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Psychotherapist D Gregory Smith says telehealth has given him an opportunity to meet his patients “where they are ”— both literally and metaphorically — and if he’s able to, he plans to continue offering telehealth services in some capacity even after COVID-19’s infection risk has receded.

Like many health care providers in Montana, Smith has been tracking developments in the telehealth landscape. If, and how much, he’ll be able to continue using telehealth with clients who are scattered across the state is largely in the hands of policymakers who govern health care programs and the private and public insurance companies that pay for it.

Smith’s practice is based in downtown Bozeman, but since policymakers loosened regulations around telehealth and increased financial incentives to offer it during the pandemic, he’s used video meetings or old-fashioned phone calls to connect with patients as far away as Great Falls and Miles City.

“I’m seeing people who are all over the state [who] probably couldn’t access me in normal circumstances,” he said. “In that way, [telehealth] has really just been a blessing.”

Smith, who specializes in counseling for LGBTQ people, said some of his clients would have a hard time finding the kind of care he offers in their own communities, and he sees telehealth as a flexible way to meet their needs while supporting public health measures and safeguarding his own health through the pandemic. As someone living with HIV, Smith is immunocompromised. He’s scarcely left his house since mid-March, save for weekly trips to his office to collect mail. But he said that hasn’t hampered demand for his services.

Smith said he has a waiting list and is as busy as he’s ever been. Although he met most of his current clients face to face before COVID-19 changed his practice, he hasn’t laid eyes on about a third of them in person. He said he doesn’t think that has diminished his ability to offer quality care.

“I’ve noticed that people who are engaged in person are still engaged online or via phone, especially patients I’ve worked with for a long time,” he said. “I do the same work if I see them in person or if I see them via telehealth. … If you’re a great therapist, you can do it in any medium.”

Smith also said there’s been a downtick in clients missing sessions, and he attributes that to eagerness for interaction and the convenience afforded by telehealth. His observation is consistent with data collected by Behavioral Health Alliance of Montana Executive Director Mary Windecker, who says her members have seen a “huge decrease in no-show rates.”

Bella Butler, a University of Montana student who’s been meeting with her psychotherapist over online video platform Zoom since July, said that given her packed schedule, she’s not sure if she would have continued to prioritize therapy without the convenience offered by online visits. 

“It’s really easy for me to push things like that off, but [telehealth] has made [therapy] more accessible to me, time-wise.”

She added that her therapist has worked hard to adapt to telehealth, and she’s grateful she’s able to continue accessing treatment, but she still prefers in-person visits. She said physically sharing a space with someone creates a different kind of experience than what’s available through a screen, allowing participants to more fully register nonverbal cues like body language.

“You’re [discussing] deeply personal and vulnerable aspects of your life,” Butler said. “There’s a human connection that supports that vulnerability that you just don’t get using a computer.”

Butler said she’s recently been wondering if providers’ rates should reflect such differences in care received online versus in person. She said she’ll be interested to see what happens with fee structures in the coming months.

She’s not alone. With health care accounting for such a huge piece of Montana’s economic pie and supporting some 48,000 jobs in the state, hospitals, clinics and individual providers are eagerly awaiting information from policymakers and insurance companies about their plans for telehealth’s future.

PAY PARITY AND BROADBAND ACCESS 

Much of what paved the way for the ascendance of telehealth in 2020 involved federal and state emergency declarations that eased regulations and created pay parity between telehealth visits and in-person visits, meaning both are reimbursed by insurance programs at the same rate. In August, President Donald Trump signed an executive order permanently expanding telehealth benefits for Medicare recipients. 

Those actions led to an explosion of telehealth visits. Community Health Partners, a federally qualified health center with locations in Bozeman, Belgrade, West Yellowstone and Livingston, reports an increase from basically no telehealth visits in 2018 to about 100 in 2019. Then the pandemic hit. As of Dec. 10, CHP has now conducted about 12,000 telehealth visits.

“The slew of policy changes that came along with the pandemic declaration … have really made telehealth a strategy for our organization to keep our doors open,” Community Health Partners CEO Lander Cooney said.

Like everyone else contacted for this story, Cooney said she supports the continuance of telehealth services in Montana in some form. There’s broad agreement that it serves an important function — especially in a rural state like Montana — but how those services are reimbursed will likely draw considerable debate if lawmakers take up the issue during the 2021 legislative session, as they’re expected to do.  

According to conversations with insurance and health industry officials, insurance companies like Blue Cross Blue Shield of Montana and Montana Health Co-Op, though supportive of telehealth in many applications, are expected to lobby to let the market, rather than legislators, dictate pricing structures. Providers and professional associations like the Behavioral Health Alliance of Montana and the Montana Hospital Association are expected to push for legislatively enacted pay parity.

It appears that the pay-parity lobby will have an important ally in Gov.-elect Greg Gianforte. Spokesperson Brooke Stroyke said Gianforte supported telehealth pay parity at the start of the pandemic as a congressman, and “he will continue to support it as governor.” 

“Telehealth will increase Montanans’ access to care and reduce their health care costs,” Stroyke added in an emailed statement to Montana Free Press. “To ensure it’s available to all Montanans, we must increase access to reliable broadband, particularly for our rural and frontier communities.” 

The broadband issue is significant: Montana ranks 50th in the nation for broadband access, according to BroadbandNow, which compiles information on internet service providers for consumers. There have been encouraging developments on the broadband front in recent days, though. Last week, the Federal Communications Commission awarded nearly $126 million for six firms to expand broadband access to about 46,000 currently unserved locations across the state. 

Though the specifics of that deal are still taking shape, it could help providers offer telehealth in the state’s frontier communities, sparsely populated areas of Montana that are isolated from population centers. Such health care providers could include organizations like One Health, a federally qualified health center that provides a suite of primary care, behavioral health, dental and pharmacy services in central and eastern Montana communities including Ashland, Hardin, Chinook and Lewistown.

Hardin-based physician and One Health CEO David Mark said although he was originally skeptical about telehealth, he now considers it a “non-optional part of how you do primary care on the frontier.” He said he’d like to see recent changes to telehealth, including pay parity, become permanent.

“I think we as an organization would feel happier investing in the technology and investing in the innovation to make it really work well on the frontier if we knew that [COVID-spurred changes are] going to be permanent,” he said.

RECRUITING PROVIDERS WHILE PROTECTING THE EXISTING HEALTH CARE WORKFORCE 

The location flexibility offered by telehealth has made some of Montana’s more rural hospitals and health care centers more attractive to clinicians who might otherwise be reluctant to move to the state’s smaller, more remote communities. That, too, is a benefit of telehealth that’s not lost on Mark.

“Being able to let people choose where they want to live and still provide care does open up a lot of opportunity,” he said. “It’s allowed people to have more flexibility in their living arrangement. Anytime we can offer that to our clinicians, it’s a really good retention tool.”

By way of example, he points to a One Health family practice physician who splits his time between Montana (where he keeps an active medical license) and Salt Lake City, where his wife is finishing up a residency.

That technology-supported location flexibility cuts both ways, though. Windecker, with the Behavioral Health Alliance of Montana, said that since emergency orders paved the way for providers in other states to offer services here, large out-of-state groups are clamoring for a slice of Montana’s health care market. It’s not an entirely welcome development.

She points to recent marketing efforts she’s seen by organizations like Intermountain Healthcare out of Utah and the Hazelden Betty Ford Foundation, which has substance use disorder treatment centers across the U.S. Windecker said these operations are catering to private insurance companies in order to secure patients with the higher reimbursement rates typically offered by the private sector.

Windecker said that such cherry-picking of the state’s most profitable clients could hurt the bottom line of existing providers already licensed in Montana. Plus, it could create concerns about quality and continuity of care if a patient receives extensive care from a provider with a limited skill set who’s not tied into local health care networks.

These and other telehealth issues will likely garner considerable notice during the 2021 session. While there are still kinks to work out, most providers and policy makers agree that health care delivery will be significantly altered by COVID-19 moving forward.

“We’ve long advocated for the kinds of changes they’ve made overnight with the pandemic,” Mark said. “You can’t put this genie back in the bottle.”

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Billings native Amanda Eggert covers environmental issues for MTFP. Amanda is a graduate of the University of Montana School of Journalism who has written for Outside magazine and Outlaw Partners. At Outlaw Partners she led coverage for the biweekly newspaper Explore Big Sky. Contact Amanda at aeggert@montanafreepress.org.