Characteristics of Mental Health Specialists Who Shifted Their Practice Entirely to Telemedicine

Hailu, R., Huskamp, H. A., et al. (2024).

JAMA, 5(1), e234982. 

https://doi.org/10.1001/jamahealthforum.2023.4982

Introduction

The COVID-19 pandemic–related shift to telemedicine has been particularly prominent and sustained in mental health care. In 2021, more than one-third of mental health visits were conducted via telemedicine. While most mental health specialists have in-person and telemedicine visits, some have transitioned to fully virtual practice, perhaps for greater work-life flexibility (including avoiding commuting) and eliminating expenses of maintaining a physical clinic. The decision by some clinicians to practice only via telemedicine has gained importance due to Medicare’s upcoming requirement, effective in 2025, that patients have an annual in-person visit to receive telemedicine visits for mental illness and new requirements from some state Medicaid programs that clinicians offer in-person visits. We assessed the number and characteristics of mental health specialists who have shifted fully to telemedicine.

Discussion

In 2022, 13.0% of mental health specialists serving commercially insured or Medicare Advantage

enrollees had shifted to telemedicine only. Rates were higher among female clinicians and those

working in densely populated counties with higher real estate prices. A virtual-only practice allowing

clinicians to work from home may be more attractive to female clinicians, who report spending more

time on familial responsibilities, and those facing long commutes and higher office-space costs.

It is unclear how telemedicine-only clinicians will navigate new Medicare and Medicaid

requirements for in-person care. While clinicians and patients may prefer in-person care,

introducing in-person requirements for visits and prescribing could cause care interruptions,

particularly for conditions such as opioid use disorder.

Our analysis is limited to clinicians treating patients with commercial insurance or Medicare

Advantage and therefore may lack generalizability. We were also unable to determine where

clinicians physically practiced, particularly if they had transitioned to virtual-health companies. Given the shortage of mental health clinicians, future research should explore whether a virtual-only model

affects clinician burnout or workforce retention.

Medicare for All: Would It Work? And Who Would Pay?

Ezekiel (Zeke) Emanuel
Podcast - Wharton
Originally posted 12 Nov 19

Here is an excerpt:

“If you want to control costs, there are at least three main areas you have to look at: drug costs, hospital costs to the private sector, and administrative costs,” he said. “All of them are out of whack. All of them are ballooned.”

On drug costs, for example, it is not clear if that would be achieved through negotiations with drug companies or by the government setting a price ceiling, Emanuel said. He suggested a way out: “We should have negotiations informed by value-based pricing,” he said. “How much health benefit does the drug give? The more the health benefit, the higher the price of the drug. But we do need to have caps.”

Emanuel also faulted Warren’s idea to limit payments to hospitals at 110% of Medicare rates as unwise. He suggested 120% of Medicare rates, adding that it would “probably have no real pushback from most of the health policy people, especially if you do have a reduction in administrative costs and a reduction in drug costs.” he said.

Emanuel pointed to a recent Rand Corporation study which showed that on average, private health plans pay more than 240% of Medicare rates for hospital services. “That seems way out of whack,” he said. “There are a lot of hospital monopolies, and consolidation has led to price increases – not quality increases as claimed. We do have to rein in hospital prices.” The big question is how that could be achieved, which may include placing a cap on those prices, he added.

On reining in administrative costs, Emanuel saw hope. He noted that the private sector spends an average of 12% on administrative costs, and he blamed that on insurance companies and employers wanting to design their own employee health plans. He suggested a set of five or 10 standardized plans from which employers could choose, adding that common health plans work well in countries like the Netherlands, Germany and Switzerland. Japan has 1,600 insurance companies, but standardized health plans and a centralized clearinghouse helps keep administrative costs low, he added.

The info is here.

Cheyenne Psychologist And His Wife Sentenced To 37 Months In Prison For Health Care Fraud

Department of Justice
U.S. Attorney’s Office
District of Wyoming
Press Release of December 4, 2018

John Robert Sink, Jr., 68, and Diane Marie Sink, 63, of Cheyenne, Wyoming, were sentenced on December 3, 2018, to serve 37 months in prison for making false statements as part of a scheme to fraudulently bill Wyoming Medicaid for mental health services, which were never provided, announced United States Attorney Mark A. Klaassen. The Sinks, who are married, were also ordered to pay over $6.2 million in restitution to the Wyoming Department of Health and the United States Department of Health and Human Services, and to forfeit over $750,000 in assets traceable to the fraud, including cash, retirement accounts, vehicles, and a residence.

The Sinks were indicted in March 2018 by a federal grand jury for health care fraud, making false statements, and money laundering. At all times relevant to the indictment, John and Diane Sink operated a psychological practice in Cheyenne. John Sink, who was a licensed Ph.D. psychologist, directed mental health services. Diane Sink submitted bills to Wyoming Medicaid and managed the business and its employees. The Sinks provided services to developmentally disabled Medicaid beneficiaries and billed Medicaid for those services.

Between February 2012 and December 2016, the Sinks submitted bills to Wyoming Medicaid for $6.2 million in alleged group therapy. These bills were false and fraudulent because the services provided did not qualify as group therapy as defined by Wyoming Medicaid. The Sinks also falsely billed Medicaid for beneficiaries who were not participating in any activities, and therefore did not receive any of the claimed mental health services. When Wyoming Medicaid audited the Sinks in May 2016, the Sinks did not have necessary documentation to support their billing, so they ordered an employee to create backdated treatment plans. The Sinks then submitted these phony treatment plans to Wyoming Medicaid to justify the Sinks’ false group therapy bills, and to cover up their fraudulent billing scheme.

The pressor is here.

Taking Single-Payer Seriously

Dave Kamper
Jacobin Magazine
Originally published May 28, 2017

Here is an excerpt:

Medicare for All wouldn’t just scrap Obamacare — it would uproot the entire industry. It would be a huge efficiency savings. But it would also be devastating in the short term for hundreds of thousands of working people whose only crime was getting a job at an insurance company, and the hundreds of thousands more who work as billing specialists for clinics and hospitals (the number of medical assistants shot up 44 percent between 2011 and 2016). Yes, the CEO of United Health Group made $101 million in 2011. But few of the 230,000 other people working for the company saw money like that.

Bernie Sanders’s recently announced Medicare for All plan asserts that we “need a health care system that significantly reduces overhead, administrative costs, and complexity,” and projects that his plan would save $6 trillion over ten years.

The article is here.

King Introduces End-of-Life Counseling Bill

Jan 11, 2017
Press Release

Congressman Steve King released the following statement after re-introducing the End-of-Life Counseling Bill:

“A year ago this month, the government increased control over one of the most highly personal healthcare decisions an individual can make when the Centers for Medicare and Medicaid Services (CMS) began paying doctors to counsel patients about end-of-life care,” said King. “Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years in exchange for their compelled funding of the program during their working years.

Furthermore, this exact provision was removed from the final draft of Obamacare in 2009 as a direct result of public outcry. The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life. My legislation prohibits Medicare payments for end-of-life counseling, blocking this harmful regulation before our government imposes yet another life-devaluing policy on the American people. ”

The bill is here.

"Just because you do not take an interest in politics doesn't mean politics won't take an interest in you." -Pericles

Why does imprisoned psychologist still have license to practice?

Charles Keeshan and Susan Sarkauskas
Chicago Daily Herald
Originally published November 11, 2016

Here is an excerpt:

Federal prosecutors said Rinaldi submitted phony bills to Medicare for about $1.1 million over four years, collecting at least $447,155. In nearly a dozen instances, they said, she submitted claims indicating she had provided between 35 and 42 hours of therapy in a single day. In others, she submitted claims stating she had provided care to Chicago-area patients when she was actually in San Diego or Las Vegas.

The article is here.

Blue Cross expands benefits for end-of-life care

By Priyanka Dayal McCluskey
The Boston Globe
First posted on December 28, 2015

Here is an excerpt:

And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives.

“The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues [around death and dying], but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.”

The article is here.

Medicare considers funding end-of-life talks

By Pam Belluck
The New York Times
Originally published August 31, 2014

Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 50 million Americans on Medicare as early as next year.

Bypassing the political process, private insurers have begun reimbursing doctors for these “advance care planning” conversations as interest in them rises along with the number of aging Americans.

The entire article is here.

Editorial note: Politics will continue to affect health care delivery in the United States.  It is critical that healthcare providers cite foundational ethical principles when advocating for changes in our healthcare system, and not become immersed in sloganeering or bumper sticker politics to support one political party or the other.  High quality health care and informed patient choice are paramount.

New bill breaks down telehealth barriers

By Eric Wicklund
Healthcare IT News
Originally published September 13, 2013

A bill introduced in Congress this week would enable healthcare providers to treat Medicare patients in other states via telemedicine without needing different licenses for each state.

The "TELEmedicine for MEDicare Act", or HR 3077, was introduced Sept. 10 in the House by Reps. Devin Nunes, R-Calif., and Frank Pallone, D-N.J. Nicknamed the TELE-MED Act, it seeks to update current licensure laws "to account for rapid technological advances in medicine," according to its sponsors.

“By reducing bureaucratic and legal barriers between Medicare patients and their doctors, it expands medical access and choice for America’s seniors and the disabled,” Nunes said in a statement.

The entire story is here.

ATA Responds to CMS Proposal for Expanded Telemedicine Coverage

Press Release
The American Telemedicine Association
Originally published July 10, 2013

The American Telemedicine Association voices its cautious support for new proposals by the Centers for Medicare and Medicaid Services (CMS) that would expand Medicare’s telehealth footprint.  CMS proposes to increase the number of beneficiaries eligible for telemedicine by modifying their urban/rural definitions and proposes several new reimbursable telemedicine services.

“Overall, the proposed rules are good news for Medicare patients and forward-thinking healthcare providers. We applaud CMS for taking steps to help these patients benefit from proven telemedicine technologies,” said Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association. "But many potential beneficiaries are still left behind.  For example, we hope that either CMS or Congress take additional steps to restore telehealth benefits to the one million beneficiaries in 104 counties that lost coverage last year due to reclassification to metropolitan areas.”

The entire story is here.

Thanks to Alex Siegel for this information

End-of-Life Care Improves But Costs Increase, Study Finds

by E.J. Mitchell
The Medicare News Group
Originally published July 12, 2013

Improvements in end-of-life care have occurred rapidly for Medicare patients but costs have increased, according to a new Dartmouth Institute brief that was released today. The study revealed that beneficiaries in their last six months of life spent fewer days in the hospital and that more patients received hospice services in 2010 compared to 2007.

However, Medicare spending for chronically ill patients at the end of life increased more than 15 percent during that time period, while the consumer price index rose only 5.3 percent.

The data from the brief, which is through the Dartmouth Atlas Project, also found that in 2010 compared to 2007:

• patients were less likely to die in the hospital;
• patients were as likely to spend time in intensive care units (ICUs) during the last six months of life;
• the variations in end-of-life care at some academic medical centers quickly changed;
• patients spent more days in hospice care; and
• patients were more likely to see more than 10 physicians during the last 6 months of life.
• The Dartmouth Atlas brief found that across hospitals improvement was variable, with some experiencing rapid change while others showed little improvement.

The entire article is here.

Dangers found in lack of safety oversight for Medicare drug benefit

By Tracy Weber, Charles Ornstein and Jennifer LaFleur
ProPublica
Originally published: May 11, 2013

Here is an excerpt:

But an investigation by ProPublica has found the program, in its drive to get drugs into patients’ hands, has failed to properly monitor safety. An analysis of four years of Medicare prescription records shows that some doctors and other health professionals across the country prescribe large quantities of drugs that are potentially harmful, disorienting or addictive for their patients. Federal officials have done little to detect or deter these hazardous prescribing patterns.

Searches through hundreds of millions of records turned up physicians such as the Miami psychiatrist who has given hundreds of elderly dementia patients the same antipsychotic, despite the government’s most serious “black box” warning that it increases the risk of death. He believes he has no other options.

Some doctors are using drugs in unapproved ways that may be unsafe or ineffective, records showed. An Oklahoma psychiatrist regularly prescribes the Alzheimer’s drug Namenda for autism patients as young as 12; he says he thinks it calms them. Autism experts said there is scant scientific support for this practice.

The entire article is here.

How Mom’s Death Changed My Thinking About End-of-Life Care

By Charles Ornstein

ProPublica – Co-published with The Washington Post

Originally published February 28, 2013

Here are some excerpts:

I've long observed, and sometimes chronicled, the nasty policy battles surrounding end-of-life care. And like many health journalists, I rolled my eyes when I heard the phrase "death panels" used to describe a 2009 congressional proposal that would have allowed Medicare to reimburse physicians who provided counseling to patients about living wills and advance directives. The frenzy, whipped up by conservative politicians and talk show hosts, forced the authors of the Affordable Care Act to strip out that provision before the bill became law.

Politics aside, I've always thought that the high cost of end-of-life care is an issue worthy of discussion. About a quarter of Medicare payments are spent in the last year of life, according to recent estimates. And the degree of care provided to patients in that last year — how many doctors they see, the number of intensive-care hospitalizations — varies dramatically across states and even within states, according to the authoritative Dartmouth Atlas.

Studies show that this care is often futile. It doesn't always prolong lives, and it doesn't always reflect what patients want.

In an article I wrote for the Los Angeles Times in 2005, I quoted a doctor saying: "There's always one more treatment, there's always one more, 'Why don't we try that?' ... But we have to realize what the goals of that patient are, which is not to be in an intensive-care unit attached to tubes with no chance of really recovering."

The entire story is here.

House Republican aims to repeal Medicare doctor pay cuts

Reuters
Originally published on February 13, 2013

Republicans in the House of Representatives will seek a permanent solution to scheduled steep cuts in physician payments from the federal Medicare health insurance plan for retirees and disabled people, a House committee chairman said on Wednesday.

Rep. Fred Upton, chairman of the House Energy and Commerce Committee, told doctors he hopes to send so-called "Doc Fix" legislation to the House floor this summer that would repeal payment reductions enacted in 1997 as part of a law to balance the federal budget.

The 16-year-old "sustainable growth rate" (SGR) provision calls for reductions in doctor pay as a way to control spending by Medicare. Congress has prevented the SGR from taking effect through temporary measures, but that has run up the fiscal and political costs of finding a permanent solution.


The entire article is here.

U.S. proposes scrapping some obsolete Medicare regulations

By Reuters
Originally published February 13, 2013

The Obama administration on Monday proposed eliminating certain obsolete Medicare regulations, a move it said would save hospitals and other healthcare providers an estimated $676 million a year, or $3.4 billion over five years.

The Department of Health and Human Services described the targeted regulations as unnecessary or excessively burdensome and said their proposed elimination would allow greater efficiency without jeopardizing safety for the Medicare program's elderly and disabled beneficiaries.

"We are committed to cutting the red tape for healthcare facilities, including rural providers," Health and Human Services Secretary Kathleen Sebelius said in a statement.

"By eliminating outdated or overly burdensome requirements, hospitals and health care professionals can focus on treating patients," she added.

Industry representatives largely welcomed the changes, saying the proposed rule would help hospitals free up more resources for patient care.

"There are a number of particularly meaningful provisions in the proposed rule," said Chip Kahn of the Federation of American Hospitals.

The American Hospital Association, though, said it was disappointed the administration did not allow "hospitals in multi-hospital systems" to have single integrated medical staff structures.

"Hospitals are delivering more coordinated, patient-centered care and (the administration) should not let antiquated organizational structures stand in the way," AHA President Rich Umbdenstock said in a statement.

The entire article is here.

SGR Repeal Bill Favors Primary Care

Robert Lowes

MedScape Medical News
Originally published February 06, 2013

Two members of Congress today reintroduced an ambitious bill that would repeal Medicare's sustainable growth rate (SGR) formula for setting physician pay and gradually phase out fee-for-service (FFS) reimbursement.

One major difference this time around for the bipartisan bill, originally introduced in May 2012, is that its price tag appears considerably lower, making passage more likely.

When Reps. Allyson Schwartz (D-PA) and Joe Heck, DO (R-NV), proposed this legislation last year, the Congressional Budget Office (CBO) had estimated that repealing the SGR and merely freezing current Medicare rates for 10 years would cost roughly $320 billion.

Since then, the CBO has reduced that 10-year estimate on the basis of lower than projected Medicare spending on physician services for the past 3 years. In a budget forecast released yesterday, the agency put the cost of a 10-year rate freeze at $138 billion.

The immediate effect of the bill from Schwartz and Dr. Heck, titled the Medicare Physician Payment Innovation Act, would be to avert a Medicare pay cut of roughly 25% on January 1, 2014, that is mandated by the SGR formula. Instead, the bill maintains 2013 rates through the end of 2014.

After 2014, Medicare would begin to shift from FFS to a methodology that rewards physicians for the quality and efficiency of patient care. From 2015 through 2018, the rates for primary care, preventive, and care coordination services would increase annually by 2.5% for physicians for whom 60% of Medicare allowables fall into these categories. Medicare rates for all other physician services would rise annually by 0.5%.

Meanwhile, the bill calls on the Centers for Medicare & Medicaid Services (CMS) to step up its efforts to test and evaluate new models of delivering and paying for healthcare (experiments with medical homes, accountable care organizations, and bundled payments are already underway). By October 2017, CMS must give physicians its best menu of new models to choose from. Two menu options would allow some physicians unable to fully revolutionize to participate in a modified FFS scheme.

The entire article is here.

U.S. could save $2 trillion on health costs - study

By David Morgan
Reuters
Originally published January 10, 2012


The United States could save $2 trillion in healthcare spending over the next decade, if the U.S. government used its influence in the public and private sectors to nudge soaring costs into line with economic growth, a study released on Thursday said.

Compiled by the nonpartisan Commonwealth Fund, the study recommends holding the $2.8 trillion U.S. healthcare system to an annual spending target by having Medicare, Medicaid, other government programs and private insurers encourage providers to accelerate adoption of more cost-effective care.

Such a plan would require new legislation from a bitterly divided U.S. Congress, where Republicans would likely oppose new government controls, despite claims by the study's authors that families, employers and government budgets would receive long-sought relief from their growing financial healthcare burdens if the changes were enacted.

But Commonwealth Fund President Dr. David Blumenthal, a former healthcare adviser to President Barack Obama, said the approach could find bipartisan support in upcoming deficit talks as an alternative to cutting so-called entitlement programs including Medicare, the popular healthcare program for the elderly and disabled.

"In comparison with what some of those proposals advocate, we think that some of what we're proposing will look like an escape valve," Blumenthal told reporters in a conference call.

The United States has the world's most expensive healthcare system, which government forecasters say will cost more than $9,200 this year for every man, woman and child. Spending growth has slowed in recent years, but costs continue to outpace inflation and restrain overall economic growth.

The entire article is here.

'If I'd Had To Wait Until 67 For Medicare, I'd Be Dead'

By Russ Mitchell
Kaiser Health News
Originally published December 18, 2012

Sam Lewis turned 65 in the nick of time. For a year, he'd been broke. His Brentwood, Calif., general contracting business had gone bust. He couldn't make payments on his home, and lost it. He couldn't make payments on his health insurance, so he let it lapse.

The day after his birthday in October, when he qualified for Medicare, Lewis got a checkup. Days later, he went under the knife: open-heart surgery, a triple-bypass, three arteries blocked with plaque, one of them, 99 percent. "If I'd had to wait until 67 for Medicare," Lewis said, "I'd be dead."

A proposal to raise the Medicare eligibility age from 65 to 67 to ratchet down spending is one of the more explosive ideas in the fiscal talks between House Speaker John Boehner and the White House. The negotiations are aimed at a deficit deal to avert automatic tax increases and spending cuts slated to take effect Jan. 1.  Liberal Democrats say they loathe the Medicare proposal, but the White House has not taken a public position on it.

President Barack Obama was open to a similar proposal last year during his failed effort to reach a "grand bargain" with Republicans.  And many expect it to pop up again in next year’s discussions about curbing entitlement costs if it is not included in this year’s deal.

The entire article is here.

Health Care Spending in Last Five Years of Life Exceeds Total Assets for One Quarter of U.S. Medicare Population

ScienceDaily

Originally published September 8, 2012

As many as a quarter of U.S. Medicare recipients spend more than the total value of their assets on out-of-pocket health care expenses during the last five years of their lives, according to researchers at Mount Sinai School of Medicine. They found that 43 percent of Medicare recipients spend more than their total assets minus the value of their primary residences.

The findings appear online in the current issue of the Journal of General Internal Medicine.

The amount of spending varied with the patient's illness. Those with dementia or Alzheimer's disease spent the most for health care, averaging $66,155, or more than twice that of patients with gastrointestinal disease or cancer, who spent an average of $31,069. Dementia patients often require special living arrangements, which accounts for the sizeable difference in cost.

Theentire story is here.

Report Finds Most Errors at Hospitals Go Unreported

By ROBERT PEAR

New York Times - Health

Published: January 6, 2012

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized, federal investigators say in a new report.

Yet even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the “adverse events,” according to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services.

In the report, being issued on Friday, Mr. Levinson notes that as a condition of being paid under Medicare, hospitals are to “track medical errors and adverse patient events, analyze their causes” and improve care.

Nearly all hospitals have some type of system for employees to inform hospital managers of adverse events, defined as significant harm experienced by patients as a result of medical care.

“Despite the existence of incident reporting systems,” Mr. Levinson said, “hospital staff did not report most events that harmed Medicare beneficiaries.” Indeed, he said, some of the most serious problems, including some that caused patients to die, were not reported.

Adverse events include medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners.

The rest of the story is here.