Should Blind Psychiatrists Be Paid Less?

Abstract

I will address the question posed in the title at the end of this commentary. The meta-analysis by Scott and colleagues1 in this issue found that video-based telehealth treatment of posttraumatic stress disorder (PTSD) in primary care was as effective in reducing symptoms as face-to-face treatment. Moreover, the therapeutic alliance was as strong, and patient satisfaction as high, in telehealth as in-person treatment. These findings for PTSD are consistent with the results of other reviews and meta-analyses that found equivalent efficacy and patient satisfaction between telehealth and face-to-face treatment for insomnia,2 substance use disorders,3 obsessive-compulsive disorder,4 depression,5 and schizophrenia spectrum disorders6 and in samples of patients with a mixture of psychiatric diagnoses.5 Telehealth interventions as adjuncts to routine care have also been found to be effective in addressing other clinically important behaviors such as enhancing medication compliance.7 In outpatient settings, appointment attendance is greater with telehealth versus in-person visits.8–10 To be sure, telehealth interventions have not been limited to patients with psychiatric disorders and have been found to be effective in other areas of medicine.11 The literature on telehealth interventions, including both telephone and televideo, goes back decades. However, the recent COVID-19 pandemic, which spurred recommendations for social distancing and other precautionary measures, resulted in a rapid transition from in-person to telehealth visits, especially in behavioral health.12 The change in how visits are conducted has been greatest in ambulatory care, though it also has occurred in emergency rooms13 and inpatient units.14,15 The widespread transition to telemedicine was economically feasible because reimbursement for services was not reduced. In part, equivalent compensation for telehealth treatment was compelled by government regulation. The COVID-19 pandemic will not pervade society forever. Thus, the ongoing role of telehealth treatment in the delivery of treatment, particularly ambulatory behavioral health treatment, is uncertain. While some states have mandated an expansion of telehealth services and required private payers to continue to reimburse telehealth services at the same level as in-person treatment, other states have already rescinded, or allowed to expire, emergency orders that required equivalent telehealth reimbursements. What will the future hold? Government regulatory agencies, at both the federal and state levels, will largely determine how widespread telehealth behavioral services will remain. To be sure, telehealth behavioral services will retain some presence because of the shortage of behavioral health providers in many areas. An as yet potential area of growth for telehealth treatment is the “expertise niche” in which clinical programs with renowned expertise in treating specific disorders expand their geographic reach. During the pandemic, programs with special expertise that heretofore had no experience with telehealth adapted and became comfortable with telehealth treatment delivery, and they might seek to expand services because the constraints imposed by physical space requirements will be lessened. Whatever the reason, telehealth will retain some future presence. To be determined is whether telehealth will be the norm (or near norm) of ambulatory behavioral health care, with patients having the choice of seeing clinicians in person or by telehealth, or whether telehealth will resume being just a small fraction of how care is delivered. How will government regulators decide whether to maintain the expansion of telehealth services or return to the pre-pandemic status quo? Undoubtedly, lobbyists, for and against, will attempt to exert their influence. What scientific-based arguments will be made? A lot of research had already been conducted pre-COVID. In fact, all of the treatment studies in Scott and colleagues’ meta-analysis1 were conducted prior to the COVID-19 pandemic. An explosion of science has occurred during the pandemic. A PubMed search conducted on November 30, 2021, with the terms telemedicine and psychiatry yielded 3,757 citations over the last 30 years, with more than 15% (n = 584) published already in 2021. The literature is near unanimous—almost all studies comparing telehealth and in-person treatment delivery have found equal efficacy, safety, and patient satisfaction.5,16,17 Equivalent efficacy is not surprising. Consider the following conceptual approach toward subtyping patients based on their response to treatment. When evaluating the response to two effective treatments, the key question is, how many and which patients will demonstrate differential treatment response? That is, how many and which patients would respond to one type of treatment but not the other? There are 4 treatment response subtypes. Group 1 consists of patients who respond to the nonspecific aDepartment of Psychiatry and Human Behavior, Brown Medical School, and Department of Psychiatry, Rhode Island Hospital, Providence, Rhode Island *Corresponding author: Mark Zimmerman, MD, 146 West River St, Providence, RI 02904 (mzimmerman@lifespan.org). J Clin Psychiatry 2022;83(4):21com14354