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SAMHSA News - January/February 2005, Volume 13, Number 1

Conference Explores High-Tech Treatments (Part 2)

Reimbursement for Services

Treatment providers interested in adding new technologies to their practices also need to determine how they will be paid for these new services. As an example, a representative from the Centers for Medicare & Medicaid Services (CMS), addressing the conference through a video-teleconferencing hookup from Baltimore, MD, focused on Medicare reimbursements. Medicare requires interactive telecommunications technology as a condition of payment for tele-health services along with certain facility and geographic criteria.

Medicare covers a range of mental health services as tele-health services. Those services include individual psychotherapy, pharmacologic management, and psychiatric diagnostic interview examinations. However, services must be furnished by physicians, clinical psychologists, clinical social workers, or clinical nurse specialists. Services by certified addiction counselors are not covered.

Medicare requires an interactive audio and video telecommunications system that permits two-way interaction between the physician or practitioner at the distant site and the beneficiary at the originating site (the location of the patient at the time the tele-health service occurs). This service must be rendered in real time with both the patient and the practitioner present and able to see and hear one another simultaneously.

However, as long as the service requirements meet the regulations for the patient and for the interactive audio and video telecommunications, Medicare imposes no limitations on the type of technology that practitioners may use. For example, wireless or Internet hookups would each be permissible.

Furthermore, the originating site must be located either in a county outside a metropolitan statistical area or in a rural health-professional shortage area.

Finally, the originating site facility must be either a physician's or practitioner's office, hospital, critical access hospital, rural health clinic, or federally qualified health center. Facilities such as a practitioner's office or a rural health clinic must be equipped for video teleconferencing. Medicare will not reimburse tele-mental health services delivered to patients' homes.

According to CMS, current Medicare reimbursement requirements are legal mandates that only the U.S. Congress can change. Medicaid, however, may cover a wider range of technology-assisted services, and coverage may vary among individual states.

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Other Issues

As presentations revealed, the range of professional services now offered as well as the technology issues to be addressed are well beyond what's widely used. Mental health and substance abuse professionals across the Nation are adapting effective treatment methods to the capabilities of various technologies and the needs of varied consumers. Dozens of hospitals, clinics, and state and local agencies already deliver mental health services through video teleconferencing. Technology-based substance abuse programs range from primary prevention for children to aftercare for adult addicts in recovery. These programs use e-mail, chat rooms, live over-the-Internet groups, and interactive Web sites.

Technology-based interventions using an equally wide range of equipment address issues including smoking cessation, weight loss, eating disorders, and depression among breast cancer patients.

Consumers receive services in schools, workplaces, their own homes, and over mobile devices, wherever they are throughout the day. Still, these technological approaches face widespread skepticism or even opposition among some treatment professionals. But compared to the needs of underserved groups such as rural residents, these objections are minor. More than 80 percent of master's-level social workers and 90 percent of psychologists and psychiatrists practice in metropolitan areas. More than 60 percent of rural Americans reside in federally designated shortage areas for mental health services, stated Dennis Mohatt, Director of the Western Interstate Commission for Higher Education's Mental Health Program.

The promise of e-therapy and tele-mental health also comes laden with many unanswered legal, ethical, and clinical questions. "Most state laws make no mention of these new services," said Anthony Ragusea, a predoctoral intern in psychology at Washington State University. He added that there is "no actual case law on this yet . . . still, most professional organizations in mental health have approved the practice of online therapy."

Because of state control of licensure, however, electronic services that cross state lines or even national borders are a "crucial legal issue" that has yet to be resolved, said Jeffrey Barnett, Psy.D., a licensed psychologist in private practice.

Service providers using electronic technologies face other serious challenges:

  • Difficulty in diagnosing or evaluating patients without actually seeing or hearing them in person

  • Requirement to ascertain true identities and obtain valid consent in the anonymity of cyberspace

  • Importance of protecting confidentiality and privacy (Who else may have access to a client's computer or e-mail account?)

  • Possibility of having to deal with emergencies or make service provider referrals in distant places.

In addition, practitioners must find ways to maintain a professional tone in electronic interactions and to make up for the nuances of facial expression, tone of voice, and body language that some technologies do not transmit.

Numerous professional associations are currently grappling with the ethics of new technologies, but a general consensus on these issues has yet to emerge, Mr. Ragusea said.

To date, research on technology-assisted services finds the outcome to be favorable and comparable to traditional methods in general, reported Aaron Rochlen, Ph.D., an assistant professor of counseling psychology at the University of Texas. Only a small number of studies have been conducted. "The importance of research cannot be overstated," Dr. Rochlen said, especially of "big-number studies" with control groups to evaluate outcomes.

"It is time for new strategies to deliver much needed care," said Dr. Clark as the conference concluded. "The discussion will continue." End of Article

See Part 1: Conference Explores High-Tech Treatments

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Conference Explores High-Tech Treatments
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Part 2
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SAMHSA News - January/February 2005, Volume 13, Number 1

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