Bob Twillman, PhD

The COVID-19 pandemic has produced substantial changes in many aspects of our lives, as witnessed by the soaring unemployment rate, oil prices sinking so low that companies actually were paying people to take oil from them, and the widespread shutdown of social activities, among other things. For those of us who are healthcare providers, aside from changes directly related to treating COVID-19 patients, perhaps the most dramatic change has been the massive surge in use of telehealth technology to care for patients. Efforts to prevent infection in both our patients and ourselves have resulted in shifting as many patient visits as possible, both inpatient and outpatient, from in-person to telehealth, and many outpatient clinics are closed entirely. Most of us are learning new clinical skillsets necessary for this type of intervention, and many of us are discovering the advantages of telehealth visits.

As a pain management psychologist with a keen interest in comprehensive integrative approaches to pain care, I’ve been thinking about the long-term implications of the surging use of telehealth for delivering this type of care. Personally, access to telehealth is something I’ve always wanted, especially for the people with chronic pain who travel two or three hours to see me. Those trips are painful and expensive, not to mention dangerous in some weather conditions, and I’ve often thought it would be ideal to see those long-distance patients via telehealth. Telehealth research tells us that both patients and clinicians find these visits more satisfying, that patient retention is higher, and that the clinical outcomes are at least equal to those when we see patients in our offices. But there have been barriers preventing us from making greater use of telehealth, including the technology requirements for both patients and clinicians, the know-how to use that technology, licensure requirements for those who might treat patients living in other states, and the universal bugaboo in integrative health, namely, adequate insurance coverage.

As the saying goes, necessity is the mother of invention. Under the pressures related to the COVID-19 pandemic, these barriers have fallen by the wayside in a matter of weeks! One month ago, I was attempting (and failing!) to have my first telehealth visit with one of my patients. Within a week of that first visit, I was working from home 100% of the time, seeing all of my patients via telehealth. I lost a few, at least for the duration of this crisis, because they either couldn’t, or didn’t want to, use the telehealth technology, but that just enabled me to fill their slots with new patients from my two-month-long waiting list, who were perfectly happy to use telehealth. Now that I’ve been using telehealth exclusively for almost a month, I’m finding that my sessions with patients are more efficient and to-the-point, and thus far, the patients seem satisfied with that. I would be delighted if I can continue doing a good chunk of my work through this medium. (And it’s really hard to argue with both the commute and the dress code!)

All of this happened while the federal government was enhancing Medicare coverage for telehealth interventions and while state governments were establishing policies allowing licensed providers to practice across state lines via telehealth—changes many had sought for the better part of the past decade. None of this was even on the radar for most of us on Valentine’s Day, but by St. Patrick’s Day much of it had changed, and by April Fool’s Day it all had changed! Now it remains to be seen if any of these governmental entities can, or will even try to, stuff the genie back into the bottle after the current crisis passes.

For the integrative pain management community, telehealth may present opportunities to break down patient access barriers, but I want to caution that I don’t think it is a panacea. Certain integrative health interventions, such as psychotherapy, nutritional counseling, routine follow-up visits with allopathic, osteopathic, and naturopathic physicians, yoga, tai chi, mindfulness-based stress reduction, and others, can easily be adapted for the telehealth environment. It’s harder to imagine how one can provide chiropractic adjustments, acupuncture treatments, and massage therapy through a telehealth link. That said, it is worth noting that Michigan passed a law a few years ago allowing the practice of physical therapy through telehealth, and some of our colleagues are rapidly innovating ways to provide these types of treatments with their patients, even sometimes involving caregivers in the process. Now we need the research to show the effectiveness of these treatments, delivered in these ways.

Those treatments that do adapt well to telehealth can now be available to many patients who previously could not access them for geographic reasons. I live in Kansas City, and throughout my 19 years in clinical practice here, I’ve seen patients who have come from as far as 400 miles away to be treated at the major medical centers where I’ve worked. It’s just not practical for those patients to travel an entire day just to spend an hour talking to me every other week, and for many of them, I am the nearest pain management psychologist. For many providers of complementary and integrative health services, the story is the same, so even if patients can afford the uninsured treatments those providers offer, they can’t realistically receive those treatments. Telehealth offers the promise of giving those far-away patients access to the treatments that can be adapted to the medium, with the caveat that we still need to work on improving insurance coverage.

But, as mentioned above, telehealth is not a panacea because some of our most evidence-supported treatments can’t be adapted to this medium. And none of the changes we’ve seen as a result of the pandemic addresses the supply of providers to deliver those services. For instance, I mentioned that I had a two-month waiting list, and that was after only five months in practice, with a limited number of referral sources and a small amount of marketing to providers only within our health system. Yes, telehealth makes it possible for more patients to access my services, but it doesn’t put more appointment slots on my calendar, and it doesn’t create any new pain management psychologists to see more patients. One could argue that, if my efficiency continues to increase, I can see more patients for shorter appointments, but it remains to be seen if that can be done. Every pain management psychologist I know has a full patient panel.

In sum, I guess my message is this: yes, telehealth may break down some access barriers for patients needing comprehensive integrative pain management, but there are a lot of things that need to happen to ensure that we gain the maximal benefit of that opportunity. We need to ensure that patients have access to the technology needed to engage via telehealth, that insurance continues to cover these services on a par with in-person visits, that other regulatory changes such as interstate practice are made universal and sustained, and, perhaps most of all, that we continue increasing the number of providers available to see all the patients who need us. Failing to do so will just widen the mouth of our referral funnel without increasing the diameter of the spout, as an increasing number of patients try to see the same small number of providers.