July 22, 2022

RE: Discussion Draft – Ensuring Access to Telemental Health Services

Dear Senators Wyden, Crapo, Thune, and Cardin,

CEO Action for Racial Equity (CEOARE) is pleased to comment on the discussion draft of the Ensuring Access to Telemental Health Services Act. We commend the Senate Finance Committee’s step toward advancing bipartisan telehealth legislation to improve access to mental health services through telehealth. Action taken by the Senate in the early days of the COVID-19 pandemic significantly expanded access to health care through telehealth. As reported in the HHS Report by Samson et al. describing trends in use of telehealth by Medicare beneficiaries in 2020, there was a 63-fold increase in telehealth visits in 2020 compared to 2019, and behavioral health visits via telehealth showed the largest increase during that same time. For Black beneficiaries, the change in telehealth visits was 60 times higher from 2019 to 2020. Telehealth has clearly become a critical care pathway for access to healthcare and mental health services during this challenging time and the waiving of previous statutory limitations have been critical to expanding access to care.^[1]

CEOARE is a national fellowship composed of over 100 companies that mobilizes communities of business leaders with diverse expertise, across multiple industries and geographies, to advance public policy in four key areas — healthcare, education, economic empowerment, and public safety. Our mission is to identify, develop, and promote scalable and sustainable public policies and corporate engagement strategies that address systemic racism, social injustice, and improve societal well-being, with a focus on issues that disproportionately and systemically impact Black Americans. From a healthcare perspective we are familiar with the research and data that Social Determinants of Health disproportionately negatively impact Black Americans. We believe a significant root cause of these adverse health and related outcomes for Black Americans is structural racism. From a policy perspective, decisions being made now about barriers to equitable telehealth access may reinforce or deconstruct some of these structural barriers. One of the policies we have identified to advance equitable access to health care for Black Americans is equity in telehealth expansion.

Our work on advocating for equitable telehealth expansion is guided by our foundational principles:

1. ENDORSE the elimination of inequitable restrictions and barriers to coverage for comprehensive telehealth services,
2. PROMOTE & AMPLIFY research that demonstrates the impact of telehealth expansion on Black patients,
3. PARTNER with & ADVOCATE for the Black community to ensure culturally competent, user-centered telehealth design and implementation, and
4. EDUCATE and ENGAGE patients and providers on digital health literacy, which fosters adoption, trust, and accountability.

We write to provide input on the proposed draft with the lens of racial equity and request that the Committee considers these comments as the legislation evolves. In summary, our comments include support for the removal of the in-person requirements; caution against additional barriers to access; support for audio-only with additional suggestions for targeted analysis relevant for Black Americans; considerations for incorporation of digital literacy priorities; and finally, areas of consideration for broadband access, best practices, and expanding beyond mental and behavioral health.

Our specific recommendations on the draft legislation are:

• Subtitle A, Section 1(a)(i)(III)(aa)(bb) – The practitioner or physician could provide the service in-person the same day or within a reasonable time frame; the practitioner or physician can partner with another provider who can give an in-person appointment the same day or in a reasonable timeframe.
  • We support the removal of the 6-month in-person requirement and have previously stated our support of the Telemental Health Care Access Act of 2021, as we believe that an in-person requirement places disproportionate undue burden on medically underserved communities.
  • However, the draft requires for each visit the ability for a practitioner or physician to be able to refer to see or be able to refer a patient to be seen in the same day or in a reasonable timeframe. We acknowledge the importance of being able to see a provider in-person in cases of mental health crisis. However, in the absence of such an emergency, this requirement may serve as a significant access barrier, particularly in areas where there are behavioral health provider shortages. As demonstrated by Ku et al. there is an association with Healthcare Provider Shortage Areas and higher suicide rates which reinforces the urgency to ensure expanded access through telehealth for these areas.^[2] These shortages limit the number of specialty providers within a reasonable distance to the patient (e.g., in sparsely populated or rural communities) and they may limit the availability of same-day or expedited appointments even in more densely populated areas where specialty providers have fewer openings. These issues are exacerbated in vulnerable and underserved communities where compounding issues (like access to transportation or ability to take time off from work and adequate childcare) can make mental and behavioral health services even harder to access. We urge the Committee to consider these and other potential barriers that this draft policy may establish.
  • Regarding referral practices and related requirements in the discussion draft legislation, we request that the Committee provide greater clarity on the purpose of this provision.

• Subtitle A, Section 1(e) Coverage and payment for audio-only services
  • We applaud the Committee for working to ensure access via audio-only telehealth services, as well as requiring the assessment of audio-only telehealth data on a regular basis. This is one important element of addressing the issue of reliable access to broadband, digital literacy and the digital divide and we encourage the Committee to consider mitigating other structural barriers to expand access for underserved communities. The digital divide is heavily interwoven with issues of race, education, and poverty. Affordability and access to the internet is a legacy problem that disproportionately affects Black Americans. As highlighted in the HHS Report assessing telehealth trends in utilization of audio vs. video services, Black individuals were amongst those with highest rates of telehealth visits, but lowest rates of video use.^[3] Audio-only telehealth has been a critical point of access, but we also recommend addressing the structural barriers that inhibit video services.
  • We encourage the evaluation of audio-only telehealth by the National Academy of Medicine to include sub-group analyses on medically underserved communities, especially Black beneficiaries.

• Digital Literacy
  • We recognize and support the Committee’s guidance in Subtitle A, Section 5, promoting best practices for integrating telehealth. In addition, we encourage the Committee to include language that promotes digital literacy support for both providers and patients. In a recent perspective piece entitled, “Reducing Disparities in Telemedicine: An Equity-Focused, Public Health Approach,” the authors highlight the critical importance of addressing community-level barriers with community-based solutions, including digital literacy.^[4] According to a report from the US Department of Education published in 2018 describing digital literacy across the US population, the proportion of Black adults described as not digitally literate was twice that of White adults.^[5] The ability to navigate devices and telehealth programs is central to the achievement of high-quality telehealth care. We recommend that the Committee consider the inclusion of policies and/or supportive services or funding that would facilitate providers efforts to furnish care through telehealth services. Similarly, we recommend that the legislative language support the simplicity, accessibility and usability of telehealth for prospective patients. This includes support for digital health literacy resources to help patients prepare for and navigate telehealth visits. Finally, in this pursuit, we recommend that the Committee require data and reports on observed best practices that improve digital literacy, which can be incorporated into future standards of care.

• Other Policy Areas for Consideration
  • Broadband access – We encourage the Committee to consider modalities and modes of telehealth delivery in relation to the user experience. Equitable access to devices and technology are critical to the delivery of quality care for patients in underserved communities.
  • Best practices for vulnerable communities and more targeted solutions for the Medicare population – As Congress works to collect data on telehealth usage, barriers and best practices beyond the PHE, we emphasize the need for the HHS Secretary to stratify data by race and ethnicity and provide recommendations on strategies to increase partnership between providers and community-based organizations for more coordinated delivery of telemental health services.
  • Call for expanding beyond mental health – We recognize the important steps Congress has taken towards advancing access to telehealth for mental and behavioral health services and encourage this Committee to consider how telehealth expansion can also serve beneficiaries’ needs in other disease states. Health inequities have had a disproportionate impact on Black Americans, and as Healthcare Provider Shortages continue to rise, telehealth may serve as a tool to bridge disparities in access to care. Bose et al. demonstrated in their analysis of Medicare data, that coverage of telehealth through the waiver increased access for all Medicare beneficiaries, but also highlighted the need for a targeted approach to enhance access.^[6] Health equity in policy implementing telemental health must serve as a central guide in considerations for expansion as well.

CEOARE believes that Congress is well positioned to guide our health care system towards a future with healthier Americans through greater access to much needed mental health services through telehealth. We encourage this Committee to leverage the work and bipartisan collaboration to unlock the potential of digital health services as a tool positioned to expand accessible and affordable healthcare, beyond the scope of mental and behavioral health. The needs of our vulnerable citizens and their health outcomes must be prioritized in consideration of what is appropriate for legislation and what should be determined by clinical practice guidelines. Emphasis on the needs of the most vulnerable in policy making may then mitigate the disparities in access to care and in turn improve the health of the Medicare population overall.

Thank you for your consideration of these comments and for the greater efforts pursuing informed decision-making around telemental health services. If you have any questions or would like to follow up on any of the items discussed in this letter, please do not hesitate to contact Roz Brooks via email at roslyn.g.brooks@ceoactionracialequity.com.

Sincerely,

CEO Action for Racial Equity

Citations

[1] Samson LW, Tarazi W, Turrini G, Sheingold S. Medicare beneficiaries’ use of telehealth in 2020: trends by beneficiary characteristics and location [Internet]. Washington (DC): Department of Health and Human Services,  Office of the Assistant Secretary for Planning and Evaluation; 2021 Dec [cited 2022 July 6]. Available from: https://aspe.hhs.gov/sites/default/files/documents/a1d5d810fe3433e18b192be42dbf2351/medicare-telehealth-report.pdf

[2] Ku BS, Jianheng L, Lally C, Compton MT, Druss BG. Associations Between Mental Health Shortage Areas and County-Level Suicide Rates among Adults aged 25 and Older in the USA, 2010 to 2018. General Hospital Psychiatry. 2021;70:44-50.

[3] Karimi M, Lee EC, Couture SJ, Gonzalez A, Grigorescu V, Smith SR, et al. National survey trends in telehealth use in 2021: disparities in utilization and audio vs. video services [Internet]. Washington (DC): Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation; 2022 Feb 1 [cited 2022 July 6]. Available from: https://aspe.hhs.gov/reports/hps-analysistelehealth- use-2021

[4] Lau J, Knudsen J. Reducing Disparities in Telemedicine: An Equity-Focused, Public Health Approach. Health Aff (Millwood). 2022;41(5):647-50.

[5] Mamedova S, Pawlowski E, Hudson L. A Description of US Adults Who Are Not Digitally Literate. [Internet]. Washington (DC): Department of Education, Stats in Brief: 2018 May [cited 2022 July 6]. Available from: https://nces.ed.gov/pubs2018/2018161.pdf.

[6] Bose S, Dun C, Zhang GQ, Walsh C, Makary MA, Hicks CW. Medicare Beneficiaries In Disadvantaged Neighborhoods Increased Telemedicine Use During The COVID-19 Pandemic. Health Aff (Millwood). 2022;41(5):635-42.