Shifting State Rules Keep Telepsychiatry Patients in Limbo

Jan. 24, 2022 — Lorraine Pereira’s mental health treatment has been in a state of limbo since August 2021.

That’s when the 23-year-old moved from Iowa to California for a research assistant position at the University of California, San Francisco. That’s also when she began seeing her longtime Iowa-based therapist via online video.

Now, every month, she wonders if expiring pandemic declarations and state laws will force her to end this long-term, and beneficial, relationship with the only therapist she’s ever had.

Pandemic Fuels Telehealth Growth

Telemedicine exploded during the pandemic, and perhaps no other specialty showed how well it can work than mental health treatment.

Telepsychiatry increased from 7% of appointments to 85.5% between January and May 2020. During that time, all 50 U.S. g overnors declared emergencies, many of which included license waivers allowing psychologists to care for patients outside of their state via the internet. But more and more states are ending their emergency declarations, cutting off providers’ out-of-state privileges and reverting to their pre-pandemic status.

Right now, 22 states continue to have COVID-19 emergency declarations in place: Arizona, California, Connecticut, Delaware, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Missouri, North Carolina, Nevada, New Mexico, Rhode Island, Texas, Utah, Washington, West Virginia, and Wyoming. As of Nov. 30, 19 of these states still offer some leeway with licensing. The more flexible licensing has expired in Connecticut, Mississippi, and New Mexico.

Licensure waivers in Georgia, Hawaii, Iowa, Louisiana, and New York are set to expire before February. New Mexico renewed its waiver Jan. 14 -- the day it was set to expire.

From Beneficial Treatment to Starting Over

It’s simple: If access to psychiatrists and psychologists disappears for out-of-state patients, all will be forced to find new professionals to treat them. In essence, it will mean starting their mental health treatment from scratch.

“I feel so much more strongly about therapists than physicians on this issue, because you have a relationship with them, and like a really strong one,” Pereira says. “Having to re-perform your trauma over and over to different people because of these laws is just stupid.”

It is possible most of those five states could renew their expiring waivers put in place during the pandemic to allow cross-state telepsychiatry care, but the short-term nature of the extensions creates problems for patients and practitioners.

Each medical specialty has its own licensing board, which is governed by a state board. The Iowa Board of Psychology, which dictates where Pereira’s therapist can practice, prohibits its members from practicing in California.

Iowa has been extending its emergency proclamations 28 days at a time. But in August, the same month that Pereira moved, Iowa Gov. Kim Reynolds issued a new disaster emergency proclamation that extended the waiver and allowed Pereira to continue to see her therapist.

“It was very scary,” Pereira says. “She's my first therapist, and I felt like I had built a lot of trust with her. It was just going to be hard to build that trust and context with another person so soon.”

Taking Your Therapist With You

Sterling Ransone, MD, president of the American Academy of Family Physicians, says telepsychology patients would benefit from looser licensing restrictions.

“We at the American Academy feel that it would enhance patient care to be able to have our licenses be valid in other states,” he says, noting that many transient telehealth companies cannot access patient medical records.

Ransone practices in central Virginia, but a lot of his colleagues practice near state borders because of these laws.

“It’s a big issue, because they have to go through and get the regulatory process and the licensure process in multiple states in order to see their patients who might live across the street from them,” he says.

But New York psychiatric nurse practitioner Anne Gallenstein, who has practiced exclusively via telehealth since March 2020, sees advantages in keeping treatment local.

“In terms of training and capability, I don't have concerns about people working across state lines,” she says. “I have a personal preference of seeing people in my locale, because I am very familiar with resources here. I'm much better positioned if I have a knowledge of my patient’s environment.”

When Expiring Rules Affect Treatment

Margaret Distler, MD, an assistant clinical professor of psychiatry at UCLA, who treats college students with mental illness, was able to continue care for her out-of-state patients throughout the pandemic via telehealth because of the interstate license waivers. Now, she and her colleagues are reluctant to take out-of-state patients because of the waiver uncertainty.

Distler is also reluctant to change medications for patients in states with expiring waivers, because she does not know if she will be able to follow up with them.

“The lesson I've learned is that when you establish a doctor-patient relationship, we think about it as being a long-term relationship, but if it's out-of-state, there's so many things that could impair that,” she says.

Many of Distler’s patients could not continue with their providers due to changing state requirements.

“I know that was a huge disruption,” she says. “It's very difficult to find a therapist these days. A relatively small number of therapists take insurance, and so it's hard to find somebody who's affordable and local.”

Distler says given the deeply personal and emotional topics discussed in dealing with mental illness, continuity of care improves treatment outcomes.

Untreated mental illness can lead to poor quality of life, including tough time with social functioning, problems building and keeping relationships, a poorer family life, and problems with work. People who are depressed and denied health care may be less likely to adhere to a healthy diet or exercise, which can add to a decline in physical health. Also, mental illness and substance use disorders can often happen together.

Out-of-State Patients Should Act Now

If you’re a patient in a good treatment relationship with an out-of-state mental health provider, what should you do?

“I would encourage people to kind of find local providers, because that will be a better long-term solution,” Distler says.

But if patients must move, she says, they should talk with their provider or insurance company about ways to maintain their connection with their out-of-state provider.

“I do think that if somebody is worried about continuity of care, which is really of the utmost importance, that perhaps we should think about interstate treatment, because psychiatric treatment now is a short-term, and not a long-term plan, which makes me sad.”

SOURCES:

Lorraine Pereira, California.

Sterling Ransone, MD, president, American Academy of Family Physicians.

Margaret Distler, MD, assistant clinical professor of psychiatry, UCLA.

Anne Gallenstein, psychiatric nurse practitioner, New York.

American Psychology: “The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery.”

Stateline: “More States Rein in Governors' Emergency Powers.”

Alliance for Connected Care: “State Telehealth and Licensure Expansion COVID-19 Dashboard.”

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