Using nationwide hospital data, this study explored geographic variations in telepsychiatry adoption across US hospitals in 2017, and findings can inform efforts to improve access to psychiatric care and reduce persistent geographic disparities in mental health [17–19]. Our data indicate that less than one in six (15.8%) hospitals had telepsychiatry as of 2017. This suggests that substantial challenges remain for increasing access to psychiatric services across the US. Although the majority of rural residents live in mental health shortage areas, telepsychiatry is not routinely being used to deliver psychiatric services in these areas. Hospitals in rural noncore areas were far less likely to have adopted telepsychiatry – with only 8% of rural noncore hospitals having telepsychiatry in 2017. Telepsychiatry adoption varied significantly by both hospital- and county-level characteristics, including provision of outpatient psychiatric services, system affiliation, hospital bed size, ownership, ratio of Medicaid inpatient days to total inpatient days, and designation as mental health shortage areas.
Although telehealth has long been advocated as a tool to improve access to care and to facilitate the transition from hospital-based care to community-based care , we find that telepsychiatry adoption by hospitals remains very limited. More importantly, our study reveals that hospitals in counties with more psychiatrists did not have higher telepsychiatry adoption rates. Clinical resources that are clustered in certain geographic areas may have little benefit for individuals residing outside of those areas without purposeful, targeted efforts to expand access. This finding may be due to the absence of incentives, a lack of hospital buy-in, and/or limited education or training for psychiatrists to provide telepsychiatry in the hospital settings [27, 42]. In addition, many patients may face barriers to engaging in such services, particularly due to the persistent rural-urban disparities in high speed Internet access .
It is concerning that hospitals in rural counties have lower rates of telepsychiatry adoption, especially hospitals in noncore areas. While mental health facilities in rural noncore areas have greater rates of telepsychiatry than their urban counterparts , it is possible that administrators of local hospitals were not sufficiently motivated to expand telepsychiatry. One prior study has revealed that around 40% of individuals who died by suicide had received care within 30 days of their suicide . In addition, poor continuity of care and lack of follow-up for individuals discharged from psychiatric inpatient settings are major issues [7, 45]. Providing follow-up after psychiatric hospitalization discharge has proven useful to reduce risk of non-adherence to medication and suicide [13, 14]. Telepsychiatry may facilitate timely delivery of follow-up care after discharge and make it easier to support patients’ adherence to treatment [16, 17].
Bridging these gaps calls for a wider availability of telepsychiatry to improve continuity of care. Our study reveals that hospitals with inpatient psychiatric services but without outpatient psychiatric services did not report greater adoption of telepsychiatry than their counterparts. This may be related to the per diem prospective payment system for inpatient psychiatric facilities and insufficient payment for outpatient services [46, 47]. Also, telepsychiatry adoption rates vary tenfold by facility operation, with 80% of federal hospitals but only 16% of non-federal public and 8.6% of private non-profit hospitals reporting telepsychiatry. This result is likely due to the significant progress that has been made by the Veteran Affairs system in promoting telehealth . To ensure access to psychiatric care for all, federal and state policymakers should expand the types of providers eligible to receive reimbursements for both live video and remote patient monitoring for patients in need.
Our study demonstrates that hospitals with a greater ratio of Medicaid inpatient days to total inpatient days were more likely to have telepsychiatry. This suggests that federal Medicaid policies could promote telepsychiatry adoption in these hospitals; surprisingly, profit margins were not independent factors associated with telepsychiatry use, even though investing in telehealth systems is perceived as a way to increase the competitive advantage of a hospital . This might be related to decreasing trends in average reimbursement for telepsychiatry . In 2018, over 10 states still did not have parity legislation in place for private insurance coverage of telehealth ; these telepsychiatry disparities are likely historically rooted, in part, in regulation and reimbursement policies. Policies to improve access to care through expanded telehealth are evolving quickly as a result of the COVID-19 pandemic; however, the public and private funding sources that will be needed for expanded telehealth remain unclear .
With the increasing demands in psychiatric services, our findings on lower rates of telepsychiatry adoption in counties designated as mental health professional shortage areas raises concerns about access to care for residents in these already low resource areas. Lack of telepsychiatry adoption in vulnerable communities is likely compounded by the limited supply of mental health professionals to begin with. Without purposeful state and federal efforts to address the inequitable distribution of mental health resources, disparities in access to care are likely to persist. These results call for allocating telepsychiatry funding based on local mental health care need. Otherwise, residents in these counties will be less likely to have access to evidence-based treatments for mental health disorders, and the health disparities affecting the rural US are likely to persist or even worsen.
This study has some limitations. First, the AHA Annual Survey asked about hospital-wide use of telepsychiatry via a single item without querying the extent of use or scope of services offered. About 25% of hospitals did not respond to the item on telepsychiatry. Assuming that hospitals without any telehealth tend not to respond to telehealth questions, the current national rate of telepsychiatry adoption may be overestimated. Second, our cross-sectional data did not allow us to make causal inferences, and we had no data about local psychiatric care needs. Third, our study focused on the telepsychiatry adoption at hospital settings, which include EDs, as well as inpatient and outpatient psychiatric services. We did not include mental health facilities in our analysis though they often provide a broad range of services . This study documented the telemedicine availability prior to COVID-19, which might have uptick during the pandemic . Future study may expand on the current baseline measures and investigate how linkages between hospital and community-based systems can be forged and strengthened, in order to close the access gaps for residents in vulnerable communities.