctance to, um, or there were these barriers to telehealth as such as concerns about privacy. Well, um, we figured this out pretty quickly. Um, and there was concerns about, you know, how persons needed to go to a, an actual clinic location in a rural area or a nursing home in a rural area, and then link to an urban based, um, clinic or hospital, et cetera. We, we don't have to do that. We can do that via our, via our smartphone. So the technology costs, um, have, are, are really much lower than they, than they were, you know, just a few years ago because again, we rapidly have recognized and been forced to adapt to, um, to telehealth services. Now, how well healthcare professionals and patients have adapted to this and how has affect has, has affected their treatment and their outcomes? I, I think we just don't have information about yet in terms of, you know, overall, um, telehealth over the past year or year and a half, as I mentioned, in terms of telepsychiatry, you know, this has been around for much longer and, um, has been shown to be very efficacious and effective. And Telepsychiatry has been more widely adopted for, for, for many years than other types of, um, health services, including, um, I mentioned opioid use disorder. We know very little about how telehealth is being used for the treatment of opioid use disorder.
Speaker 1:Among my clients, and I have a number who treat, um, clinics who treat opiate use disorder inpatient and outpatient. And they're big, big concern had been how to get patients to feel comfortable because there's a big stigma in admitting I'm an addict and seeking treatment. And in a rural area, we had found that, um, particularly for your doctor's, lawyers, teachers, preachers, those folks had a huge reluctance to go for treatment, whether it was psychiatric or addiction, because people would see you, um, even if you said, oh, I'm just visiting Dr. Bob, he's my friend, people would assume you were going for mental health care. And so, uh, you know, that that group of individuals with social standing and, and the position of responsibility in the community were afraid to access the care they needed. So we've seen in Kentucky, just in our limited practices, a great increase in people who feel comfortable seeking treatment because it's more, um, publicly anonymous. Has that been the case, do you think, across the nation?
Speaker 2:Probably. I don't like, like I said, I don't think we know for sure in terms of, you know, there hasn't been enough time to do research on these issues, but I think that that would make sense that, um, and not just in rural areas, but also urban areas, um, I, I think there's sort of this, this perception that rural, this stigma stigma is greater than in rural and urban areas. But I'm not so sure that's the case, um, because many persons who reside in urban areas also have some concerns about confidentiality and, and, and, and anonym being anonymous when they go visit a, um, you know, a, a a healthcare professional for, well, for, for a variety of reasons. But I do think it makes sense that telehealth has made perhaps in some ways the, um, healthcare professional inpatient interaction, um, better in terms of persons being more comfortable talking about things. And, um, and that's something that we, I think we need to further explore.
Speaker 1:Uh, something that I've noticed in Kentucky, and I presume it's in all states that have the rural health designation, is that prior to Covid, prior to the pandemic, a lot of those organizations were forbidden by their reimbursement structure to use telehealth, except in very limited, um, circumstances. And obviously with the pandemic that was expanded. And I've seen my primary care docs who used to be very resistant to broad telehealth, um, fearing that it would make their offices empty or that they couldn't effectively treat the primary care patients if telehealth was an option, really, to me, seemed to be on board. And I don't know if that's just the empirical, I'm just hearing that because I have a narrow spectrum, but, um, what's your impression and the center's impression moving forward on hoping that rural health entities, the RHCs, get to continue to use this expanded telehealth? Mm-hmm.
Speaker 2:<affirmative>, that's a good question. And I would, I'm hopeful that, um, rural clinics and clinics overall and, you know, primary care professionals will continue to, um, offer telehealth services. My, my my my assumption is that, um, for some time that many healthcare organizations were a bit reluctant to offer telehealth services because of lower reimbursement rates. However, my hunch is that what has really occurred is that it, this is enabled, um, clinics and healthcare professionals to be more productive, that they're actually able to, um, have visits virtual visits with more patients than they were able to before. And this productivity, um, probably has made up for any, um, reduction in the payment per visit. In other words, they're, they're, they're, they're likely more visits that are occurring under telehealth. So this is something that we need to further explore also. But I am a bit concerned because, you know, who knows behind the scenes now, what different types of organizations and advocacy groups are lobbying against telehealth, um, because they simply want to go, you know, revert to the, the, the pre pandemic area of in-person visits and so forth, which may have higher reimbursement from rates.
Speaker 1:And in Kentucky, we have been very firm, even in the Medicaid system, um, with payment parity. And so we have said, you're gonna pay the same whether that provider sees you via, via your smartphone or in her o own office. And the rationale behind that was really, if we allow differential reimbursement, then there are going to be some providers who simply can't afford to keep their office open if they're seeing the same number of patients. But those patients are all via telehealth. The provider still has to have an office, still has to have EMR staff, uh, records a lab, um, they still have the same overhead essentially. And if there's a lower reimbursement, some providers who are doing limited business may not be able to keep that office open. And so our big concern as a, uh, state telehealth, the advisory committee and group, was we want the decision as to whether to use telemedicine or not to be between the provider and the patient, the medical necessity, what's best for this person at this time. And we're really trying to get the providers to agree, the payers to agree with that. Um, Medicare's been very good, but we're we're hearing of some other insurers who are, who are easing back to that lower reimbursement. And federally, obviously Medicare's had very different payment structure for telehealth versus in-office for some things. And so I'm hopeful that advocacy occurs and, um, I think it's vital in the rural areas for your rural providers. It's my impression that telehealth gives them the opportunity to easily access expertise for whatever their clients, their patients need. Has that been, um, your experience and what you've seen?
Speaker 2:That's a good question. And that's, you know, perhaps to some extent, I think this is another area in which there hasn't been a much investigation on, on the coordination of, of services between rural and urban healthcare providers or organizations, um, via telehealth. And, um, that's a good question. I think that's, would be simply don't have enough information about that yet. Um,
Speaker 1:So
Speaker 2:Wanna speculate on it.
Speaker 1:<laugh>, I'm hopeful cause, um, for a lot of our rural counties across the nation, just simply physically accessing, uh, expertise has been difficult. It takes hours to get from rural areas to a big city, and particularly for the Medicaid population, getting time of fork can be hard. Um, buying gas can be hard. Finding childcare can be hard. And we're hoping that if a patient and their local provider can easily access expertise at big cities or even out of state, that we'll see better care and, um, more consistent care. And certainly in Kentucky, and I think most states, Medicaid was not paying for missed visits. And so if the patient didn't make it, um, the provider just had that$0 whole in her schedule. Um, so we're very hopeful that, uh, telehealth is cutting down on missed visits and, um, getting people to see their doctor because it's a little bit easier. On the flip side of that, a lot of our rural and primary care providers have expressed concerns about when you're using telemedicine, you can see your patient, but you can't really see a lot of what's around them. And there's been some privacy issues like our family members listening in, or if you're treating a teenager is mom or dad or the foster parent or the school teacher listening in and it's somehow impeding that care. Um, do you have any concerns about telemedicine use, particularly telepsych and tele behavioral health, um, for that reason, privacy concerns?
Speaker 2:You know, not, not so much, I'm just gonna anecdotally or recall talking with a, um, clinical, clinical psychologist and researcher who works in the, the va. And the VA has really led the nation in terms of telepsychiatry, um, undoubtedly. And, um, mentioning that in a program that they had for the treatment of P T S D and anxiety for rural veterans, they were engaging in telehealth via smartphones or laptops. And that this, you know, they had, they had to just sort of educate the, the patient and remind them that they shouldn't have other people around when they were engaged in the, um, in a session. But the other thing that, that, you know, comes to mind as, as you mentioned this, is that it's not as if when somebody goes to an in person visit, that that patient is there with the healthcare professional by, you know, just the two of them. There may be a family member there, right? Especially for children or adolescents or, or also for adults who may take somebody along with them. Um, so is it as, yes, this is, it is a concern, but does that concern outweigh the benefits of having the visit, um, via telehealth in terms of the accessibility, um, for the, the patient? And perhaps there may, as we talked about earlier, there may be other benefits in terms of the, um, patient practitioner interaction, um, in a visit that's done virtually via a telehealth instead of in person. Um, so personally, I kind of think that these privacy concerns have been, um, overblown, I guess I might say. Um, and for telehealth,
Speaker 1:Yes, I think the big thing that the pandemic taught me was all of our fears about how hard it would be to implement telehealth and how resistant patients would be and how much it would cost everybody. Um, all came to nothing. We all seem to transition fairly rapidly and effectively. Um, what do you think the pandemic, uh, taught, taught you or those you work with the most about using telemedicine?
Speaker 2:Well, I don't think my best, I'm the best person to, to, to, to really answer the question about, you know, what has worked well because I'm serving the outside of as a researcher and reading things and, and so forth. And again, we don't have enough evidence yet to really, um, state, you know, definitively or more definitively how the pandemic has changed the, um, accessibility and outcomes especially for per, for, for, for telehealth. Um, because it, it is gonna take a while to figure this out in part cause when we have to have research dollars to study these issues, and if we apply for funding, let's say to the nih, it may take a year or two to get the funding and then, you know, several years to do the research itself. So there's a big lag time, um, for better or worse, and we just don't have a lot of information about the details of the effects of the, um, pandemic overall and also it's effects on the healthcare system and telehealth in particular. So over the next, you know, months and years, we will learn more about what has happened. Um, but I think that just, you know, anecdotally and hearing from, from what you know, persons who are working in practice have said, you know, I've heard that many psychiatric clinics are not planning to go back to in-person visits. They're just going to stay pretty much virtual, um, regardless of where a person's live, if it's in a rural urban community. Um, I was talking with somebody who works in a pain clinic, um, for dentistry. They're not planning to go back in person and regardless of where people reside, and, um, my my hunch is that, you know, there are lots of healthcare professionals and organizations, um, providing, you know, outpatient care that are going to revert to much in-person services unless they really need to. And patients want this, you know, to the extent that patients and consumers are asking for this, and I think that there's probably enough patient consumer interest and continue in telehealth that I will continue that the, the pressure will be on private insurers to maintain those. Um, now what the federal government does through Medicare and West State states do with Medicaid, I think it's, you know, who knows?
Speaker 1:And we've been very lucky in Kentucky, our<laugh>, there you go, rhyming. Our Medicaid has been very proactive and, and very much advocated for telemedicine, um, to the extent that surrounding contiguous states have adopted a lot of our, um, draft legal language or administrative regulations. So I'm hopeful we'll see Medicaid nationally continue to push forward. Um, the, the private insurers in Kentucky have, have been helpful as well, but, uh, they, they operate on such a national scope that sometimes they have less flexibility than state Medicaid does. Um, I'm hopeful that, that we see payment stay, um, stay close to parity even if there are some tweaks because I think you're right, patients are really asking for this. And it does seem to me just in my limited scope to be really enhancing what patients can do. And, um, for our small town providers, I'm hopeful that this gives them a way to stay viable, that they can get enough folks in the door or on the phone, um, that they can keep their offices open, even if patients, uh, typically would've had to drive a long way to see them. So I'm hopeful the access issue is being resolved via telehealth. What challenges are you seeing or hearing about that still exist, uh, particularly rural challenges, but urban as well with regards to telemedicine or just medicine moving forward?
Speaker 2:Well, as I, as I mentioned earlier, I, I think that the most, um, consistent challenge related to mental health services, um, is the low level of availability of healthcare professionals. So if we look at primary care, including family medicine, physicians and, um, nurse practitioners, I'm now on college in nursing, as I mentioned. And, um, um, doctorates in nursing practice are really on the rise in terms of the supply, um, nationally, whereas the supply, which is a good thing because the supply of primary care physicians, MDs, or dos, has really remained pretty flat. And, um, some dps are, are choosing to specialize in, um, psychiatry and filling some of the, um, the low capacity and, and unmet needs, um, for mental health services because the, the supply of psychiatrists is remain pretty flat also. But overall, we look at the supply of, um, social workers, clinical psychologists, psychiatrists, um, other types of physicians and dps who are providing mental health services. There just is arguably not in adequate availability of persons in these specialties. And until there's a greater availability, there's just going to be, we're going to have continued unmet needs for, for, um, mental health services, but also under that umbrella sub and related to that substance use, um, treatment services. And I mentioned the latter because the biggest predictor of substance use and abuse is mental health problems. And until we address mental health problems more effectively, I don't think we're going to resolve the, um, the, the problems of substance abuse, whether it's with opioids or methamphetamine or cocaine, et cetera. We're just going to continue to, you know, have, have, um, problems with substance use of some kind.
Speaker 1:I, I agree. I think that's a very, very important point. I'm hopeful that some of the, uh, interstate com compacts that will allow folks with an MP or an MD to operate across state lines without going through months of credentialing and licensure. Um, we'll help alleviate that. One of my, um, substance use clinics actually has their, their best MP is a psych, uh, focused person and she's in Turkey. And because of telemedicine and her licensure, she can treat Kentucky patients, even though her husband's serving in the military abroad. And, um, she's changed so many lives. And so I think if we can do that, uh, from state to state, we'll help alleviate the, the personnel crisis, at least short term while we can get more folks through school. Um, and I love the plug for the nps. I, I love the nurse practitioners. Seeing that field grow over the last 10 years, I think has changed very positively the face of medicine in Kentucky and across the nation. Um, any general last thoughts, rural practice? What should we be advocating for as attorneys for providers or telling our provider clients to, uh, try, think about, to do
Speaker 2:Maybe a couple. Um, so just to kind of continue with our, our last thoughts, and I mentioned the supply problem and, uh, this, this might resonate with an audience that primarily attorneys, we think about law schools, you know, the, the supply of lawyers for many decades was, you know, really increased. I think law schools have kind of scaled back because there's perhaps been a admissions because there's been perhaps an oversupplied attorneys on the other side hand, the medical schools haven't really, um, expanded supply much over the past few decades. There have been a few medical, new medical schools and high growth states like Texas and Florida, but medical schools have really kept the supply of physicians pretty low. And some persons, I, I think I'm in this camp, would argue that this is not good from a health policy perspective because it not just keeps the supply low, meaning we have lower access, but also keeps the prices high. And, um, you have a colleague who actually argues that medical school deans may engage in collusion to keep the prices high by keeping the supply low. But I think it's an interesting con contrast to, um, legal education because they haven't seen this in law. Um, and regarding another point in terms of rural, um, I guess healthcare overall is that we're slowly, um, recognizing that not every rural community can support a full-fledged hospital or even a critical access hospital, which, um, Medicare has given different, has given cost-based reimbursement too. Um, because there's just not stuff the adequate demand for hospital services in many rural communities. So the federal government is moving towards some new, um, payment models, which will take a while to, to, to roll out in which, for example, there will be an allowance for emergency department, um, departments that are more or less freestanding and, and not not attached to what we think of as a hospital. And we have to, I think we just have to have to recognize that, you know, we, we have to think about new ways of organizing care and delivering care to rural populations because this idea of a, an actual building where people go for hospital care or outpatient care, it's, it's just not cost feasible. And in terms of telehealth, we don't need all these buildings per se. We don't have to have, you know, perhaps even a, a waiting area in a, in a, in a clinic. People can, waiting on their cars like they had been during the pandemic. And I think that there would be a lot more, um, options in the future in terms of, um, where and how people access health services in, in rural areas.
Speaker 1:Well said, I agree. I think it's a very, very exciting time to be working in this field because I'm seeing so many interesting discussions and new partnerships and innovation and certainly telemedicine is woven into all of those. Um, I appreciate you sharing some time with us today. Um, thanks again for joining us and have a wonderful day. Thank you.