Therapists’ Perspectives on Access to Telemental Health Among Medicaid-Enrolled Youth

ABSTRACT

Objective: The COVID-19 pandemic exacerbated risk for poor mental health (MH) outcomes among youth from low-income families and propelled a shift to telemental health. Yet, little is known about barriers to and facilitators of MH care access when services are delivered via synchronous telehealth to Medicaid-enrolled youth.

Study Design: Between December 2020 and March 2021, we conducted in-depth interviews with 19 therapists from a large safety-net organization who served Medicaid-enrolled youth (< 18 years of age) to elucidate their perspectives on barriers to and facilitators of access to telemental health services among this population.

Methods: We conducted a thematic content analysis, guided by the 5 dimensions of health care access identified by Fortney and colleagues: geographical, temporal, digital, cultural (including acceptability of services), and financial access.

Results: Therapists noted that when components of digital access are met (ie, access to hardware and software, connectivity, and technological literacy), then telehealth could facilitate temporal access and eliminate geographic barriers; elimination of these barriers was particularly beneficial for youth in rural and hard-to-reach communities. Notably, many families depended on smartphones for telemental health access, and many youth depended on their caregiver’s smartphone. When considering acceptability of services, some youth preferred in-person services, whereas other youth (especially some teenagers with high technological literacy) had a preference for telemental health.

Conclusions: Our results highlight the need for flexibility in reimbursement policies that allows providers to optimize MH care access by offering telehealth delivered via telephone and video as well as in-person services, depending on the needs and preferences of youth and families.

Am J Manag Care. 2023;29(11):e339-e347. https://doi.org/10.37765/ajmc.2023.89430

Takeaway Points

We interviewed therapists who served Medicaid-enrolled youth to elucidate their perspectives on barriers to and facilitators of access to mental health services delivered by telehealth.

• Therapists noted that when families have digital access (ie, hardware and software, internet and/or phone connectivity, technological literacy), then telehealth eliminated geographic barriers to care.
• Whereas some youth preferred in-person services, some youth (especially teenagers) preferred telehealth services.
• For some families, telemental health reduced barriers related to the youth’s and/or caregiver’s schedule.
• Results highlight the need for continued flexibility in reimbursement policies that allows providers to optimize mental health care access by offering telehealth as an option, depending on the needs and preferences of youth and families.

Mental health (MH) disorders are prevalent among children and adolescents,^1,2 and youth living in poverty are at greater risk of poor MH outcomes.³ Stressors adversely affecting youth MH increased in the early phase of the COVID-19 pandemic, including grief due to loss of caregivers to COVID-19,⁴ disruptions in education, and greater social isolation.⁵ Given the rise in anxiety, depression, and suicidal thoughts and behaviors among US youth,^6,7 3 organizations—including the American Academy of Pediatrics—declared a national emergency in youth MH on October 19, 2021.⁸

Barriers to MH care access have long been noted for low-income youth,^9,10 including those insured by Medicaid. Medicaid is a public insurance program that covers tens of millions of youth living in families with low income.^11,12 Medicaid beneficiaries face significant barriers to accessing services, including the availability of in-network providers and geographic access to services.^13,14 These barriers are exacerbated by the overall shortage of MH providers,^14-17 the low rate of MH provider participation in Medicaid,¹⁸ MH agency challenges with recruitment and retention of clinicians,^19,20 and the lack of reliable transportation among low-income families.²¹

Against the backdrop of increasing MH needs among low-income youth and geographic barriers to care, MH care rapidly shifted to telehealth at the beginning of the pandemic.²² From May 2020 through the end of 2021, nearly all states covered telemental health services for Medicaid enrollees.²³ Among Medicaid-enrolled youth (aged 3-17 years), there was an 830% increase in the number who received telemental health services from 2019 to 2020.²⁴

Prior to the pandemic, emerging research highlighted the feasibility and acceptability of telemental health for youth and its potential to eliminate access barriers such as travel time and distance to care.²⁵ However, the literature on the effectiveness of telemental health services for children and adolescents, as highlighted by systematic reviews, is nascent.^26,27 Nevertheless, the dramatic increase in Medicaid-enrolled youth who received telemental health services at the onset of the pandemic²⁴ raises questions about the barriers to and facilitators of access to telemental health services for families with low income.

Recent studies of MH providers examine questions concerning the shift to telemental health for the populations they serve, including the impact on access to care.^28-30 Yet 2 of these studies recruited MH providers exclusively or predominantly from an urban setting,^28,30 and none focused on providers who serve Medicaid-enrolled youth in particular.^28-30 Given the potential unique factors that may affect access to telemental health services among Medicaid-enrolled youth, more data are needed to understand the barriers to and facilitators of care for this underserved population.

To address this gap, we conducted in-depth, semistructured interviews with therapists at a MH care safety-net organization that serves Medicaid-enrolled youth in a large, diverse Southern state. We sought to understand their perspectives on barriers to and facilitators of access to synchronous MH services delivered via telehealth to Medicaid-enrolled youth. Our findings are discussed in light of current shifts in the MH care delivery system for Medicaid-enrolled youth and the current policy environment.

METHODS

We conducted qualitative interviews with therapists who were recruited from a large MH organization that serves urban, suburban, and rural communities in Georgia; most youth served by the organization are enrolled in Medicaid. Approval for this study was granted by Emory University Institutional Review Board.

The MH organization provided contact information for 26 master’s-level therapists who met the following eligibility criteria: (1) provided therapy services to youth younger than 18 years who are enrolled in Medicaid, and (2) worked at the organization for at least 2 years (to reflect on service provision pre-/post pandemic). We invited them to participate in the study, and our final sample included 19 therapists with at least 2 years’ experience providing MH services to Medicaid-enrolled youth (< 18 years of age) at this or a similar type of organization.

We emailed potential participants a link to an online questionnaire to confirm their eligibility, the consent form, and a short survey. Individuals who met the eligibility criteria continued to the consent form. We conducted semistructured interviews by Zoom and telephone with participants between December 2020 and March 2021. Interviewers included a faculty member (J.R.C.) and a master’s-level research assistant (T.K.) trained in qualitative methods. Participants received a $50 gift card upon completion of the interview. We determined, through review of interview notes and transcripts, that meaning saturation was reached in our sample.³¹

Participants were asked open-ended questions about barriers and facilitators that youth experienced while receiving synchronous telemental health services during the pandemic. Interviews were audio recorded, professionally transcribed, and deidentified. Transcripts were uploaded into Maxqda (VERBI Software), where the initial codebook with structural codes identified based on the interview guide was applied using a directed approach to content analysis.³² Examples of structural codes included youth age and internet access. Each transcript was double-coded by 2 master’s-level research assistants trained in qualitative methods. Coded segments were exported into Excel files and reviewed to make sure each was representative of both the construct and a barrier or facilitator. The coding team met regularly to review coding agreement, refine code definitions, discuss discrepancies, and reach a consensus. Once coding was finalized, we reexamined each sheet to identify themes and subtopics related to the structural codes.

We used the Fortney model of health care access to organize and consolidate coded segments into themes pertaining to barriers to and facilitators of access to MH services delivered via telehealth to Medicaid-enrolled youth.³³ This framework conceptualizes health care access as “the fit between the patient and health care system”³³ and defines 5 dimensions of access: geographical, temporal, digital, cultural, and financial.

RESULTS

Sample

Nearly nine-tenths (89.5%) of the 19 participating therapists were women, 47.4% were 40 years or older, 73.7% of participants were non-Hispanic White, and 21.1% were non-Hispanic Black (Table 1). More than one-fourth (26.3%) had their associate license, and 31.6% were fully licensed.

At the time of the interview, all participants had at least 10 months of experience delivering telehealth services. Prior to the pandemic, all therapists delivered in-person services in community-based settings (including schools and homes). Participating therapists served a catchment area that included 24 counties, 8 of which are rural (as designated by the Georgia State Office of Rural Health)³⁴ and 19 of which are designated as MH professional shortage areas.

Barriers to Accessing MH Services via Telehealth

Barriers to accessing telemental health services matched with 4 of the 5 dimensions of access in the Fortney model. Themes and illustrative quotes are shown in Table 2 [part A and part B].

Digital access: connectivity, technology access, and technological literacy. Digital access to health care services includes the connectivity facilitating digital communication with health care providers and access to appropriate equipment and applications.³³ Every participant described how challenges related to family access to internet and/or phone service were a barrier to the delivery of telemental health services among Medicaid-enrolled youth. Internet access (especially lack of high-speed internet) was a barrier to telehealth when a youth lived in a home without either internet service or reliable service because they resided in a rural location, had limited or no reliable internet service options in the community, and/or had poor service/coverage generally during times of bad weather. Participants also described challenges related to poor cellular phone service/coverage, especially in rural areas. A poor internet or phone connection often resulted in challenges using video, issues with inconsistent sound, or interruptions during sessions (eg, the video froze or the session discontinued entirely).

The majority of participants also described limited access to technology (including hardware and software) as a barrier to full engagement in telehealth appointments. Some therapists noted challenges when the youth depended on their caregivers’ device for the session, such as interruptions by incoming calls, texts, or emails. A few therapists also noted barriers when only a cellular phone was available due to unreliable phone service or more limited visual cues on a smaller screen. Another challenge described by several participants occurred when the personal device was not compatible with Zoom.

The caregiver’s and/or youth’s technological literacy (ie, their familiarity with and ability to use the video platform, such as Zoom) for the telehealth session was another digital access barrier. Several participants noted that technological literacy was an issue when trying to serve younger children or if the caregiver was a grandparent. One therapist explained, “With the younger kids, it was tough simply because they would turn off the camera and then think it wasn’t working and…Mom would have to fix it every 5 minutes because they would accidentally hit the wrong button.”

Temporal access: youth’s and/or caregiver’s schedule. Temporal access includes “the time required to receive health services and the opportunity cost of that time.”³³ Some participants described how the caregiver’s schedule can pose a barrier to telehealth because they were busy with work or childcare responsibilities or forgot about the appointment. Two therapists discussed how scheduling challenges were especially acute when the youth depended on the parent’s phone for the session and there were incoming calls or the caregiver needed the phone for another reason.

Some participants also noted that the youth’s schedule could pose a barrier to telehealth services because many youth could not meet during the school day, and some were busy with after-school activities or jobs. One participant noted that youth’s inconsistent schedules during virtual schooling posed challenges to scheduling telehealth visits.

Cultural access: acceptability of services. One dimension of cultural access includes the “acceptability of health services” among patients,³³ which can refer to specific consumer reactions to attributes of the provider or health care facility.³⁵ For the current study, acceptability refers to the youth’s reaction to or attitudes about telemental health services. Some therapists described barriers pertaining to the acceptability of telehealth for youth, including youth’s stated preference for in-person services because they do not like telehealth, boredom with telehealth, and/or resistance to telehealth.

Financial access. Financial access includes health insurance eligibility, which affects the out-of-pocket costs for services (including telehealth services).³³ Some participants explained how breaks in Medicaid coverage for youth resulted in gaps in service delivery (including telemental health services) because families cannot afford to pay for services out of pocket. A few participants explained that these breaks in coverage occur because the caregiver(s) forgot to complete the required paperwork or because of other administrative challenges filling out the required paperwork.

Financial access also includes the cost of internet access and the cost of a personal device that can be used for synchronous telemental health services.³³ Several participants reported that the cost of internet access and/or a personal device posed a barrier to telemental health services for the Medicaid-enrolled youth they served. These financial barriers also contribute to the digital access barriers described above.

Facilitators of Accessing MH Services via Telehealth

Facilitators of accessing telemental health services matched with 4 out of 5 of the access dimensions from the Fortney model. Facilitator themes and illustrative quotes are shown in Table 3 [part A and part B].

Digital access: connectivity, technology access, and technological literacy. Some therapists noted how the family’s connectivity to internet and/or cellular phone service enabled service provision to continue from any location via telehealth. One therapist mentioned, “I think the enhancer is that if they have the internet and if they have the technology, they’re able to log on from pretty much anywhere as long as it’s in the state of Georgia.” Several therapists mentioned different efforts to facilitate internet access for the families they served, including the provision of free internet services by local internet companies, the provision of free hot spot devices by schools, and/or school willingness to let the therapists deliver telehealth to youth while they were at school.

Most therapists described how families’ access to a device, including a phone or computer, was an important facilitator of telehealth services. One therapist commented on the ubiquity of smartphones among the families they served: “…It’s amazing. Everybody has a smartphone. I have not yet had a family [who] did not.” Two therapists described how the provision of Chromebooks or computers by schools to youth facilitated their access to the technology needed for telehealth.

Some therapists described how youth technological literacy was also a facilitator for telehealth. One participant explained, “So it was definitely easier if the kid was already familiar with some kind of video, whether it was FaceTime or [another app]—it made the process a little [smoother].” Several therapists noted that teenagers in particular have a high level of comfort with technology that facilitated telemental health services. As explained by one therapist, “I think they’re so technology driven that to them, it’s not different. They’re on Snapchat or Insta[gram] or Skype or Zoom or FaceTime or Duo. I mean, name an application and they’re using it in some form. For [teenagers],…I actually hear that they prefer it [telehealth].”

Temporal access: easier to make appointments and scheduling flexibility. Several therapists noted that telehealth appointments were easier for the caregiver’s schedule and that it was easier to get in touch with the caregiver when delivering telehealth services. Several therapists also mentioned that it was easier to make appointments with youth when delivering telehealth, especially for teenagers with activities after school. One therapist said that telehealth scheduling helped ensure the youth did not have to be pulled out of school for sessions, reducing this particular opportunity cost of services. A few therapists also noted the advantage of telehealth scheduling flexibility, including the ability to (1) schedule crisis intervention appointments as needed, (2) help a youth sooner if the therapist had a last-minute cancellation, and (3) make last-minute scheduling adjustments (eg, pushing a session back by 30 minutes).

Cultural access: acceptability of services. Most participants described the acceptability of telehealth services as a key facilitator of access for some youth. Several therapists described the importance of the youth’s openness to try to adapt to telehealth as a facilitator of access. Some therapists said they had many clients who preferred telehealth to in-person services—especially teenagers—because they felt comfortable with technology and communicating online and felt there was less of a stigma if services were received virtually. One therapist explained, “I would say my older teens, 15, 16, 17 [years old], sometimes…enjoy the telehealth a little bit more because they’re used to talking on the phone or FaceTiming their friends,…so it’s a little less threatening to them. It helps them to feel more comfortable.…”

Geographic access: elimination of distance and travel time. Geographic access to health services includes “the ease of traveling to health care provider locations,” which can encompass “road travel distance, time to nearest provider, [and] nearest facility with telemedicine equipment.”³³ Most participants explained how telehealth service delivery to Medicaid-enrolled youth eliminated the need for transportation and distance as barriers to care. Several therapists noted that they could provide services to clients in communities that would not have been possible without telehealth. One therapist mentioned, “I’ve seen new demographics of clients or new…regions of clients because I can work anywhere, really.”

Some participants also described how telehealth eliminated travel time as a barrier to care for families and for this sample of community-based therapists who visited clients at schools or in client homes. When they no longer had to travel to appointments, therapists were able to serve more clients and reduce their level of burnout. One therapist said, “It gives us a lot more time for self-care because you’re not driving and driving and driving, and they’re not driving and driving and driving.”

DISCUSSION

The COVID-19 pandemic exacerbated risk of poor MH outcomes for youth^6,7 and propelled a rapid switch to telemental health services for patients including Medicaid-enrolled youth.²⁵ Our findings highlight key barriers pertaining to digital access, cultural access (ie, acceptability of services), temporal access, and financial access to telemental health services among this population. We also identify facilitators related to digital, cultural, temporal, and geographic access.

Therapists in our sample consistently noted that when key components of digital access are met for youth and families (ie, access to hardware and software, technological literacy, and connectivity), then telemental health eliminates geographic barriers to care (ie, travel distance and travel time) for low-income Medicaid-enrolled youth, particularly in rural communities. Challenges reported in this study pertaining to connectivity are consistent with prior studies on telehealth among low-income and rural populations.^36-38 Participating therapists also described several innovative, but limited, local efforts to improve internet access for youth, such as provision of free internet services by local internet companies, free hot spot devices by schools, and/or school willingness to let the therapists deliver telehealth to youth while they were at school. In November 2021, the Infrastructure Investment and Jobs Act allocated $65 billion over 8 years to expand access to broadband internet, which should also help reduce internet access barriers over time.³⁹

Our findings also align with prior research reporting that access to connected devices (including computers, smartphones, and tablets) could have been a barrier or facilitator to using telehealth services for youth during the pandemic.⁴⁰ Notably, our findings underscore not only the extent to which many of these families depend on smartphones for telemental health access,³⁸ but also the extent to which the youth depends on their caregiver’s smartphone to access services. This is consistent with prior research reporting that socially vulnerable areas and families are more likely to rely on telephone as the primary telehealth modality.^41,42 The youth’s dependence on the caregiver’s phone in our study prompted challenges such as coordinating sessions with the caregiver’s schedule and interruptions by the caregiver’s incoming calls, texts, or emails. Some participants described local school efforts to provide Chromebooks to students, which had the added benefit of facilitating access to telemental health services.

Another important dimension of digital access discussed as a barrier and facilitator was technological literacy. Some therapists described challenges with telemental health services when the youth—especially younger children—had difficulties using the technology. In other instances, therapists described challenges when the caregiver—particularly grandparents—had limited technological literacy. Yet, several participants also noted teenagers’ high technological literacy and ease with online communication as facilitators of telemental health services, which have been discussed in prior literature.⁴³ Technological literacy is an important factor for clinicians to weigh when considering the delivery of telemental health vs in-person services,^43,44 and technological literacy for youth and families is increasing over time.^45,46

Acceptability of services (a component of cultural access)³³ was also discussed as both a barrier to and facilitator of telemental health services. Participants described how some youth strongly preferred in-person services, whereas other youth—especially some teenagers—preferred telehealth services. A finding that merits further exploration was that telemental health has potential to reduce the stigma associated with seeking MH care for some youth when services are available in the privacy of their own home vs more public settings such as a school or clinic. Indeed, prior studies have noted that concerns about peer perceptions and stigma can be barriers to seeking MH help among some youth in school and/or clinic settings.^47-49 Beyond acceptability of services, future research is needed to examine how telemental health may facilitate other dimensions of cultural access in the population such as language services, racial/ethnic patient-provider concordance, and cultural competency.

Although temporal access was discussed in some instances as a barrier to services once in-person schooling resumed, there were also important ways that it facilitated service delivery via telehealth (vs in-person services). Consistent with prior research,^50,51 we show that the convenience of telehealth can improve temporal access and allow for more timely care through the flexibility of scheduling telehealth appointments, making it easier to connect with a youth during a moment of higher need and being able to fill appointment slots if there is a last-minute cancellation or a no-show for an appointment. These findings identify potential advantages of increasing the timeliness of care for low-income youth as well as the benefit of increasing productivity for MH providers and organizations that serve this population.

Given the potential of telemental health to improve geographic, temporal, and cultural access to care for Medicaid-enrolled youth, these findings highlight the need in reimbursement policies for flexibility that allows providers to optimize access to MH services by offering both telemental health delivered via telephone and video and in-person appointments. Many of the families served by therapists in our sample depended on smartphones or cell phones to access telemental health services, and many youth depend on their caregivers’ phone. State Medicaid programs had the flexibility to continue coverage of various telehealth modalities after the COVID-19 public health emergency ended in May 2023. For example, Georgia is 1 of 9 states that passed a law to make state Medicaid coverage of audio-only telemental visits permanent beyond the public health emergency. Coverage for other types of modalities, such as asynchronous store-and-forward and text-based communication, remains more limited.⁵² Ultimately, maintaining flexibility in the modalities offered is key to facilitating access to care.

Strengths and Limitations

A few strengths and limitations are noted. One strength is the inclusion of experienced therapists who regularly provide services to Medicaid-enrolled youth across urban, suburban, and rural communities. Yet, one limitation is that this study does not include the perspectives of youth or caregivers. Moreover, although the sample was drawn from a MH organization serving a broad geographic area, the data do not capture perspectives of therapists employed in other organizations, health systems, or states. For example, one contextual factor that can incentivize or disincentivize the provision of telemental health services is whether a “facility fee” can be charged by an eligible facility when services are delivered via telehealth and/or in person; the ability to charge a facility fee for telehealth can vary across states and/or across Medicaid managed care plans within states.^53-56 During the study period, the participating MH organization was able to bill a facilitating site fee in some, but not all, of the Medicaid managed care plans in which the youth were enrolled. Continued research is needed to understand how specific Medicaid policies at the state and plan levels affect access to telemental health services.

CONCLUSIONS

Notwithstanding limitations, our study provides important insight into the potential of telemental health services to improve key dimensions of access to MH services for many Medicaid-enrolled youth. Telemental health has the potential to expand access to MH services among Medicaid-enrolled youth in rural and difficult-to-reach communities. Moreover, common themes between barriers and facilitators point to the divergent needs and preferences of Medicaid-enrolled youth and families. Continued investment in broadband infrastructures along with flexible reimbursement policies that allow for multiple modalities (phone, video, in-person) to be offered at various settings including home or school will help enhance equitable access to MH service among lower-income youth.

Author Affiliations: Department of Health Policy and Management (JRC, TK, ST, IG) and Department of Behavioral, Social, and Health Education Sciences (ERW), Rollins School of Public Health, Emory University, Atlanta, GA.

Source of Funding: This research was supported by the Robert Wood Johnson Foundation.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JRC); acquisition of data (JRC, TK); analysis and interpretation of data (JRC, TK, ST, ERW, IG); drafting of the manuscript (JRC, TK, ST, ERW, IG); critical revision of the manuscript for important intellectual content (TK, ERW, IG); provision of patients or study materials (JRC); obtaining funding (JRC); administrative, technical, or logistic support (TK, ST); and supervision (JRC).

Address Correspondence to: Janet R. Cummings, PhD, Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Room 650, Atlanta, GA 30322. Email: jrcummi@emory.edu.

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