Physician’s Weekly recently spoke with Matthias B. Bowman, MBA, of The Bowman Family Foundation, a private nonprofit organization with a primary mission of improving the lives of people with mental illness and providing funding to support the education and welfare of children.

PW: What is your background in the area of digital therapeutics?

MB: About 10 years ago, I got interested in digital mental health, and the Bowman Family Foundation founded the website PsyberGuide (later donated to One Mind), which reviews apps and other software that can be used to help people with mental illness or substance use problems, somewhat like Consumer Reports but focused only on digital therapeutics for mental health. The site has several methods through which it evaluates mental health apps, including the level of evidence supporting that each app is effective in helping users, how engaging each app is, their ease of use, and the quality of its stated privacy policy.

How can digital therapeutics help deliver content and resources and encourage changes in patient behavior?
We started PsyberGuide about 10 years ago because of the recognition that most patients with mental illness will never meet a psychiatrist or psychologist, which is still true today. There is an insufficient number of behavioral health specialists; more than half of the counties in the United States have no mental health professional—no psychiatrist, no psychologist, no mental health social worker. Clearly, many people don’t have access to a professional behavioral health specialist. Telehealth helps with access across state lines, but there’s also the problem of cost and the issue of not enough psychologists and psychiatrists to be at the other end of the video call with every patient. We need other methods, and digital tools can definitely help people at the most basic level to track treatment adherence, but also to help them with various techniques to improve their mental health, reminders, coaching tips, and the like. To me, it’s self-evident that we have to utilize digital tools to help more people. Some have said that the normal protocol for behavioral health will evolve to be digital, then virtual, then personal, the idea being that mild to moderate cases can be helped by digital tools; if someone needs more, then they use virtual, meaning a video or audio session with a therapist; and if that’s not sufficient, then personal visits should be utilized.

The COVID-19 pandemic has brought about a dramatic transformation in the use of telemedicine for behavioral health. In fact, The Bowman Family Foundation commissioned a study pre-COVID, and the percent of treatment for behavioral health that was conducted via telehealth was less than 1%—growing very rapidly, but at a very low base. With COVID, most mental health treatment went to telehealth within 3 weeks. It’s now been rebalanced, but overall, it’s been a dramatic transformation for telehealth. Digital tools are a part of telehealth; there are three kinds of tools. There are tools similar to FaceTime that are just to facilitate a visit with a professional. On the other extreme, there are “do-it-on-your-own” tools in which the user downloads the tool and receives help just from it. And then there are tools that integrate both; the therapist monitors patient progress via the tool and perhaps once per month coaches the patient.

Do you think the changes in telehealth and digital therapeutics use that came about with the COVID-19 pandemic are here to stay?
There are many of us trying to make them permanent. When you think about the delivery of health, mental or otherwise, you have to think about very mundane topics like payment codes, licensing, and delivery systems. With COVID-19, there were three enablers for telehealth. 1) State licensing requirements being waved temporarily, meaning that a Massachusetts therapist could treat someone in Ohio without an Ohio license. 2) Insurance companies paid better for telehealth codes. 3) For the first time, insurance companies paid for audio only visits. The telehealth codes were originally designed to be applied only to video calls of a certain nature. So, patients who didn’t have a smartphone or weren’t comfortable doing a video call couldn’t do telehealth visits. This was waved during the COVID-19 pandemic.

Some of the state licensing requirements have now come back into effect. Some insurance companies may not now be reimbursing for audio only, so the leading edge of the factors impacting telehealth are these technical, but critically important, issues. Another issue is whether insurers pay for telemedicine at the full rates that they pay for in-person visits. The percent of no-shows drops dramatically with telehealth visits, compared with in-person; many reports show that with physical visits, patients don’t show up about one-quarter of the time for various reasons. With telehealth visits, no shows drop to almost zero. Not every visit can be a telehealth visit, but when telehealth is suitable, it’s much more efficient from a public health perspective because of this no-show phenomenon. There are many issues with this, and I’m involved in a group that is working on having audio-only receive an equivalent reimbursement rate to video telehealth visits.

Do you feel that patients and clinicians have both, as a whole, “bought in” to the benefits of digital therapeutics after seeing the benefits because of the necessity for it that came with the COVID-19 pandemic?
Yes. Uptake was very slow prior to the pandemic, and now it’s much, much higher. The Bowman Family Foundation has commissioned two studies, one of which is a survey—launched on December 6, 2021—of patients and their families, as well as healthcare practitioners and focused on access to mental healthcare. The survey asks if respondents have ever heard of telehealth or ever used telehealth, their views on telehealth (prefer it; not prefer it; why). We’re gathering frontline information about views of telehealth. The other study we’ve commissioned is assessing volumes of claims, including how many were in- or out-of-network, for both in-person and telehealth meetings. We know telehealth use went way, way up a year and a half ago. It’s come down somewhat, but my guess is that use today is 10-20 times higher than it was 2 years ago.

What else do clinicians need to know about digital therapeutics, particularly as it relates to mental healthcare?
A few months ago, colleagues and I started the Society for Digital Mental Health, a professional, non-profit society with the mission to engage in education, policy, and research to support the use of digital tools to improve mental health and substance use disorder outcomes, including access to affordable and effective care, for the benefit of the public. We hope to draw in both mental health and non-mental health practitioners to educate families about digital tools and how to determine which are useful and which are not, as well as to help drive development of better digital tools.