Rural veterans have fewer ED visits, more psychotherapy with VA tablets

Rural veterans who received tablets from the Department of Veterans Affairs had more telehealth psychotherapy appointments and fewer suicide-related emergency department visits, according to a new study published Wednesday.

Study authors from the VA Health Economics Resource Center located at the VA Palo Alto Health Care System in California tracked more than 13,000 veterans with a mental health history over the first year of the pandemic, after receiving a broadband- and video-enabled tablet from the VA. The tablets enabled veterans to receive more mental healthcare than they normally would have, and they had a lower likelihood of having an emergency department visit for any reason, according to the study.

Researchers concluded that other health systems could undertake similar projects for their rural patients to increase access to mental healthcare and prevent suicides.

"The findings seem really promising for reducing the rural disparity in suicide, which is growing as we're seeing higher and higher rates of suicide in rural areas," said Kimberly Smathers, managing director at ATI Advisory.

She added that using tablets at hoe may help older adults living in rural areas erase the stigma around suicide and mental health.

There are higher rates of suicide among people living in rural areas than urban areas, and that gap has only increased since 1999, according to the Centers for Disease Control and Prevention. U.S. veterans' rate of suicide is almost twice as high as people who haven't served in the military. Rural veterans are more likely to die by suicide than veterans living in urban areas.

The VA's Office of Rural Health and Office of Connected Care in 2016 started distributing tablets to veterans. As of September 2021, more than 100,000 veterans had tablets, with 93% of those distributed during the pandemic. One-third of veterans who received the electronic devices live in rural areas, and researchers used data from the health system to track outcomes those rural residents with a previous mental health visit.

Tablets were associated with an overall 20% reduction in the likelihood of an ED visit, a 36% reduction in the likelihood of suicide-related ED visit and an increase of 3.5 video psychotherapy visits per year.

Though the findings offer a potential template for non-VA health systems and payers, the VA system has a dramatically different integrated structure. For instance, most U.S. insurers operate business units in silos, where mental healthcare and medical care operate separately.

"They [insurers] certainly should be interested in this finding, but one difficulty companies often have are separate budgets and management systems for inpatient and outpatient," said Dr. Joe Parks, medical director at the National Council for Mental Wellbeing. "There's a number of interventions that show treating mental illness reduces medical hospitalization, but if those costs are to behavioral health, and all the savings go to medical, it's not sustainable."

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Many insurers have tried pilot projects similar to the VA's program, but they face issues with grant funding and extending the initiatives, Parks said.

"Grant-funded pilots usually show good results but very commonly never result in permanent change to the system of care," Parks said. "They die once the grant funding runs out because there's no volume across all payers to keep it going."

Scan Health Plan, a not-for-profit insurer with 275,000 members mostly in Medicare Advantage, launched a project shortly before the pandemic started to target mental healthcare access. The plan worked with a physician group in California in a region with a shortage of mental health clinicians. Plan members, but also any older patient of the practice, gained access to psychiatrist via video that was set up in a primary care office, all funded by Scan. Once the pandemic hit, in-office telehealth visits shifted to patient homes.

The plan stopped funding the program after 18 months, but because of results in lower depression and anxiety measure scores and other results, the physician group decided to continue the program and scale it to all patients. Scan Health Chief Medical Officer Dr. Romilla Batra said they discontinued funding because it operates value-based care pay arrangements where the physician group was already being paid to deliver mental healthcare.

"We knew that physicians perhaps were not ready to try and test new things, but we knew there was a need for it [mental health service innovation]," Batra said. "We are always thinking about how we can bring care to members, but also in partnership with the primary care physician so it's [care delivery] not disjointed."

Scan is currently working with UCLA to evaluate the program and will soon publish findings on improvements in depression scores and impacts to hospitalizations or suicide-related emergency department visits.

Community behavioral health centers receive higher Medicare reimbursement in exchange for coordinating patients' medical care by making formal relationships with area hospitals and primary care physicians, according to Parks. Many centers transitioned to telehealth because of the pandemic.

Non-VA providers got a boost to expand telehealth when the Department of Health and Human Services broadened telehealth payment under the COVID-19 public health emergency in 2020. The Biden administration is expected to extend the current deadline past April 16, but there is a question of how long it will continue as COVID-19 cases subside. While Congress recently put in place a five-month extension for telehealth payments past emergency expiration, it will have to pass legislation to keep the changes permanent.

Mei Kwong, executive director at the federally designated national telehealth policy research group the Center for Connected Health Policy, said private payers have flexibility to make these payments permanent, but many also follow Medicare's lead of Medicare policy.

"Providers should have the option of utilizing it [telehealth] if they think it's appropriate for that specific patient at that specific time," Kwong said.