Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Sunday, April 14, 2013

Dr. Tele-Love, or, How I learned to Stop Worrying and Love Skype

In the process of learning all about the new CPT coding, I also learned that phone and Skype sessions are not covered by insurance. The reasoning seems to be that they are considered substandard care. And apparently you can't cut a deal with your patient in which he will pay you for a phone or Skype session, regardless of his coverage, because a patient cannot legally agree to substandard care. Well, I guess you CAN make that agreement with your patient, but if he ever decides to sue you, you're buggered.

Furthermore, the point was made by the lawyer who gave the talk I attended that if you call your doctor to ask about something, say, at night, you don't get a bill for it. So, by extension, you can't bill for a full session that takes place on the phone.

True. Only lawyers can bill for phone exchanges. By the minute.

Personally, I don't like phone sessions. Maybe because I don't like talking on the phone, in general. I find it difficult to lose that sense you get of a patient who's in the room with you, not to mention the facial expressions and other visual cues (admittedly, these are lacking in analysis, as well).

That said, sometimes, it's necessary. A patient who needs to move suddenly, but hasn't transitioned to another psychiatrist yet. Or maybe doesn't want to. A patient who's laid up at home because of illness. Or maybe because of maternity or paternity leave. A patient who has to fly to a distant city due to a family emergency or a death.

It seems to me there are a lot of good reasons to rely on phone or Skype sessions, especially when the patient would suffer without any session at all. Are we, as psychiatrists, really supposed to spend 45 minutes on the phone with a patient, making the same comments and interpretations we would make in person, working just as hard as we would in person, and then not charge for the session?

This is a topic for another time, but why do people think it's immoral, or somehow distasteful, for doctors to want to make a living? Are we really supposed to work for free?

So what's the deal, here? Why is tele-medicine considered substandard? Is it just an excuse to limit coverage, or is it based on some factual data?

As it turns out, prison systems routinely use tele-psychiatry. I hope it isn't the case that prisoners are getting substandard care.

And you can use telepsychiatry in some states, but not others. Additionally, the use of telepsychiatry varies based on type of insurance.

For instance, medicaid covers telepsychiatry in NY.

Private insurance varies by insurer. My guess is, if there's any excuse not to cover, they won't cover.

Medicare covers telepsychiatry with some provisos. First, the consumer must be located in a "non-metropolitan statistical area", which may or may not be the same thing as a Health Professional Shortage Areas (HPSA) .

From what I can tell the consumer also has to have the session in a qualified facility, which I guess means that he or she needs to show up at a clinic or hospital, and have a qualified staff person with him or her. During the actual session? I can't figure that out.

The clinician, on the other hand, can be anywhere, even at home, but has to be licensed in the appropriate state. I assume that's the state where the patient is located.

Now, back to that "substandard care" business. If it's good enough for prisoners and people in rural, underserved areas, it should be good enough for anyone. Alternatively, it's not really good enough for anyone, but it's the best anyone can do under certain circumstances.

The next question is, "What does the literature say about how telepsychiatry compares to in-person treatment?"

Stay tuned.


  1. The military also uses tele-psychiatry.

    I think you just made the point that Skype provides more than psychoanalysis, if you believe that information you get from seeing the patient is important.

  2. My malpractice carrier will not cover me for any events that occur as a result of a tele-psychiatry session but will cover me for a house call.

    1. My goodness. When was the last time anyone made a house call?

  3. I believe the 2nd alternative: "It's not really good enough for anyone, but it's the best anyone can do under certain circumstances." Apparently that's why being in prison, or in a non-metropolitan area (with presumably less access to mental health providers) justifies it. Here are some other scenarios where it would be the "best anyone can do": the bedridden, Antarctic explorers, highly dependent patients who just moved or are temporarily away, and so forth.

    Leaving those special cases aside, treating someone through a narrow-bandwidth channel trades off clinical excellence for expediency. Skype is way better than texting, text-chat, email, or phone call — I've heard of such "sessions" being charged for by a few therapists. But even Skype deprives the clinician of subtle nonverbal facial or vocal expressions, subtleties of vocal tone, body position, the smell of alcohol on the breath, and potentially important details of the environment the patient is in. Then there's the treatment frame: I've heard of clients lounging by the pool while wearing a bikini, holding a drink in one hand, and Skyping their therapist with the other. Might that affect the frame a little? Finally, much has been written about patients in far away places, who can threaten or commit suicide in real time, with the therapist helpless to do anything about it.

    The bandwidth limitations of tele-psychiatry are very different, and I would submit far more restrictive, than those of traditional psychoanalysis. One picks up many subtle cues being in the same room with another person.

  4. 1.) Believe me, prisoners get substandard care. Full stop. In person or not. No dental care until they need to pull out the tooth etc.

    2.) I know that some tele-medicine in developing countries involves a local doctor or NP/PA type equivalent who is legally responsible, and the expert in Europe--or wherever--is not licensed to practice there. It leverages expertise for unusual conditions. I think that this is useful for specialty consults.

    1. I believe that prisoners get substandard care, although I know a couple of forensic psychiatrists who make it their business to try to change that fact.

      I agree that the tele-model is useful for specialty consults like you describe. In fact, I think it had a lot of applications, and if utilized properly, may be able to provide much needed care to people who would otherwise go without. But I'm concerned about checks and balances. Why bother going to someone's office when it's cheaper and "just as good" to meet by phone? It's the kind of thing that could play out as an insurance issue rather than a clinical one.