Telepsychiatry Use Before and During the COVID-19 Pandemic Among Children Enrolled in Medicaid

The COVID-19 pandemic prompted a surge in mental health needs among children (1). Recent research has documented that rates of anxiety, depression, and conduct problems among children increased significantly in 2020 (2). This rise could be explained by a variety of factors, including prolonged periods of social isolation, school closures, food insecurity, and negative economic consequences for families, among other factors (1). Increases in suspected suicide attempts and mental health–related emergency department visits have also been documented among adolescents and young adults (3, 4). In addition, research has shown heightened risk for mental health conditions among children after a COVID-19 diagnosis (5).

In addition to increasing the need for mental health services, the COVID-19 pandemic resulted in a significant shift in the delivery of mental health services. The Coronavirus Aid, Relief, and Economic Security (CARES) Act passed in March 2020 (https://www.congress.gov/bill/116th-congress/house-bill/748) included provisions that expanded telehealth coverage for Medicare and Medicaid beneficiaries, including reimbursement at rates equivalent to those for in-person services. Use of telehealth services increased significantly during the early months of the pandemic (6), especially telepsychiatry, which accounted for approximately 48% of all outpatient services delivered (7). However, the utilization rate of telepsychiatry among children covered by Medicaid is yet unknown. This is an important gap in the literature because public health insurance coverage significantly increased during the pandemic (8) and Medicaid continues to be the largest payer for mental health services in the United States (9). In addition, the demographic characteristics of the Medicaid-covered children who used telepsychiatry, including the types of mental health conditions for which services were sought, are not known. This study contributes to the literature by using a national Medicaid claims database to compare use of telepsychiatry by Medicaid-enrolled children before and during the pandemic.

Methods

We conducted a retrospective individual-level observational analysis by using claims data from the 2019–2020 Centers for Medicare and Medicaid Services (CMS) Transformed Medicaid Statistical Information System (T-MSIS). T-MSIS data are the most current and complete Medicaid and Children’s Health Insurance Program data available and capture health service use for more than 73 million low-income Americans from all 50 states and Washington, D.C. The sample for our analysis included Medicaid-covered children between the ages of 3 and 17 years who used any mental health services in 2019 (N=5,606,555) or 2020 (N=5,094,446) and were enrolled for the full calendar year.

We categorized encounters as telehealth by using a combination of Current Procedural Terminology (CPT) and place-of-service codes recommended by CMS (10). Telehealth appointment visits include both audio-only and audio-video visits. Other service settings (such as outpatient, inpatient, intensive outpatient/partial hospitalization, residential, and emergency department) were also measured by using a combination of CPT and place-of-service codes. Psychotropic prescription medication use was identified by using National Drug Codes (NDCs) (please see the first online supplement to this report for the list of codes used to measure service settings and the NDC codes used to measure psychotropic medication). In addition to gender, race (non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian, non-Hispanic other), age (3–5, 6–11, 12–17 years), and location (rural, urban) of children who used mental health services through telehealth, we report the type of mental health condition associated with the telehealth service.

A descriptive analysis was conducted to compare telehealth service use before and during the COVID-19 pandemic. We first compared encounters by service setting. Next, for those mental health services delivered through telehealth, we compared patients’ age, gender, race, location, and psychiatric diagnosis in 2019 (before COVID-19) with those in 2020 (COVID-19 period).

Results

In 2020, there was a 9.1% decline in the number of children using mental health services compared with 2019 (N=5,606,555 in 2019 and N=5,094,446 in 2020) (second online supplement). The number of children using mental health services delivered in other care settings (outpatient, inpatient, residential, emergency department, intensive outpatient/partial hospitalization) also declined, ranging from an 8.6% (outpatient: N=4,543,712 in 2019 and N=4,154,543 in 2020) to a 23.1% (emergency department: N=377,395 in 2019 and N=290,360 in 2020) decrease. There was an 8.9% reduction in psychotropic medication use between 2019 and 2020 (N=3,216,683 vs. N=2,931,033 children, respectively). Telehealth was the only service setting that had an increase in use by children, with 2,214,677 children seeking mental health services in 2020 compared with 238,233 children in 2019—an 829.6% increase. Expressing these values as percentages of total Medicaid enrollment showed a similar pattern; that is, fewer children used mental health services for all settings except for telehealth, where the percentage of children in this setting increased from 0.9% (N=238,233 of 26,781,826) in 2019 to 8.8% (N=2,214,677 of 25,208,678) in 2020 (second online supplement).

Table 1 shows that among children who used telepsychiatry, a majority were male in both 2019 (56.4%) and 2020 (53.6%) and between the ages of 12 and 17 years (51.9% in 2019; 48.7% in 2020). In 2019 and 2020, a majority of Medicaid-covered children who used telepsychiatry were non-Hispanic Whites (46.2% in 2019; 44.5% in 2020). Among children using telepsychiatry in 2020, 16.1% were non-Hispanic Blacks and 19.7% were Hispanics; these rates were higher than the rates observed in 2019 (13.0% were non-Hispanic Blacks and 15.3% were Hispanics). Between 2019 and 2020, the percentage of children using telepsychiatry services who resided in urban locations increased (86.9% to 91.9%), whereas the percentage of children in rural locations decreased (11.8% to 7.2%).

Attention-deficit hyperactivity disorder (ADHD), trauma- and stressor-related disorders, anxiety disorders, depression, and behavior/conduct disorders were the most prevalent mental health conditions for which telehealth services were administered to children in 2020. These conditions were also the most prevalent conditions in 2019 for which telehealth services were administered to children.

Discussion

We used a national claims database of all Medicaid-covered children who utilized mental health services in 2019 and 2020 and found a large increase in telepsychiatry use. This increase in telehealth use was accompanied by a decline in mental health services administered across other setting types. Our results are consistent with recent findings that document substantial increases in telehealth adoption among adults seeking treatment for mental health conditions (6, 7). However, to our knowledge, this is the first study that examined telepsychiatry use among children covered by Medicaid.

Our study found ADHD, trauma- and stressor-related disorders, depression, anxiety disorders, and behavior/conduct disorders to be the most prevalent mental health conditions associated with telehealth service use during the COVID-19 pandemic. The same conditions were also prevalent before the pandemic, possibly because these are common pediatric mental health conditions. Our findings that mental health–related emergency department visits and suicidal ideation declined among children differ from the prior literature for several reasons. First, our population of interest consisted of children ages 3–17 years, whereas in prior literature the study population included individuals ages 12–25 years (4). Second, our study was limited to children covered by Medicaid, whereas prior studies were not limited by type of health insurance coverage and included children with various types of health insurance provider (3, 4). Finally, the unit of analysis of our study was the individual patient, whereas a previous study used claims as the unit (3); thus, it was possible that one individual in our study could have multiple claims. Our study also found a decline in psychotropic medication use among children, a possible reason for which could be challenges in getting prescriptions filled at pharmacies during the pandemic.

The COVID-19 pandemic has called attention to, and in some cases potentially exacerbated, existing inequities in the health care delivery system (11). For example, although we found increased telepsychiatry use in both rural and urban counties, uptake of telehealth was more robust in urban counties, such that the urban-rural gap in telepsychiatry use actually widened between 2019 and 2020. On the other hand, our study found relative increases in telepsychiatry use among non-Hispanic Black and Hispanic children, compared with a relative decrease in such use among non-Hispanic White children, during the pandemic. Further research is needed to understand which factors might be driving these racial-ethnic and geographic differences in adoption of telepsychiatry services. Inequitable access to broadband Internet and Internet-enabled devices among communities of color and in rural communities, as documented in prior studies, is one possible factor (12).

A particular strength of this study is the use of a large, national claims database that included information on all Medicaid-covered children in 2019 and 2020 who used mental health services. However, the results should be interpreted in light of a few limitations applicable to administrative claims data. First, the study population included only children covered by Medicaid; thus, our study’s findings may not be generalizable to uninsured children or children covered by private insurance. Second, the data used in the analysis have a high rate of missing information on race-ethnicity (22.0% in 2019 and 16.5% in 2020). Although incomplete race-ethnicity data have been a long-standing challenge in T-MSIS (13) and that point is beyond the scope of this analysis to address, high-quality and complete data are essential to understanding disparities in mental health treatment. Third, the data used here do not capture treatment received in other settings or paid for by sources other than insurance, such as school mental health services, or treatment for which no claims were submitted or insurance claims were denied.

Conclusions

Despite the substantial increase in telepsychiatry use, this study found an overall decline in mental health service use during the COVID-19 pandemic in 2020 among children covered by Medicaid. Although telehealth can be a valuable tool to expand access to mental health services among children, it may not fully address unmet needs. Even with expanded telehealth flexibilities, additional measures may be needed to maintain access to care.