Use of telebehavioral health services by critical access hospitals in the United States: A qualitative study of the impacts of medicare flexibilities and future opportunities.

Objective: This study examined the delivery of telehealth for behavioral health services among Critical Access Hospitals (CAH). More specifically, we describe how CAHs representatives reported using telebehavioral health (TBH) to meet the behavioral health needs of patients, identify ways in which Medicare billing flexibility did or did not affect TBH use and behavioral health staffing among CAHs, and explore opportunities and challenges CAHs face for using TBH in the future. Methods: We conducted semi-structured interviews of CAH administrators and providers to examine the circumstances under which TBH was used. Results: The extent of TBH use varied across CAHs in our sample; however, provider-to-provider consultations were generally more common in the inpatient and ED settings, with provider-to-patient encounters being more common in outpatient clinics. Medicare flexibilities, such as allowing a patient's home as an eligible originating site and reimbursement for audio-only visits, were reported to be useful by many participants, although staffing changes resulting from the flexibilities were not commonly reported. Concerns about reimbursement levels for behavioral health and uncertainty about reimbursement telehealth in the future were common. Lack of availability of behavioral health providers and administrative staff to support telehealth compounded challenges of planning for telehealth within uncertain policy and reimbursement conditions. Conclusion: Telehealth has potential to close the rural-urban access gaps, but CAHs likely will need supportive policies and technical assistance to meet their communities' needs with TBH.