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Psychiatrist Dr. Tichianaa Armah, left, conducted a simulated treatment session with Hearst Connecticut Media Columnist Dan Haar, Monday, March 9, 2020, as her employer, Community Health Center Inc., works to persuade the state to allow reimbursement for tele-medicine visits under Medicaid.
I had a session Monday with a psychiatrist, Dr. Tichianaa Armah of Community Health Center Inc. She sat in her office in Stamford and I was at home, on my laptop. She made sure I was stable and asked how I would ideally like to spend the postcard-perfect, early spring day.
Nothing odd there. Mental health professionals for years have treated patients remotely, either by phone or, more recently, using any number of video apps.
Ours was a simulated session to demonstrate a point. This type of treatment, whether for mental health or for many physical medical issues, can happen easily and efficiently. State law allows it and many insurance companies pay for video doctor visits like the one we recreated.
Here’s who doesn’t reimburse for live, remote visits: Connecticut’s Medicaid system, known generally as HUSKY Health. Any HUSKY patient who needs treatment, whether for mental health or any other medical service, needs to trudge to a doctor’s office.
That’s a population of 800,000 people who often don’t have a way to get there, and can’t take half a day off from work. And poverty tends to afflict them with more than the typical bevy of ailments, as poverty does.
The rule should have changed in 2015 when the state allowed tele-medicine. It should have changed in the years since, when Armah’s colleagues at CHC — by far the largest primary-care provider for low-income Connecticut residents on Medicaid — pleaded, cajoled and lobbied the state Department of Social Services to do so.
Now we have the COVID-19 coronavirus forcing vast swaths of society to remain isolated. Suddenly it not only makes sense for DSS to loosen its restriction — it would be dangerous if it didn’t happen.
And so we’re finally seeing some movement, with a hastily arranged meeting set for Tuesday — probably remotely, by video, of all ironies.
Crises will do that, but it shouldn’t have come to this. Most other states are way ahead of Connecticut when it comes to tele-medicine.
“I have argued from a humanitarian standpoint, we have a technology we should use,” said Mark Masselli, founder and CEO of the 48-year-old Community Health Center, which has 17 full-service clinics in Connecticut cities and 210 locations, many in schools and homeless shelters.
Better than in-person?
Arguments against Medicaid reimbursement have been somewhat murky. Perhaps it would lead to a flood of new patient visits that would cost taxpayers many millions of dollars — as if treatment for poor people isn’t good for all of us. Perhaps it would lead to an influx of low-quality charlatans, as if there’s a crush of doctors eager to treat the poor.
I thought the argument might be about quality. How could a remote session, whether with a psychiatrist or an internist, work as well as a good-old, in-person visit?
In fact, in some cases at least, Armah — who teaches at Yale School of Medicine and did her residency there, and heads behavioral health for CHC — said remote visits can be preferable. They keep patients at ease and the docs can see their surroundings.
“Some of our patients, because of the neighborhoods they live in, they don’t really come out of their homes,” she said And if they’re suffering from depression, “They don’t really get out of their beds to wash their faces and brush their teeth.”
And they miss appointments they would make remotely. On Monday, after coronavirus hit Connecticut, some patients didn’t show up in Stamford.
Meredith Johnson, the CHC chief of staff, came to the health center from Yale New Haven Health System, where she set up the tele-medicine system. Protocols for remote treatment are far along in the industry, she said. “We can’t reach through the camera and feel your glands,” she said, but for many issues, it’s no problem.
CHC has been testing tele-medicine for mental health for months now. I saw how efficient it can be, as they sent me a disclosure and approval form, then a link with help in setting up a Zoom account if I needed it, then a phone call to make sure I was ready for the lunchtime appointment.
“If DSS allowed us to be able to bill tele-health like they have in other states, we should be able to bill the full spectrum of patients,” Johnson said.
‘You’re not alone’
It took a public health crisis to make it happen, if it does happen in the coming days and weeks.
“I think COVID-19 is to urban areas what the rural need was for rural areas 10 to 15 years ago,” Johnson said, referring to the rise of tele-medicine in places like Wyoming and Montana.
Connecticut? Here’s a line from a recent blog post at eVisit, a company that offers remote medical treatment technology: “Almost all states (except Connecticut and Rhode Island) have some form of coverage for live telemedicine within their Medicaid programs.”
“This is a tipping point,” Johnson said. “If we’re not going to approve tele-health now, when would we approve it?”
In my “session” with Armah, I told her I felt isolated, living alone with my child grown and gone, working at home most days. She showed how she can delve quickly into my psyche. “You’re not alone,” she said.
Even as one of the fortunate healthy people, with access to medical care and transportation, I could see how her words, her face, her treatment, could be a lifeline. That’s all the more true for the thousands of students in Community Health Center care, who may soon be homebound in the coronavirus crisis.
And if HUSKY qualifies for reimbursement, doctors treating many privately insured patients may get online more readily, and perhaps accept more Medicaid patients. “My whole purpose in life is to improve access to mental health care,” said Armah, who’s from The Bronx.
State ‘actively working on changes’
On Friday, the 18 federally qualified community health centers across the state, of which CHC is the largest, sent a letter to Dr. Deidre S. Gifford, a medical doctor who’s Gov. Ned Lamont’s social services commissioner.
“COVID-19 presents yet another significant challenge to our patients, including potential quarantines and other public health measures that may restrict movement and access to health care facilities throughout our state,” the letter said. “For patients with anxiety and other medical and behavioral health issues, the consequences of isolation and lack of access to their providers can lead to very negative consequences.”
About an hour after I sent an email to DSS asking about the issue, CHC received an invitation to a meeting Tuesday. The department isn’t saying it will immediately approve billing for HUSKY patients.
“We understand the importance and are actively working on policy changes in response to the COVID-19 issue, as well as for routine use in Medicaid/HUSKY Health under certain circumstances,” DSS spokesman David Dearborn said in an email.
It’s a challenge, with federal rules and technology and privacy concerns. But with Connecticut late to the party, it ought to happen fast.
“And here we are in a crisis,” said Masselli, the CEO, “where unfortunately even if they say ‘Okay, go ahead,’ many people won’t be ready because the department did not give them ample time to prepare.”