Telehealth Applications in Military and Veteran Healthcare Settings

Abstract

COVID-19 has brought increasing health care challenges upon providers throughout the country, let alone military healthcare professionals. Behavioral telehealth applications in the United States date back to the 1950s in Nebraska rural state-run mental health hospitals and clinics. Drs James and Folen developed innovative behavioral telehealth in the mid-to-late-1990s since there was a paucity of behavioral telehealth clinical applications and research from the 1960s to the early 1990s. Then, the need to deliver behavioral health services via telehealth platforms became of critical importance as our military and veteran hospitals needed to offer services in response to the COVID-19 health crisis. In this chapter, the authors will define behavioral telehealth and provide the reader with examples of clinical and research applications as well as discuss potential ethical and practical challenges.

Telepsychology, also referred to as telehealth, is defined by the American Psychological Association as:

the provision of psychological services using telecommunication technologies. Telecommunications is the preparation, transmission, communication, or related processing of information by electrical, electromagnetic, electromechanical, electro-optical, or electronic means (Committee on National Security Systems, 2010). Telecommunication technologies include, but are not limited to, telephone, mobile devices, interactive videoconferencing, email, chat, text, and Internet (e.g., self-help websites, blogs, and social media). The information that is transmitted may be in writing, or include images, sounds, or other data. These communications may be synchronous with multiple parties communicating in real time (e.g., interactive videoconferencing, telephone) or asynchronous (e.g., email, online bulletin boards, storing and forwarding information). Technologies may augment traditional in-person services (e.g., psychoeducational materials online after an in-person therapy session), or be used as standalone services (e.g., therapy or leadership development provided over videoconferencing). Different technologies may be used in various combinations and for different purposes during the provision of telepsychology services.

Since the mid-1950s, Telehealth applications have “waxed and waned” and come and gone. In the mid-1950s, at the Nebraska Psychiatric Institute, a collection of Psychologists, Psychiatrists and Nurses transformed old analog black and white televisions to connect therapists between the east and western borders of Nebraska. It was a successful outcome. However, amid all the excitement was the letdown of reality from two perspectives. First, would insurance companies reimburse for mental health services via tele health platforms in the 1950s? No! Behavioral Health interventions provided via technology was not a reimbursable clinical encounter. Second, very few medical centers throughout the world had the technological capacity to tele behavioral health in the mid-1950s.

Thus, telehealth enthusiasm across the United States whittered away. Behavioral Health practitioners returned to the face-to-face model of mental health delivery.

Then, in the mid-1990s, political pressure was placed upon military psychologists assigned to Tripler Army Medical Center in Honolulu, Hawaii by the US Congress. Military patients throughout the pacific region complained to their congressman and senators that they were deprived of tertiary medical care because they were assigned to South Korea or Japan rather than the Army Medical Center in Hawaii. The Health Psychology staff at Tripler Army Medical Center were “ordered” to pioneer technology to provide services via telehealth applications from the Army hospital in Honolulu, to South Korea and Japan.

To “jump start” the research into the feasibility of this project, Congress earmarked approximately $400,000.00 for Colonel (Dr.) Larry C. James and his colleagues to ascertain the possibility of service delivered thousands of miles apart via analog telephone technology. James and his colleagues (James et al., 1999, 2001, 2003).

1 Some Telehealth Applications

In 1999, James et al. published two papers describing tele-behavioral health clinical applications. In fact, James and his colleagues pioneered tele-behavioral health in the United States when very few, if any, large military Centers were engaged in tele-behavioral health applications.

Tele Biofeedback

In 2001, Earles, Folen, and James published an article entitled “Biofeedback Using Telemedicine: Clinical applications and case illustrations.” In this article the researchers developed technology whereby the provider was in his office in Honolulu and conducted biofeedback with chronic pain patients in Japan and South Korea. The researchers applied a software called “pcAnywhere” to control the computers between their office in Honolulu, Japan, and Korea. A behavioral science technician located at the clinics in Japan and Korea assisted in orienting the patient, equipment use, and assisting with any clinical emergencies. Figure 12.1 illustrates the equipment that was purchased “off the shelf” in the 1990s for the study.

Fig. 12.1

Picture of telehealth equipment for health psychologists

Tele Biofeedback was applied to treat patients diagnosed with chronic pain, migraine headaches, and dental pain (such as TMJ).

Tele Health Applications in the Treatment of Obesity and Eating Disorders

James et al. (2001) and Earles et al. (2001a, b) highlighted the use of telehealth applications in the treatment of obesity and eating disorders. In these studies, the researchers not only used video teleconferencing but interactive web-pages were applied for patients to track and log in their weight, food intake, exercise, and interact with counselors in real time. At the end of the project, the researchers found no significant differences in among variables and patients were very satisfied with the telehealth applications. Figure 12.2 illustrates a clinical health psychologist providing services to patients in Japan and Korea from the doctor’s office in Honolulu.

Fig. 12.2

Illustration of telehealth being performed by a health psychologist

Baggett et al. (2002) pushed the envelope to apply web-based evaluations to conduct neuropsychology assessments. Baggett and his team found no significant difference in conducting these evaluations either in person or via a web-based platform.

Telehealth Applications Post Covid-19

By the early- to mid-2000s, telehealth applications in behavioral health patients dramatically decreased. Perhaps one silver lining in the COVID-19 epidemic is the medical face-to-face clinic closures around the country championed in a new era in telehealth applications across the country. The United States Congress passing emergency legislation as well as numerous governors signing emergency authorizations forced insurance companies to reimburse providers for all medical services. As of this writing, it does appear that Telehealth is here to stay and will be a permanent and common platform for service delivery.

The US health and Human Services has approved several telehealth platforms that are HIPPA compliant and safe for not only patient care but also for behavioral telehealth services. Table 12.1 below provides a list of HIPPA approved and secure telehealth platforms.

Table 12.1 List of HIPPA approved telehealth platforms

Legal and Policy Telehealth Policy Changes Post COVID-19

In this section, the authors will discuss pre- and post-COVID19 legal and policy changes.

1.1 Before-COVID CMS Telehealth Policies

Prior to COVID-19, the Centers for Medicare and Medicaid Services (CMS) stipulated four requirements regarding reimbursement for telehealth services prior to March 6, 2020, the beginning of the COVID-19 pandemic (Congress, 2020). These included:

• 1. Patients must be located in an originating site to receive telehealth services, excluding their homes. Approved originating sites included physician offices, hospitals, rural health clinics, and federally qualified health centers (FQHCs). Only a few exceptions would permit a patient’s home to be an originating site.

• 2. Telehealth services were only allowed for established patients. New patients must have had at least one in-person visit to be eligible for telehealth.

• 3. Telehealth services were only allowed for patients residing in rural areas. This included a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) in a rural census tract.

• 4. Audio-only telephones did not meet the requirements for telehealth. There must be two-way real-time audio and visual communication capabilities.

All four of these policies were altered to address the COVID-19 Public Health Emergency (PHE) in March 2020.

After COVID-19 ravaged the nation during-COVID CMS Telehealth Policy, CMS expanded telehealth policies under the authority of the Coronavirus Preparedness and Response Supplemental Appropriations Act, effective March 6, 2020. This expansion worked to benefit both providers and their patients. CMS implemented Sect. 1135 Blanket Waivers that altered telehealth stipulations and adjusted billing policies for the COVID-19 Public Health Emergency (PHE) (Office of Health Care Financing, 2020). These changes were at the federal level. States implemented their own set of guidelines.

CMS uses Section 1135 Blanket Waivers to respond to disasters or emergencies. These waivers can modify stipulations such as pre-approval requirements, reporting requirements, and conditions of program participation. In the case of the COVID-19 PHE, two blanket waivers were initiated to expand flexibility for Medicare telehealth services.

The first waiver extended the list of healthcare practitioners that are eligible to provide telehealth services. For example, physical therapists, occupational therapists, speech language pathologists, and psychologists may now provide telehealth services. The second waiver allows for the use of audio-only technology to provide services. Only certain services are allowed to be delivered via audio-only. These allowable services are detailed in the table below.

The stipulations of furnishing telehealth services were altered for both providers and patients. This included:

• Providers are now eligible to provide telehealth services from their homes. The detailed list of services and billing codes are provided in the table below.

• Telehealth services are reimbursed for the same dollar amount as in-person visits, with the exception of a few services.

• Providers are able to serve both new and established Medicare patients as well as those living in both urban and rural areas.

• Providers can visit Skilled Nursing Facility patients via telehealth. Providers can deliver visits on the basis of need rather than once every 30 days.

• Penalties for HIPAA violations are waived against providers who employ non-HIPAA approved telecommunication platforms such as Skype or FaceTime, so long as they are used in good faith.

• Medicare patients are not required to be in an originating site but can now receive telehealth services in their own home.

• Providers may reduce or waive cost-sharing policies for telehealth visits. However, this does not apply to brief communications, known as E-Visits. E-Visits are patient-initiated forms of online communications via secure health platforms that require a professional patient assessment and subsequent health decision-making.

• Providers can deliver audio-only telephone assessment and management services. These are patient-initiated services. These are reimbursed at a lower rate than traditional psychotherapy because they are meant to be brief and direct. They are not considered to be telehealth services and are not included in the table below.

• All states (excluding Oklahoma) have allowed some form of emergency licensure waiver for out-of-state providers to practice. However, many states require some form of registration and verification with local health departments. Oklahoma only allows out-of-state psychologists to practice for no more than 5 days in Oklahoma. Other states allow out-of-state providers to practice for much longer periods or for the entire duration of the PHE.

Telehealth Billing

Billing policies for telehealth services are divided into three categories: (1) telehealth non-covered services; (2) traditional telehealth only; and (3) audio only and traditional telehealth.

The first category of telehealth services are allowed but not reimbursable by Medicare. The second category defines “Traditional Telehealth” to include telecommunication with audio and video functions that provide two-way real-time interactive communication. The third category includes both reimbursable audio only and traditional telehealth services.

The corresponding current procedural terminology (CPT) codes are in parentheses. All claims for traditional telehealth and audio-only telehealth services must include modifier 95. The Place of Service (POS) must be reported as if the service had been furnished in person. For example, a psychologist who would have seen a patient in a private office should use POS 11 rather than POS 02 (Table 12.2).

Table 12.2 Billing for telehealth services

State telehealth guidelines mostly mirrored CMS’ mandates. For example, every state (except for Wisconsin,) permitted coverage for telehealth services. Most states also allowed for some form of Emergency Out-of-State Licensure Waiver that would allow out-of-state licensed providers to practice in state. However, almost every state requires registration in the state that a provider intends to deliver services for a temporary permit.

Table 12.3 provides state guidelines for three stipulations: (1) state coverage of telehealth services under the PHE; (2) emergency out-of-state licensure waiver for providers; (3) supervised trainees can provide telehealth services. The last topic addresses if postdocs and interns can provide telehealth services and receive Medicaid reimbursement. It is important to note that these guidelines are only valid as part of the state’s declared emergency. Each declaration is subject to end on the state’s terms.

Table 12.3 State guidelines for telehealth services under PHE

1.2 Interstate Medical Licensure Compact Relevant to Telehealth

The Federation of State Medical boards established The Interstate Medical Licensure Compact (IMLC) in 2014. Eligible physicians can practice medicine in multiple states that are involved in the IMLC. The licensing is still state-based, but the process is streamlined so physicians can easily qualify to practice in multiple states at once.

To be eligible, physicians must already have a full, unrestricted medical license in a member-state. This serves as the state of principal license (SPL). There are four stipulations for a physician to designate a state as an SPL:

• 1. The physician’s SPL is his or her primary residence.

• 2. One quarter of the physician’s practice occurs in the SPL.

• 3. The physician is employed to practice medicine by a person, business, or organization located in the SPL.

• 4. The physician’s state of residence for US Federal Income Tax purposes is the SPL.

The use of the IMLC has grown significantly during the pandemic. Almost half of the issued licenses (8000) between 2017 and 2021 were issued between March 2020 and March 2021 (American Medical Association, n.d.). The Compact currently has 30 member states, as identified in the map below (Fig. 12.3).

Fig. 12.3

Interstate medical licensure compact member states. (Source: https://www.imlcc.org/)

1.3 After-COVID CMS Telehealth Policies

The COVID-19 Public Health Emergency (PHE) policies paved the way for the future of telehealth. Although the Department of Health and Human Services will most likely extend the duration of the PHE until the end of the year, some changes will surpass this calendar year.

CMS issued a final rule on Dec. 1, 2020, that updated the list of Medicare telehealth services. Services were added to either a Category 1 or Category 3 basis. Category 3 services will remain through the end of the calendar year of the PHE with the potential to become permanent at the end of the PHE. The table below outlines additions to these two categories with corresponding CPT codes. Audio-only services may not be reimbursable after the COVID-19 PHE (Table 12.4).

Table 12.4 CMS list of telehealth services and CPT codes

2 Discussion

In this chapter, the authors provided a discussion of the history of telehealth behavioral health and its development. Also, a review of the diseases that can benefit from behavioral interventions via telehealth platforms was discussed and important references were provided. Important information in regards to state telehealth policies and guidelines was offered. The benefits of Telehealth as a platform to deliver health psychology services are many.

Schoebel et al. (2021) provided an excellent article entitled “Qualitative Analysis of Provider Experiences and Perspectives.” In this article, the researchers described updated advances in current telehealth outcome research as well as benefits and challenges. Telehealth has filled a terrible clinical void, particularly in military and Veteran hospitals, as many of these military treatment centers closed during the COVID outbreak. Through these telehealth applications, valuable patient needs will continue to be safely and efficaciously met.