Grand Canyon University Telehealth Healthcare Topic Essay

As a counselor, you will be making decisions on how to select evidence-based treatments. For this assignment you will be conducting a brief literature review about the use of telehealth in counseling. For this assignment you can focus on any aspect of telehealth in counseling (examples: the use of telehealth in treating depression, use of telehealth with children). In your literature review you will use three different research articles on telehealth. You must use both qualitative and quantitative research articles. You can use any of the telehealth articles already used in class. Write a 1,000-1,250-word literature review that discusses your chosen healthcare topic.

Include the following in your literature review:

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A discussion about how qualitative and quantitative research reports inform professional counseling practice.

A discussion about the key characteristics of effective writing and publication in counseling and psychological research. How do these characteristics help to inform professional counseling practice?

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Journal of Rural Mental Health © 2020 American Psychological Association ISSN: 1935-942X 2020, Vol. 44, No. 4, 217–231 http://dx.doi.org/10.1037/rmh0000160 Telebehavioral Health (TBH) Use Among Rural Medicaid Beneficiaries: Relationships With Telehealth Policies Jean A. Talbot, Yvonne C. Jonk, Amanda R. Burgess, Deborah Thayer, Erika Ziller, Nathan Paluso, and Andrew F. Coburn This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. University of Southern Maine This study examined associations between state Medicaid telehealth policies and telebehavioral health (TBH) use among rural fee-for-service (FFS) beneficiaries with behavioral health needs and assessed relationships between beneficiary characteristics and TBH use. Data sources included the 2011 Medicaid Analytic eXtract, the Area Health Resources File, and a 2011 survey on state-level Medicaid telehealth policies. Specific policies studied included telehealth-specific informed consent requirements and facility fee payments to sites hosting TBH users. Participants included 70,459 rural FFS Medicaid beneficiaries who used outpatient behavioral health services; lived within 36 states whose Medicaid programs provided telehealth reimbursement in 2011; and who were not dually eligible for Medicare and Medicaid. Generalized estimating equations were used to examine how odds of TBH use were related to informed consent, facility fees, and the interaction between these variables after adjusting for covariates. Contrast analyses were performed to further specify the nature of the interaction. Although the overall prevalence of TBH use in the study sample was low (2.1%), TBH use was highest among beneficiaries with severe mental illness (3.2%), and those living in rural nonadjacent counties (2.6%) or in mental health professional shortage areas (2.2%). Where informed consent rules were present, the odds of TBH use were 327% greater among users in states that also had facility fees than for those in states without such fees (p ⬍ .0001). In the FFS Medicaid environment, engaging patients through informed consent within provider settings that receive facility fees may facilitate access to TBH services. Public Health Significance Statement Using administrative claims data reflecting fee-for-service (FFS) Medicaid environments across multiple states, this study serves as an important reference for researchers and policymakers interested in understanding what policy levers support sustained use of telehealth services. Among rural Medicaid FFS beneficiaries with behavioral health needs, engaging patients through informed consent within provider settings that receive facility fees may facilitate improved access to telebehavioral health services. Keywords: telebehavioral health, rural health, Medicaid, telehealth policy This article was published Online First September 3, 2020. Jean A. Talbot, X Yvonne C. Jonk, Amanda R. Burgess, Deborah Thayer, Erika Ziller, Nathan Paluso, and Andrew F. Coburn, Maine Rural Health Research Center, Edmund S. Muskie School of Public Service, University of Southern Maine. This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) to the Rural Telehealth Research Center under Cooperative Agreement UICRH29074. The information, conclusions, and opinions expressed are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred. Portions of this work were presented at the Academy Health Annual Research Meeting, Behavioral Health Services Research Interest Group in Washington, DC on June 1, 2019 and at the National Rural Health Association Annual Meeting in Atlanta, Georgia on May 9, 2019. Correspondence concerning this article should be addressed to Yvonne C. Jonk, Maine Rural Health Research Center, Edmund S. Muskie School of Public Service, University of Southern Maine, P.O. Box 9300, 34 Bedford Street, Portland, ME 04104-9300. E-mail: yvonne.jonk@maine.edu 217 This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 218 TALBOT ET AL. Rural residents experience behavioral health problems at rates similar to those observed in urban populations (Jameson & Blank, 2010; Kessler et al., 2005; Paxton, Valois, Watkins, Huebner, & Drane, 2007), with some estimates indicating higher rural prevalence for particular problems such as serious mental illness (SMI; Meit et al., 2014), suicide (Ivey-Stephenson, Crosby, Jack, Haileyesus, & Kresnow-Sedacca, 2017), and drug overdose deaths (Mack, Jones, & Ballesteros, 2017). Nevertheless, behavioral health services are less available in rural communities than in urban ones (Andrilla, Patterson, Garberson, Coulthard, & Larson, 2018), and some research suggests that rural residents use behavioral health treatment at lower rates (Hauenstein et al., 2007; Oser, Harp, O’Connell, Martin, & Leukefeld, 2012; Wang et al., 2006). Rural Medicaid beneficiaries, in particular, are at greater risk of facing access barriers than their urban counterparts, as counties with higher proportions of rural residents are less likely to have behavioral health treatment facilities that accept Medicaid (Cummings, Wen, Ko, & Druss, 2013). Some stakeholders and policymakers have expressed interest in telebehavioral health (TBH) as a means of increasing behavioral health access and appropriate treatment use among underserved populations (Goodwin & Tobler, 2016; Totten et al., 2016), including rural Medicaid beneficiaries (Medicaid and CHIP Payment and Access Commission, 2018; U.S. Government Accountability Office, 2017). In this article, TBH is defined as the delivery of mental health or substance abuse treatment through live, interactive video communication. Medicaid programs in 49 states currently offer some coverage for TBH (American Telemedicine Association, 2017). However, TBH use rates in rural Medicaid appear low (Douglas et al., 2017; Talbot et al., 2019). A study using 2008 – 09 data indicated that in states where Medicaid reimbursed for telehealth, only 0.1% of the general Medicaid population were telemedicine users (Douglas et al., 2017). Another study found that 0.26% of rural nondual Medicaid beneficiaries used telehealth services, and still fewer accessed TBH (Talbot et al., 2019). Studies conducted in other sectors (private insurance and Medicare) note that the use of TH has grown over time, and that rates, although low, vary widely across types of insurance cov- erage and across states (Mehrotra et al., 2017; Yu, Mink, Huckfeldt, Gildemeister, & Abraham, 2018). These findings illustrate that reimbursement, though necessary, is not sufficient to ensure widespread use, and raises questions as to how state Medicaid programs might create a policy environment that would facilitate broader provision and uptake of TBH among rural Medicaid enrollees. Although there appears to be no previous research addressing this specific question, a 2018 study by Park and colleagues used patient survey data to assess linkages between state policies and the use of live-video telehealth for any purpose in the Medicaid population as a whole. This investigation considered how Medicaid beneficiaries’ telehealth use was related to 11 indicators that reflected whether state Medicaid programs had permissive or restrictive telehealth policies on issues such as eligible provider types, patient settings and rural/urban residence, permitted technologies, scope of reimbursable services, and telehealthspecific informed consent. After controlling for population characteristics, Park and colleagues identified no associations between any of the Medicaid policy indicators and telehealth use (Park, Erikson, Han, & Iyer, 2018). While findings from this study suggest that telehealth policies in Medicaid have little bearing on provider adoption or beneficiary use of telehealth, it remains unclear whether this conclusion applies equally to all types of telehealth services or Medicaid subpopulations. Therefore, it may be useful to assess relationships between telehealth policies and TBH use in particular, given that TBH appears to be the primary driver of telehealth use in Medicaid (Douglas et al., 2017; Talbot et al., 2019). Moreover, in light of the fact that TBH is sometimes viewed as a solution to rural behavioral health access problems (Medicaid and CHIP Payment and Access Commission, 2018; U.S. Government Accountability Office, 2017), policymakers may wish to know whether any Medicaid telehealth policies are linked to higher rates of TBH use among rural beneficiaries with behavioral health needs. Finally, although Park and colleagues studied multiple telehealth regulations, they did not explore how TBH use varies as a function of interactions among policies. This issue may be important, as the implications of a potentially restrictive policy may This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TELEBEHAVIORAL HEALTH USE IN RURAL MEDICAID differ depending on whether other aspects of the policy climate are facilitative, and vice versa. To address these three issues, the current study focused on rural Medicaid beneficiaries who use outpatient behavioral health services (OP BHS), and examined how TBH use in this subpopulation related to two specific Medicaid telehealth policies in combination: facility fee payment and telehealth-specific informed consent. A telehealth facility fee is a payment made by an insurer to an originating site, that is, a facility that hosts a patient receiving telehealth services. This fee is intended to help compensate the originating site for use of its space and telehealth equipment (Gilman & Stensland, 2013), and is seen as a strategy for increasing providers’ adoption of telehealth technology. In 2001, the Medicare program was required to pay facility fees to rural originating sites under the Benefits Improvement and Protection Act (Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, 2000), the aim of which was to stimulate broader delivery and utilization of telehealth in rural Medicare by reducing restrictive regulations, increasing reimbursement, and expanding the range of covered telehealth services (Gilman & Stensland, 2013). Policymakers and analysts have surmised that facilities may be reluctant to serve as originating sites unless they receive fees to defray their costs, and that the absence of a facility fee payment policy may inhibit rural telehealth use (Butler & Reck, 2018). Telehealth-specific informed consent requirements are also believed to have potential for influencing TBH use (Center for Connected Health Policy, 2017). Opinions differ regarding the desirability and likely impacts of such consent policies. Some experts in the field express concern that clinicians may regard these rules as an undue administrative burden, which could discourage their participation in telehealth programs (Center for Connected Health Policy, 2017). The American Telemedicine Association (ATA) has implicitly shared this generally negative view of these policies: In evaluating states on the extent to which their policies promote telehealth adoption, the ATA gives states lower grades if their consent requirements for telehealth are more stringent than those for inperson services (Thomas & Capistrant, 2017). Other stakeholders regard telehealth-specific informed consent more favorably. In its Guide- 219 lines for the Practice of Telepsychology, the American Psychological Association has specified that psychologists are ethically obligated to provide patients with a clear, complete description of the TBH services they offer, addressing any modality-specific considerations related to information security, confidentiality, and the comparability of TBH with face-to-face services (Joint Task Force for the Development of Telepsychology Guidelines for Psychologists, 2013). According to this perspective, clinicians who share this information in appropriate, sensitive ways can empower patients to take part in shared decision-making, enhance patient engagement, and build the therapeutic alliance (Murphy & Pomerantz, 2016). As a result, patients may be more likely to initiate TBH use, sustain participation in treatment, and achieve positive outcomes. The primary objective of this study was to determine how the interaction of facility fee payments and telehealth-specific informed consent policies was associated with TBH use among rural OP BHS users in Medicaid, before and after controlling for covariates. As a secondary objective, the study examined how beneficiary characteristics, including indices of mental illness severity and residence in underserved or remote rural areas, were related to TBH use in the population of interest. Available information on state Medicaid telehealth policies was obtained from a survey of Medicaid programs (Hall, LaMothe, & Reiser, 2011). The materials provided by these programs articulate policies established for fee-forservice (FFS) providers and patients, and they do not necessarily apply to managed care organizations (MCOs; Medicaid and CHIP Payment and Access Commission, 2018). Therefore, this study focused on TBH use among FFS beneficiaries. Method Data Sources The primary data source for this study was the 2011 Medicaid Analytic eXtract (MAX). The MAX is constructed by the Centers for Medicare & Medicaid Services (CMS) from data submitted by state Medicaid programs. Data from the MAX person summary (PS) and other therapy (OT) files were analyzed. The PS This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 220 TALBOT ET AL. file contains beneficiary information such as demographics and county of residence, and the OT file comprises claims data on beneficiaries’ use of outpatient hospital, physician, and clinic services (Borck, Ruttner, Byrd, & Wagnerman, 2014; Research Data Assistance Center, 2016). A 20% random sample was drawn from the PS and OT files of each state in the study. Data on state-level telehealth policies in Medicaid programs were obtained from the 50-State Medicaid Statute Survey (Hall et al., 2011), which was completed by the Center for Telehealth & eHealth Law (CTeL) in February 2011. In conducting this survey, CTeL identified state Medicaid programs that offered reimbursement for the delivery of telehealth services to their FFS beneficiaries and asked these programs for provider manuals or other documents describing their telehealth policies. Thirty-nine states contributed to the survey. Information on statelevel, private-payer telehealth parity laws in 2011 was compiled from a resource created by the American Telemedicine Association (American Telemedicine Association, 2017). Data on beneficiaries’ counties of residence were derived from the 2017–2018 Area Health Resources File (AHRF), produced by the federal Health Resources and Services Administration (HRSA; 2018). Study Population To define the study population, inclusion/ exclusion criteria were established for states and for Medicaid beneficiaries within these states. Inclusion/exclusion criteria for states. States were included in the sample if (1) information was available on their FFS telehealth policies for the study year of 2011, (2) their state Medicaid programs reimbursed for TBH services delivered to FFS Medicaid beneficiaries in the study year, and (3) they contributed data on behavioral health claims to the 2011 MAX OT files. Based on these criteria, 36 states were retained. Inclusion/exclusion criteria for beneficiaries. Because this study focused on nonelderly adults, and because state Medicaid programs are required to define beneficiaries up to age 19 as children eligible for age-based coverage (Borck et al., 2014; Schwartz & Damico, 2010), individuals under 19 were omitted from the sample. Beneficiaries dually eligible for Medicare and Medicaid were also excluded, as MAX data were more likely to be missing or incomplete for this subpopulation (Borck et al., 2014). In addition, the study excluded those receiving any behavioral health services through managed care or behavioral health carve-outs. As noted in the preceding text, MCOs may not be required to adhere to the Medicaid telehealth policies established for FFS providers (Medicaid and CHIP Payment and Access Commission, 2018), and thus, these organizations may create different telehealth policy contexts for the providers and beneficiaries with whom they work. Once these criteria were applied, beneficiaries were selected for inclusion if they (1) were residents of rural areas and (2) were users of FFS OP BHS. To create a measure for rurality of beneficiary residence, Social Security Administration county codes in the MAX PS File were linked to 2013 Rural–Urban Continuum Codes (RUCCs; U.S. Department of Agriculture Economic Research Service, 2013) obtained from the AHRF (HRSA, 2018). RUCCs situate counties on a nine-level continuum of rurality/urbanicity, classifying metropolitan counties by their population size and nonmetropolitan counties by their levels of urbanization and adjacency to metropolitan areas (U.S. Department of Agriculture Economic Research Service, 2013). Beneficiaries in nonmetropolitan RUCCs 4 through 9 were considered rural residents. Beneficiaries were designated OP BHS users if they had at least two claims for such services. A claim was classified as an OP BHS claim if (1) the first or second diagnosis on the claim was a behavioral health condition and (2) the procedure listed was an OP BHS. To identify behavioral health conditions, the study used diagnosis codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM; Centers for Disease Control and Prevention, 2015). Codes from 291 to 316 designate mental illness and substance use disorders. All codes in this range were included except for 310 (mental disorders due to brain damage) and 305.1 (tobacco dependence). OP BHS procedures were defined as psychiatric diagnostic interviews, nonphysician mental health assessments; psychotherapy or counseling; psychopharmacological medication management; psychological testing; crisis intervention; support services, including case man- This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TELEBEHAVIORAL HEALTH USE IN RURAL MEDICAID agement; and laboratory services related to behavioral health care. In addition, because primary care providers are an important source of behavioral health treatment in rural areas (Geller, 1999; Himelhoch & Ehrenreich, 2007), behavioral health services delivered in primary care settings were included (Mauch, Kautz, & Smith, 2008). Relevant current procedure terminology (CPT; American Medical Association, 2010) and Healthcare Common Procedure Coding System (HCPCS; HCPro, 2010) Level II codes on MAX OT records were used to identify OP BHS services. The final sample meeting all selection criteria consisted of 70,459 nondually eligible, adult FFS Medicaid beneficiaries who were OP BHS users and who resided in rural areas of the 36 study states. Variables Outcome: TBH use. OP BHS claims were flagged as claims for TBH if they contained either the standard CPT modifier (GT) for interactive video communication (American Medical Association, 2010). South Carolina required the use of a state-specific modifier (TM) for TBH billing. Therefore, the TM code was used to identify TBH claims in that state (Hall et al., 2011). Beneficiaries with any TBH claims were designated TBH users, and those without such claims were categorized as TBH nonusers. Explanatory variables: Telehealth policies in state Medicaid programs. Using statelevel policy information from the CTeL survey, this study classified beneficiaries based on whether or not they were enrolled in state Medicaid programs that (1) explicitly granted payment of a facility fee to the originating site and (2) explicitly required a telehealthspecific informed consent process. A fourlevel variable was also created to categorize beneficiaries as enrolled in programs with neither policy, an informed consent requirement without a facility fee policy, a facility fee policy without an informed consent requirement, and both policies. Covariates. Selection of covariates for multivariate analyses was informed by the behavioral model for vulnerable populations, which identifies potential influences on health service use among underserved groups such as rural residents (Gelberg, Andersen, & Leake, 221 2000). Individual-, county-, and state-level variables were included as covariates. The study measured beneficiary characteristics including age; gender; race/ethnicity (White, Black, Hispanic, other, or unknown); and presence of SMI. Consistent with definitions of SMI commonly used in the research literature (Crowther, Marshall, Bond, & Huxley, 2001; Mehrotra et al., 2017; Reilly et al., 2013; Salzer, Brusilovskiy, & Townley, 2018), beneficiaries were identified as having SMI if they had at least one claim with a diagnosis of schizophrenia, bipolar disorder or other episodic mood disorder with symptoms of mania or hypomania, other psychotic disorder, or severe major depressive disorder with or without psychotic features.1 In addition, beneficiaries were classified as living in rural counties that were either adjacent or nonadjacent to metropolitan areas: RUCCs 4, 6, and 8 designated rural adjacent counties, and RUCCs 5, 7, and 9 identified rural nonadjacent counties (U.S. Department of Agriculture Economic Research Service, 2013). Further, a three-level variable from the AHRF (HRSA, 2018) was used to indicate whether beneficiaries lived in counties that were classified as Mental Health Professional Shortage Areas (MHPSAs) by HRSA (U.S. Department of Health and Human Services, Health Resources, & Services Administration, 2018).2 Each beneficiary was assigned to a category reflecting whether all, part, or none of their home county was a MHPSA. Finally, private-payer telehealth parity requirements were conceptualized as a covariate. Parity rules, which mandate the coverage of telehealth by private insurers, are assumed to strengthen telehealth infrastructure by broadening the payer mix and creating additional reve1 The ICD-9-CM (https://www.cdc.gov/nchs/icd/icd9 cm.htm) codes corresponding to these diagnoses included 295.xx, 297.xx, 296.23, 296.24, 296.33, 296.34, 301.12, 309.1, 296.0x-296.9x, 301.11, and 301.13. 2 HRSA designates MHPSAs based primarily on population to provider ratios. MHPSA designations can be based on (1) a population-to- psychiatrist ratio, (2) a populationto-core mental health provider (psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists) ratio, or (3) ratios of population to both psychiatrist and core mental health providers. Thresholds for qualifying ratios vary depending on provider type and population need (https://bhw .hrsa.gov/shortage-designation/hpsas). 222 TALBOT ET AL. nue streams for telehealth (Mehrotra et al., 2017; Mehrotra et al., 2016; Neufeld, Doarn, & Aly, 2016). In the present study, beneficiaries were categorized as living in states with or without private-payer telehealth parity laws as of 2011. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Analysis At the bivariate level, chi-square tests were conducted to determine whether TBH use was related to the two Medicaid telehealth policies of interest and the selected covariates. At the multivariate level, generalized estimating equations were used to examine how odds of TBH use were related to telehealth-specific informed consent, facility fee payment, and the interaction between these variables after adjusting for covariates. Contrast analyses were performed to further specify the nature of the interaction. All analyses were conducted using SAS (Version 9.2). Multicollinearity diagnostics were at acceptable levels, with tolerance values greater than 0.40 for all explanatory variables (Allison, 2012). This study was approved by the University of Southern Maine’s Institutional Review Board. Results Bivariate Analyses TBH use: Unadjusted associations with beneficiary characteristics. Rural TBH users and nonusers differed significantly on multiple characteristics (see Table 1). Compared with nonusers, TBH users were more Table 1 Characteristics of Rural, Non-Elderly Adult Outpatient Behavioral Health Service Users by Telebehavioral Health Use Characteristic Gender (p ⬍ .05) Female Male Race/Ethnicity (p ⬍ .0001) White Black or African American Other Hispanic Unknown Age (p ⬍ .0001) 19 to 29 30 to 39 40 to 49 50 to 64 In state with telehealth parity law (p ⬍ .0001) Law absent Law present SMI diagnosis (p ⬍ .0001) Diagnosis absent Diagnosis present Rurality (p ⬍ .0001) Rural adjacent Rural nonadjacent MHPSA (p ⬍ .001) Not a MHPSA Partial county MHPSA Whole county MHSPA TBH users (n ⫽ 1,459) TBH nonusers (n ⫽ 69,000) OP BHS users (N ⫽ 70,459) % SE % SE % SE 63.3 36.7 1.3 1.3 64.2 35.8 0.2 0.2 64.2 35.8 0.2 0.2 70.2 14.2 4.9 5.0 5.7 1.2 0.9 0.6 0.6 0.6 77.7 10.6 4.0 2.2 5.6 0.2 0.1 0.1 0.1 0.1 77.5 10.6 4.0 2.2 5.6 0.2 0.2 0.1 0.1 0.1 21.5 22.9 27.4 28.3 1.1 1.1 1.2 1.2 26.1 24.4 23.0 26.6 0.2 0.2 0.2 0.2 26.1 24.3 23.1 26.6 0.2 0.2 0.2 0.2 58.5 41.5 1.3 1.3 64.4 35.6 0.2 0.2 64.3 35.7 0.2 0.2 29.6 70.4 1.2 1.2 54.6 45.4 0.2 0.2 54.1 45.9 0.2 0.2 54.0 46.0 1.3 1.3 63.1 36.9 0.2 0.2 63.0 37.1 0.2 0.2 8.6 12.0 79.4 0.7 0.8 1.1 9.5 15.4 75.1 0.1 0.1 0.2 9.5 15.3 75.2 0.1 0.1 0.2 Note. Chi-square tests assess differences by telebehavioral health (TBH) user status. OP BHS ⫽ outpatient behavioral health service; SMI ⫽ serious mental illness; MHPSA ⫽ Mental Health Professional Shortage Area. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. TELEBEHAVIORAL HEALTH USE IN RURAL MEDICAID likely to be