Purchasers of addiction treatment services in this project had an interest in using telemedicine modalities in addiction treatment. The modalities that seemed to create the greatest interest were those that were perceived as readily embraced by treatment providers and their patients.
Level of research findings and their role in decision-making
Meta-analyses support the use of telephone-based continuing care, [5] web-based addiction treatment interventions [12, 13], video-based telemedicine [36], and even smartphone use in mental health [37]. A weakness in these meta-analyses is that they pool studies conducted by the developers. In selecting technologies to consider, the states wanted to know the results of specific products and typically trusted the results reported by developers located in academic settings. However, the states usually wanted to talk to other users of the product and use the product themselves before forming their overall opinions of the technology. The lack of an evidence base for virtual worlds and other considerations affected how the states viewed this modality.
Other reasons for modality selection
Use of videoconferencing was attractive because it met a specific need: to provide access to a scarce medical resource—buprenorphine (Suboxone), in geographic areas that lack physician prescribers. Videoconferencing was also used in South Carolina to increase access to adolescent psychiatrists in remote or rural areas.
Use of smartphone mobile devices was attractive for a variety of reasons: the apparent low entry costs of equipping patients who already have mobile phones with mobile apps; the ability to create a valuable ongoing relationship with a patient using mobile apps; and the research evidence of their effectiveness [27].
Implementation considerations
The project identified several issues to consider when implementing telemedicine technology. Among them is the fact that the substance use treatment field lags behind general health care in the use of non-electronic health record (EHR) technologies [33]. As a result, participants in the project experienced a significant learning curve, as they were either just beginning to investigate technology or were in the early stages of implementation.
Implementing technology also changes the traditional workflow, as well as the roles and functions of clinical staff members. Accordingly, treatment organizations will need to develop new workflows and overcome clinical resistance to these changes.
Cost is a significant challenge that states, counties, and providers face in implementing telemedicine. First, start-up costs can be an issue. Despite initial interest, virtual worlds or web-based treatment systems were perceived as too costly to purchase and operate and were not pursued. Second, reimbursement for basic telemedicine services varies broadly between state Medicaid systems and private insurers, with many not reimbursing for these services.
An additional consideration for telemedicine use involves protecting patient anonymity and compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the 42 Code of Federal Regulations (CFR) Part 2 [38]. HIPAA protects the confidentiality and security of health care information. The more restrictive 42 CFR affords special privacy protections to alcohol and drug abuse patient records. Both regulations present an additional challenge when using technology, because no accreditation system documents that a telemedicine system is in compliance. Prospective users must carefully evaluate whether or not the services meet the requirements of these regulations.
State/county payer and regulatory policy considerations
The participants and the study team considered policies that could promote or hinder the use of the telemedicine modalities piloted in this project.
Telephone-based services
There are no licensing, purchasing fees, or equipment costs associated with telephone-based services. The only potential costs are long-distance or cell phone service charges. Clinical staff would need training in delivering brief focused clinical sessions if the telephone-based continuing care model is adopted.
Since telephone-based services involve synchronous (real-time) communication between the clinician and the patient(s), existing individual, group, or case management payment rates could be used for reimbursement. Only policy or rule changes would be required to extend coverage to telephone-based services. For example, Iowa currently reimburses for telephone-based counseling sessions through Substance Abuse Prevention and Treatment block grant funds.
Web-based treatment
The lack of payment mechanisms to support the costs of using web-based treatment systems is a major barrier to their adoption by specialty substance use treatment organizations. Because their use involves asynchronous (not in real time) use by the patient, without the immediate involvement of a clinician, the services do not fit the existing fee-for-service reimbursement system. Yet, there are costs to an organization for using computerized treatment, including annual licensing fees, training patients on the use of a system, providing ongoing support as needed, and the clinical time needed to monitor progress reports generated by the system.
If research studies continue to demonstrate effectiveness and future studies show a cost benefit and lower costs per episode of care in using the web-based systems, states may start to experiment with reimbursement models that cover the costs.
Videoconferencing
Several policy issues also need to be considered for videoconferencing. First, because platforms are proliferating (and claim to be HIPAA compliant), selecting a platform can be daunting. Second, interstate regulation—when the patient and the counselor are videoconferencing from different states, determining which state regulates the transaction can become complicated. Typically, the state where the patient is located becomes the licensing authority. Hence, the counselor or physician will need to carry a license from the state where the patient is located. Third, at least one state, Florida, offers a certification program for counselors who provide treatment using distance technologies: Certified E-Therapists. Florida’s Certification Board selected the Online Therapy Institutes’ training program. Most states, however, allow licensures achieved for the delivery of in-person clinical care to apply to video care. Lastly, states must allow clinicians providing services through videoconferencing to be reimbursed for those services.
Smartphone mobile devices
The lack of payment mechanisms to support services delivered through smartphone mobile devices is a major barrier to their adoption by specialty substance use treatment organizations. Several A-CHESS features use asynchronous technology that does not provide a clinical therapy session. Therefore, the services do not fit the fee-for-service reimbursement system. Costs to an organization for using smartphone mobile devices include annual licensing fees, training patients and staff on the use of a system, providing ongoing support as needed, and the clinical time needed to monitor progress reports generated by the system. Another potential cost, providing smartphones to those who do not have access to them, could result in the cost of providing smartphones and service plans. Fortunately, in some settings carriers and vendors have developed special programs for low- or no-cost services that states, counties, and providers can use to increase access to mobile devices and data plans. As mobile smartphones and computer tablets become more and more ubiquitous, the services could be delivered more affordably to people who have the smartphone mobile devices and adequate service plans.
Virtual worlds
Initial costs are an impediment to use of virtual worlds, with implementation cost estimates ranging from $10,000 to $100,000. Few provider organizations can afford costs in the higher range; nor are states likely to support such expensive upfront investments.
Existing virtual worlds such as Second Life could be utilized with lower costs. Second Life will lease use of a virtual “island” that only allows access to those with pass codes. The island has no features, so the environment still has to be created. Second Life provides tools for creating an environment, requiring support from someone with the development knowledge and skills. Also, a person using Second Life can access all but the closed environments, and many existing Second Life environments, such as bars and parties, are not conducive to recovery support.
Since use of the technology involves synchronous (or real-time) communication between the clinician and the patient(s), existing individual and group session payment rates could be used for reimbursement. However, policy or rules would have to be changed to extend coverage to these services.