This opinion piece is a response to the March 15, 2021 article from mHealth Intelligence, “Congress Targets Telehealth Coverage for Mental Health, Substance Abuse Treatment” by Eric Wicklund. The article discusses telehealth legislation on Capitol Hill that aim to expand private health plans’ telehealth coverage for mental health services and substance abuse services.
The COVID pandemic quickly confirmed to everyone in healthcare that telehealth is very useful and has long-term staying power, but for it to truly be a long-term solution, we need federal legislation that continuously addresses more than just the physical barriers to care. Telehealth-specific legislation needs to include language access, as we continue working to bridge healthcare disparities.
The bills under consideration are a big first step: it’s critical to ensure that mental health and substance abuse care delivered via telehealth are given the same value (read: payment parity) as if delivered in person. Though the exact text for bill S 660 isn’t yet public, “it aims to level the playing field for an expanding number of healthcare providers who are using connected health platforms to deliver mental health and substance abuse services,” Wicklund stated.
Senator Lisa Murkowski (R-AK), one of the bill’s authors, stated in a press release, that the legislation will “eliminate barriers to important behavioral health and community-based therapies.” She continued, “Access to care is the key to solving any medical issue – the substance-use epidemic is no different.”
Murkowski is right: it’s timely to focus on mental health and substance abuse treatment in telehealth. It’s no secret that we’re witnessing the predicted “parallel pandemic” resulting from the most stressful year that many of us have ever faced. A March 2021 study published by the American Psychological Association reveals that “when asked how the level of stress in their life has changed compared with before the pandemic, nearly half of U.S. adults (47%) said the level of stress in their life has increased.” And virtual mental health care is still skyrocketing: based on data from FAIR Health’s Monthly Telehealth Regional Tracker, “from November to December 2020, mental health conditions continued to be the number one telehealth diagnosis nationally and in every region” (from a FAIR Health press release published earlier this month).
So, we know we need insurers to cover mental health and substance abuse treatment both in-person and virtually. Telehealth solves for social distancing and serving patients while keeping them safe at home, and it’s a great solution for people with transportation challenges – even when we’re not in a pandemic. It enables people in remote areas to get care outside their local area, and it might even allow for care well out of a patient’s region – a luxury many couldn’t afford if limited to in-person care. However, there are accessibility concerns beyond just the physical barriers, and virtual care on its own leaves many patients unserved, due to language and cultural barriers.
Making telehealth a viable, financially covered alternative to in-person care addresses the physical barrier, but new legislation also needs to reinforce accessibility beyond that first step: it needs to include language access.
Members of underserved, often marginalized communities already face compound challenges around care – even in person – and the resulting disparities are amplified in telehealth. For example, the Latinx community encounters barriers specific to substance abuse treatment. In addition to having an increased likelihood of transportation difficulties that might prompt for virtual care, these individuals are also more likely to have limited English proficiency and to experience cultural misunderstandings that impede their care. They have a real need that could be met by the potent combination of behavioral health and technology – but that technology is useless to them, without language interpretation.
What good is virtual care if it’s not delivered in the patient’s native language? How much of the intended care is truly “lost in translation” when providers sometimes rely on Google Translate to help patients get by? A new study of Google Translate’s use in emergency departments includes this explanation: “Frequently, there is no mechanism for requesting written translations in the acute setting. While the optimal response in this situation is to write the patient’s discharge instructions in English and have the instructions verbally interpreted to the patient using a certified health care interpreter, many providers resort to the use of machine translation for efficiency. Google Translate is an increasingly popular option for written translation and, in some hospital systems, has become the go-to source of written translations, especially for patient-specific discharge instructions given to LEP [limited English proficient] patients.”
On the flip side, technology used correctly is a powerful asset in breaking down language barriers. Video remote interpretation (VRI) serves as a cost-effective, efficient method of providing interpretation during consultation, treatment, and discharge. It humanizes healthcare in such a way that critical health information and care instructions aren’t lost in translation. It enhances the patient experience and builds better outcomes throughout the care continuum.
Of course, existing legislation requires language access, and interpretation is standard practice. Except when it’s not (see above re: Google-translated instructions given at discharge – i.e., not during a medical emergency, when exceptions can legally be made). And here’s a little-known fact: translation and interpretation are different; translation converts one written language to another, whereas interpretation converts spoken or signed languages. Online machine learning programs that provide translation, while powerful in some contexts, do not match the ability of a human interpreter qualified to convert medical language in all its nuance: words and meaning and tone and cultural implication. We have to emphasize that critical difference: language access means qualified interpretation, and new legislation offers an opportunity for renewed language access advocacy.
While we’re angling to build new federal requirements around private plans, let’s eliminate all the barriers to care, including language. When we legislate financial accessibility without also reinforcing the need for language and cultural access, we leave whole swaths of patients just as they were – underserved, still in desperate need of a basic human right: healthcare.