Mental Health Access, Telehealth Policy and the Future of Behavioral Health Care with Andrea Fox

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies, and all the folks in between. Let's explore what's working, what's not, and what's next.

Welcome back, everyone, to the Mental Health Evolution podcast, where we talk about how mental health care is changing and where it's headed. Today we are joined by Andrea Fox, senior editor at Healthcare IT News. That's Healthcare IT News. She has spent more than two decades covering topics of health, technology, public health, and government policy. Andrea has been talking to providers, IT leaders, and industry groups who are on the front lines of expanding access to mental health care. She has followed the rise of telehealth, the ongoing fight over virtual prescribing rules, and the growing conversation about how data on things like housing, income, and community resources could change the way we identify and reach people who need behavioral health support. Today we are going to talk about what has actually gotten better when it comes to mental health access, where the gaps still are, and what the future might look like as technology and policy continue to evolve. Andrea, welcome to the show.

Thank you, Rachel, for having me. It's great to be here.

Awesome. Well, before we dig into some questions, I want to give our guests some relevant articles. All of these will be in the show notes. But just to give everybody a little baseline of some of the work that Andrea has done done, I'm going to talk about a few of the articles that she has published. The first one is called Where Telehealth Stands Shut Down. Every Day Goes It's Worse. And this article captures the precarious state of telehealth found itself in as pandemic era flexibilities came under threat of expiration. You all might remember if you're a provider, certainly if you are on the business side, we all experience this question of is telehealth still covered? Is it not covered? Are there end dates and what does that look like for providers and for patients? And Andrea covered that very well. Second article called telehealth Prescribers Urge Feds to Act Quickly on Virtual Prescriptions. And in this piece, she covered the urgent calls from telehealth prescribers for the federal government to establish clear and permanent rules around virtual prescribing, particularly for controlled substances used in mental health and addiction. Treat treatment the story highlights the tension between regulatory caution and patient need and documents the real world impact of that uncertainty on both providers trying to deliver care and of course, patients trying to access it remotely. The next article called Stakeholders Ask New DEA Administrator to Resolve telehealth Prescribing Rules. This was again, more information about some of these rules about resolving telehealth prescribing and some of the limbo there. And I can't wait to dive more into you into that, Andrea, as we talk. And then the last one here is addressing behavioral health resources and costs in Ohio. And this piece, though it's specific to Ohio, it reveals structural barriers that stand between people in need and the behavioral health services available to them, including things like cost, geography and a shortage of providers. Andrea reported on how Ohio stakeholders were working to navigate those gaps and what technology and policy tools were being brought to bear. It's a grounded on the ground story that illustrates both how far access has come and how much further it still needs to go, particularly in rural and underserved communities. So with that kind of a backdrop of the things that we're covering, the things that we're looking at, I'm excited to sort of dig into this conversation. Andrea, you have been covering telehealth, mental health policy, this industry, for years now. I'm wondering what do you see as the most meaningful shifts in how people are able to access behavioral health services? What has actually changed?

All right, well, so all statements I make are of course, my own views. From my experience covering these topics, I think the most meaningful change for access has been the ability for mental health providers to work and bill outside of traditional locations such as their home offices, and to provide services to patients based on clinical needs, not just their locations. That's made it possible for some practitioners to transition to a more personalized and patient centered integrated care model that better aligns with their specialties. For the practicing specialists that I know personally, these flexibilities have eased their personal work life balance strains and they anecdotally report feeling more available to care for their families and themselves as they focus their practice on patients with behavioral health health needs that they align with. So combined with like the privilege to practice compacts that states have set up, TELESYC has made it theoretically possible for patients in behavioral healthcare deserts, like a lot of our rural areas, to connect with providers outside of their local area.

Yeah, that access to care, I think has really been important. Is there anything right now happening that is restricting telehealth in the mental health care Industry at all. Are there any policies, are there any insurance restrictions that are happening that are restricting that, that you're aware of?

No, not that I am aware of. As far as recent restrictions. However, a recent study that I just covered in the last week or so suggests that access in rural and low access areas, at least for Medicare patients seeking care outside of the federally qualified healthcare centers, has not improved as much as we had hoped with the increased flexibilities that followed the pandemic. So that I found really interesting because you know, that's been touted even by Dr. Oz. As you know, telehealth is essential to making sure that we have mental health access in rural areas. But this study looked at different rates and overall the researchers have been seeing increases in mental health telehealth utilization since the pandemic. However, EPIC System's own online telehealth utilization tracker, which gets its data from all the healthcare organizations on its electronic health record system, the percentage of mental health encounters has dropped from 32.8% in January 2023 to 28.2% in December 2025. So we're actually seeing a drop. And now when you combine that with the projected 1 to $2 billion cuts to grant funded mental health and substance use treatment and services under samhsa, that has not been reversed. That had been reversed the beginning of the year, that would surely have disrupted mental health and addiction care and deteriorated positive post pandemic access trends that we saw. So luckily that funding remained in place. But I think we would have seen a significant drop had that occurred.

Yeah, yeah, definitely. I do believe that some insurance providers, maybe more commercial insurance providers, have set up paying less to telehealth versus an in person session. Do you have any thoughts on that?

Yeah, on the commercial side you see a lot more, you see a lot more flexibility. There's all kinds of programs where people can access these services. But I don't have a lot of insight into what the usage rates are.

And it's interesting anecdotally, I know too here locally we get a lot more calls for in person appointments than for telehealth at this point. So it's harder to fill telehealth sessions than it is to fill in person sessions.

Interesting.

Yeah, right. It has, it's been, I'd say the last two years, it's definitely been a shift where people prefer to come into the office. Now they might utilize telehealth for convenience, like there might be some of using it, but they, they are wanting the ability to be in the office.

Yeah. I mean, I can sort of see that as an individual, you know, getting out of your environment and, you know, being able to focus on what you focus on and in those sessions to make them, I don't know, I guess the most bang for your buck.

Yeah, yeah. So let's talk a little bit about these prescribing battles that you have reported extensively on, specifically around the DEA and virtually controlled substance prescribing for clinicians and our audience who are on the ground trying to manage this. Can you walk us through what is resolved, what's still unresolved kind of what's happening on that landscape?

Yeah, absolutely. So the virtual controlled substance prescribing is currently living on a fourth temporary waiver extension until the end of this year that was announced in January by the Department of Health and Human Services and the Drug Enforcement Administration. Let's back up just a little bit. So, authorized in the 2008 Ryan Haidt act, enforced by the 2018 Support act, telehealth stakeholders are generally quick to note that a meaningful resolution allowing patients to receive prescriptions for controlled medications without a prior in person visit has remained unfulfilled for about 18 years. That's a pretty bad track record. I don't know any other business that would allow you to wait so long to, to produce a program that you're required to. Well, at the end of 2025, stakeholders urged DEA to work with Congress on a dedicated special registration framework that would give providers, quote, give providers the ability to care for patients responsibly while ensuring DEA has the tools it needs to prevent inappropriate prescribing. The trouble is back and forth over operational challenges with the three registries proposed. So there's a telemedicine prescribing registration to prescribe Schedule 3 to 5 controlled substances, an advanced one to prescribe Schedule 2 to 5 controlled substances, and then a telemedicine platform registration to dispense Schedule 2 to 5 controlled substances. It's a lot to sort of wrap around, but the long and the short is, last year DEA issued a final rule, the expansion of buprenorphine treatment via telemedicine encounter, that would allow patients to receive a six month supply of the addiction treatment medication through a telephone consult with a provider. But any further prescription would require an in person visit to a medical provider. Telehealth stakeholders immediately felt this pressure was too restrictive and could harm patients and asked U.S. attorney General Pam Bondi to toss it out earlier this year. So at the same time, the agency also released A rule on the continuity of care via telemedicine for Veterans affairs patients that would exempt VA telehealth providers from these registries and require them to review and update the patient's VA electronic health record and review the Prescription Drug Monitoring Program data for the state in which the VA patient is located at the time of the telemedicine visit before prescribing a Schedule 2 to 5 controlled substances. So while these two rules were supposed to go into effect March 21, just a couple of weeks before we were recording this, the January 20th regulatory freeze by the incoming Trump administration delayed and likely recalibrated the entire rulemaking.

Okay, so as of now, what are providers operating under?

So they're still operating under fourth temporary waiver. So basically we're still again chasing the carrot. It's still just as it's been with the last three waivers since the pandemic. What's interesting is last fall, telehealth stakeholders had been meeting with HHS Deputy Secretary Jim o' Neill about several topics including remote prescribing of controlled substances. But he has since left the agency. He's been nominated to, say, service six year term as the director of the National Science Foundation. So I think just as as of this conversation, his role as acting CDC director has been temporarily backfilled. So I'm not sure who's kind of the point person now that these stakeholders are talking to. And I have a meeting coming up with a key group and I'm definitely going to ask how things are going with the permanence of telehealthy prescribing.

Yeah, that is so interesting. When you think about access to care and rural communities. Again, like we were talking about earlier, having that in person rule certainly gets complicated.

Yeah, absolutely. You know, with, with funding and with legal liabilities, a moving target. It's, you know, it's probably made a lot of providers uneasy.

Definitely. Let's talk a little bit about this idea of behavioral health access. And we've kind of talked about the rural piece a little bit, but in different communities, even though policy is getting better, what do you see in terms of structural barriers like cost, provider shortage? Like I said, we've talked about rural versus maybe city access, but what are you seeing as still a gap for access?

So stakeholders and proponents of telehealth are bullish that bipartisan support will ultimately deliver telehealth permanence. But as far as what's happening in the rural area, we have this huge pocket of funding now from the Rural Health Transformation Program, which is the 50 billion over five years with basically the first round of funding released to the states. And many of the state's programs are online. Many of the states have now opened up for healthcare providers to propose their plans underneath those individual state programs. A lot of them really focus on telehealth. I was looking at Mississippi's this week and spoke to some folks there, just published a piece on what Mississippi is doing. Telehealth is hugely important in that state. They want to expand it and they want to do a lot more things with it.

Okay, okay. And what about this idea of social determinants of health data and mental health and behavioral health systems? What are you seeing in regards to that?

So that's really interesting, the data piece. That's something that, you know, real world barriers to integrating social determinant data into behavioral health care. Right now there's two main challenges. The first is that there is friction in exchanging siloed data in terms of quality as well as technical feasibility. There's a series of federal health IT regulations and timelines that require compliance with various data exchange standards to create secure, interoperable systems for sharing usable patient data between providers and these social agencies, these public health agencies, when we add to that the behavioral health was largely left out of meaningful use of funding under the HITECH act that fostered the use of electronic health records, but not for behavioral health. So there are some digital maturity issues there, as this audience well knows, I'm sure. While funding to address those barriers was proposed but did not pass it, developers and federal agencies are slowly chipping away at that. The second major issue is privacy and patient consent. Some industry initiatives seek to unify consent across agencies and providers to make it easier for patients, which is especially helpful when patients want data shared. You know, many patients encounter like, they've got to fill out another authorization form, you know, countless authorization forms to get data shared to make things happen, whether it's access or treatment. So while patients may want data shared from social agencies with behavioral health providers, they may not want certain provider data shared back with social agencies. So data exchange through health information exchanges is rules based and it relies on trust. So the idea is the data flows back and forth, but there has to be a number of gates that have to be under patient control. So discussions about maintaining trust are ongoing as policymakers and a bunch of legal challenges flesh out operational protocols.

What do you see as some of the advantages or disadvantages to sharing that information back and forth?

So if we think about some examples, so you have EMTs in the field, and they encounter somebody that they either know or don't know, they're able to look up in their system. And if the data is connected in the background, they can see when social agencies have flagged these patients for services and if they've not responded to those services. So if a social agency has said, okay, this person is, you know, suicide watch, and we've tried to connect them with mental health support, but they just simply haven't been going, that's really helpful for the EMT in the field to know that, you know, for their decisions.

Yeah, that makes sense. When would it not be helpful?

You know, I think in certain cases, with certain private behavioral health information that they don't want shared with a social agency, I think that there is the fear that they could be denied access to things or be labeled in a certain way.

I do think there are some diagnostic biases that exist within the field of healthcare, certainly when it comes to mental health diagnoses, at least. I don't know as much about medical diagnoses, but, yeah, I could see that being potentially challenging or someone being maybe ignored for symptoms or for behaviors because they're just written off as like, oh, they're this kind of person.

And, you know, and the opposite is true, especially for young people that may be experiencing symptoms that some people might say, require medication, that maybe doesn't require. Require medication.

True, true.

Don't want to especially lock somebody who's still developing into. Into that. Into that road if they don't want to go down that road.

Right. So we are just about out of time here today. If you could share something that you think would be important, I'd love to kind of just encapsulate for our listeners, whether they are industry leaders, whether they are providers, or whether they are patients. What do you think is most important to know about some of these topics we've talked about today? What's something you would love to leave listeners with as a. As a thought, as a perspective? What would be helpful?

That's a really good question. You know, I was thinking about if everything went right over the next five to 10 years, what would a mental health care system that has fully leveraged both technology and policy change actually look like? What I can say is that in an ideal world, the patient is at the center of what data they want exchanged, and an appropriate level of screening would happen at the point of care so that depression and anxiety and things like that are not overlooked, regardless of where people live or who they are. So this could be at a primary care or urgent care visit at a VA clinic or because of a referral from a social agency.

Okay, well, thank you very much, Andrea, for the reporting that you do for keeping people informed. It's hard to keep track of all of these things and these changes, so your work is very important that way. I'm really glad that you have been here today and I appreciate the time that you've spent with us.

Well, thanks for having me. I'm really glad to be able to share these stories as things evolve and for our audience.

Thank you so much for listening. We will have links to Andrea's articles in the show Notes and we look forward to talking with you again next week when we are back with more conversations about how mental health care is evolving. Thank you for listening and bye for now.