Key Points
Question
What proportion of mental health treatment facilities (MHTFs) offer telehealth services to children, and what facility-level and county-level characteristics are associated with offering telehealth?
Findings
In this cross-sectional study of 5559 US MHFTs serving children, 77.5% offered any telehealth services and 56.1% offered telehealth-based medication management. Facilities not accepting Medicaid or private insurance were less likely, and public facilities were more likely, to offer telehealth-based medication management compared with their counterparts; these differences were statistically significant.
Meaning
These findings suggest that telehealth availability for child mental health care remains uneven across facility types, despite its growing importance as a delivery mode, potentially because of differences in state policies and organization finances.
This cross-sectional study examines what percentage of mental health treatment facilities in the US offer telehealth services for children and what factors are associated with offering any telehealth services and medication management via telehealth.
Abstract
Importance
Although the COVID-19 pandemic accelerated adoption of telehealth for mental health services, it is unclear how many, and which types, of mental health treatment facilities (MHTFs) offer telehealth mental health care to children.
Objective
To quantify what percentage of MHTFs in the US offer telehealth services for children and what facility-level, state-level, and county-level factors are associated with offering any telehealth services and specifically medication management via telehealth.
Design, Setting, and Participants
This cross-sectional study involved a secret shopper study of all outpatient MHTFs contained within the Substance Abuse and Mental Health Services Administration’s Behavioral Health Treatment Locator, conducted from September 24, 2024, to May 12, 2025.
Main Outcomes and Measures
The primary outcomes were whether MHTFs offered (1) telehealth-based behavioral services for children and (2) telehealth-based medication management for children. Multivariable logistic regressions estimated associations between facility-level and county-level characteristics and each outcome.
Results
Among 5559 respondent facilities (response rate, 73.0%), 4314 (77.6%) offered treatment to children. Among children-treating facilities, 3345 (77.5%) offered telehealth services, and 2419 (56.1%) offered telehealth-based medication management. Hawaii (1 of 1 facility [100.0%]), Montana (32 of 33 facilities [97.0%]), and Colorado (79 of 85 facilities [92.9%]) had the highest rates of offering telehealth services to children, whereas Georgia (52 of 81 facilities [64.2%]), Vermont (9 of 15 facilities [60.0%]), and Alabama (25 of 46 facilities [54.3%]) had the lowest. Noncommunity mental health centers had lower odds (adjusted odds ratio [aOR], 0.36; 95% CI, 0.25-0.52) of offering telehealth for children compared with community mental health centers. Facilities that did not accept Medicaid or private insurance as a form of payment were less likely to provide medication management via telehealth (aOR, 0.46; 95% CI, 0.25-0.86) compared with facilities that accepted Medicaid as a form of payment. Public facilities had greater odds of providing telehealth-based medication management (aOR, 1.86; 95% CI, 1.20-2.88) than private for-profit facilities. Facilities in counties in the second (aOR, 0.67; 95% CI, 0.48-0.93), third (aOR, 0.66; 95% CI, 0.45-0.97), and highest (aOR, 0.67; 95% CI, 0.45-0.99) household income quartiles were less likely to offer telehealth medication management.
Conclusions and Relevance
In this cross-sectional study of a sample of US MHTFs, most facilities offered telehealth services for children, but the offering varied across facility types and states. Addressing potential gaps in telehealth offering will be essential to advancing equity and ensuring that all children can benefit from emerging modalities of remote mental health care.
Introduction
Telehealth for child mental health care offers several advantages to practitioners and patients, including reducing no-show rates and the burden of accessing care on children and their families, and potentially increasing access to diagnostic, therapeutic, and follow-up services.1 In 2022, 45.3% of adolescents who received mental health care in the past 12 months had at least 1 visit via telehealth.2 Despite the existing data on telehealth use, there are few recent data characterizing telehealth services for children at mental health treatment facilities (MHTFs). This information could be used to guide policy development aimed at ensuring equitable and sufficient access to child mental health care.
The future of telehealth services for children and adolescents remains uncertain. Although disparities in telehealth availability for mental health care have been documented,3,4,5,6 prior studies have not focused on the availability of telehealth services to child and adolescent populations among specialty practices. In 2022, about 16% of adolescents aged 12 to 17 years who obtained mental health services did so at a mental health treatment center; however, only a small proportion of those children received these services through telehealth.2 In the wake of the COVID-19 pandemic, it also remains to be seen whether and to what extent pediatric practices will continue offering telehealth rather than reverting to in-person care.7,8,9 This decision may be based partly on perceived quality of telehealth vs in-person services, as well as reimbursement policies of insurance companies.10,11
We conducted a secret shopper study, contacting MHTFs in all 50 states and the District of Columbia to inquire about telehealth availability for children and the offering of medication management via telehealth to children. We also examined differences in telehealth service availability based on facility-level and county-level characteristics. On the basis of prior literature,4,5 we expected to observe differences in the geographic availability of telehealth services offered to children by specialty clinics. We also expected to observe differences by the clinic’s ownership structure, accepted forms of payment, and service settings.
Methods
This cross-sectional study was conducted from September 24, 2024, through May 12, 2025, and the sampling frame included all MHTFs in the US. The study was deemed exempt by Harvard Pilgrim Health Care’s institutional review board. The study also received a waiver for informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines for cross-sectional studies.
Data Collection
We focused on MHTFs reporting information in the Substance Abuse and Mental Health Services Administration (SAMHSA) Behavioral Health Treatment Locator, recorded on December 4, 2018, and September 4, 2024. The locator includes information on licensed MHTFs throughout the US that completed the National Substance Use and Mental Health Services Survey and agreed to be listed. The locator is considered a comprehensive source of information on behavioral health treatment services in the US on a given day. New facilities are added monthly, and the records of existing facilities are updated weekly as SAMHSA is notified of changes.12 The SAMHSA locator is populated from facility surveys that target specialty treatment facilities (clinics, centers, hospitals, and residential programs) and excludes individual private practitioners or small group practices not licensed as a clinic or center.
Telephone surveys were administered by doctoral-level trainees (including coauthor S.W.) serving as assistant policy researchers at RAND who completed standardized training on survey protocols, including use of a structured script and consistent data recording procedures. The survey was conducted with the callers posing as the parent of a potential child patient. Callers contacted each facility’s main line and obtained responses from available staff knowledgeable about services, including telephone operators, front office staff, or administrative personnel. Up to 5 call attempts were made per facility at varying times and days; facilities were classified as unresponsive after 5 unsuccessful attempts. During each call, callers documented notes in a structured spreadsheet while simultaneously entering survey responses into a RAND-designed survey software platform.
In total, our data contained 9933 MHTFs. We removed the following MHTFs: 1598 facilities not offering outpatient treatment services, for which telehealth is a relevant modality; 305 VA medical centers, because they are unlikely to provide mental health treatment services for children; 43 facilities located in Puerto Rico, because our analysis was limited to US states and the District of Columbia; 244 facilities that completed a beta version of our survey, which we had used for cognitive testing and survey refinement; and 255 facilities in Alaska or Connecticut, because of recent changes to county Federal Information Processing Standard codes. In total, 2319 MHTFs were excluded, and the remaining MHTFs were contacted by our secret shopper study. Missing data were handled using a complete case approach, with analyses restricted to facilities that completed the survey items required for each outcome and covariates included in the model.
Measures
Facility-level variables obtained from the Treatment Locator data included service type (outpatient only vs outpatient plus either hospital or residential treatment facility), facility designation (whether the facility identified as a community mental health center [CMHC] or certified community behavioral health clinic [CCBHC]), accepted payment forms (Medicaid, private insurance only, and neither Medicaid nor private insurance), and ownership type (private for-profit, private not-for-profit, or public). County-level variables included whether the county in which the MHTF was located was designated a mental health professional shortage area (full, partial, or not) by the Health Resources and Services Administration in 2022,13 the percentage of residents identifying as Hispanic and as non-Hispanic Black, and median household income from the 5-year American Community Survey (2018-2022).14
Outcomes
There were 2 primary outcomes: (1) whether the MHTF reported providing telehealth services for children (yes or no) and (2) whether the MHTF reported offering prescribed or managed medications (hereafter medication management) for child mental health needs through telehealth (yes or no). The eAppendix in Supplement 1 provides a list of detailed survey questions.
Statistical Analysis
First, we conducted descriptive analyses to summarize information about the MHTFs that completed the secret shopper calls. Furthermore, we summarized county-level geographic variation in MHTF outcomes using heat maps and reported state-level variation numerically.
Then, we conducted separate multivariable logistic regressions to examine the associations between facility-level and county-level characteristics with whether (1) the MHTF offered telehealth services for children, and (2) offered medication management through telehealth for children. Because of the questionnaire skip patterns, MHTFs were asked about medication management through telehealth for children only if they first reported offering telehealth services for children. The regression models included the facility-level (service setting and community mental health center status, insurance type, and ownership) and county-level (mental health professional shortage area designation, quartiles of county Hispanic population, quartiles of county non-Hispanic Black population, and quartiles of county median household income) characteristics and state fixed effects. Facility-level and county-level characteristics were selected as potential factors associated with the likelihood of offering telehealth services. SEs were clustered at the state level. All tests were 2 sided, and statistical significance was defined as α ≤ .05. All analyses were conducted using Stata statistical software version 19.5 (StataCorp).
Results
Sample Characteristics
Of 7614 MHTFs contacted, we received a response from 5559 (73.0%). Table 1 provides an overview of MHTF characteristics. Among the 5559 respondent MHTFs, roughly one-third (1845 facilities [33.2%]) were a CMHC or CCBHC. The vast majority of MHTFs (5049 facilities [90.8%]) accepted Medicaid, whereas 406 (7.30%) accepted only private insurance and 104 (1.9%) accepted neither private insurance nor Medicaid. Most MHTFs were privately owned, including 3354 (60.3%) for-profit and 1421 (25.6%) not-for-profit; 784 (14.1%) were publicly owned. At the county level, 3631 facilities (65.3%) were in areas where part of the county was designated as a mental health professional shortage area, and 1541 (27.7%) were in counties where the entire county carried this designation.
Table 1. Characteristics of Responding and Nonresponding Facilities.
| Facility and county characteristics | Facilities, No. (%) (N = 7614) | P valuea | |
|---|---|---|---|
| Responding (n = 5559) | Nonresponding (n = 2055) | ||
| Facility characteristics | |||
| Facility type | |||
| CMHC or CCBHC | 1845 (33.2) | 600 (29.2) | .003 |
| Non-CMHC or CCBHC with inpatient or residential | 521 (9.4) | 191 (9.3) | |
| Non-CMHC or CCBHC outpatient only | 3193 (57.4) | 1264 (61.5) | |
| Accepted forms of payment | |||
| No Medicaid or private insurance | 104 (1.9) | 48 (2.3) | .43 |
| Yes private insurance only | 406 (7.3) | 151 (7.4) | |
| Yes Medicaid (with or without private insurance) | 5049 (90.8) | 1856 (90.3) | |
| Ownership | |||
| Public | 784 (14.1) | 244 (11.9) | .002 |
| Private, for-profit | 3354 (60.3) | 484 (23.6) | |
| Private, not-for-profit | 1421 (25.6) | 1327 (64.6) | |
| County characteristics | |||
| Mental health shortage area designation | |||
| Not a shortage area | 387 (7.0) | 162 (7.9) | <.001 |
| The whole county was designated as a shortage area | 1541 (27.7) | 454 (22.1) | |
| One or more parts of the county was designated as a shortage area | 3631 (65.3) | 1438 (70.0) | |
| Percentage of county is Hispanic residents | |||
| Lowest quartile | 857 (15.4) | 297 (14.5) | .02 |
| Second quartile | 872 (15.7) | 276 (13.4) | |
| Third quartile | 1525 (27.4) | 562 (27.4) | |
| Fourth quartile | 2305 (41.5) | 918 (44.7) | |
| Percentage of county is non-Hispanic Black residents | |||
| Lowest quartile | 703 (12.7) | 222 (10.8) | <.001 |
| Second quartile | 1047 (18.8) | 337 (16.4) | |
| Third quartile | 1874 (33.7) | 674 (32.8) | |
| Fourth quartile | 1935 (34.8) | 820 (39.9) | |
| County median household income | |||
| Lowest quartile | 637 (11.5) | 199 (9.7) | <.001 |
| Second quartile | 1053 (18.9) | 337 (16.4) | |
| Third quartile | 1284 (23.1) | 443 (21.6) | |
| Fourth quartile | 2585 (46.5) | 1074 (52.3) | |
Abbreviations: CCBHC, certified community behavioral health clinic; CMHC, community mental health center.
P values were calculated with χ2 tests.
The response rate differed by facility type and ownership but not insurance acceptance. Responding facilities were more often CMHCs or CCBHCs than nonresponding facilities (1845 facilities [33.2%] vs 600 facilities [29.2%]), whereas nonresponding facilities were more often non-CMHC outpatient-only facilities (1264 facilities [61.5%] vs 3193 facilities [57.4%]). Responding facilities were also somewhat more likely to be publicly owned (784 facilities [14.1]% vs 244 facilities [11.9%]), nonresponding facilities were more often private not-for-profit (1327 facilities [64.6%] vs 1421 facilities [25.6%]), and responding facilities were more often private for-profit (3354 facilities [60.3%] vs 434 facilities [23.6%]). Medicaid acceptance was similar between groups (5049 facilities [90.8%] vs 1856 facilities [90.3%]).
The response rate also differed by county characteristics. Responding facilities were more likely to be located in counties designated as whole-county mental health professional shortage areas (1541 facilities [27.7%] vs 454 facilities [22.1%]), whereas nonresponding facilities were more often located in counties without health professional shortage area designation (1438 facilities [70.0%] vs 3631 facilities [65.3%]). Response status also varied by county Hispanic quartile, county non-Hispanic Black quartile, and county median household income quartile. Nonresponding facilities were more concentrated in counties in the highest quartile of Hispanic residents (918 facilities [44.7%] vs 2305 facilities [41.5%]), the highest quartile of non-Hispanic Black residents (820 facilities [39.9]% vs 1935 facilities [34.8%]), and the highest-income counties (1074 facilities [52.3%] vs 2585 facilities [46.5%]).
We found that 4314 facilities (77.6%) reported offering any mental health services for children. Of child-serving MHTFs, 3345 (77.5%) reported offering telehealth services for children (Figure 1). The states with the greatest proportion of MHTFs offering telehealth services for children included Hawaii (1 of 1 facility [100.0%]), Montana (32 of 33 facilities [97.0%]), Colorado (79 of 85 facilities [92.9%]), Oklahoma (64 of 70 facilities [91.4%]), and New Mexico (32 of 35 facilities [91.4%]), whereas the states with the lowest proportion of MHTFs providing telehealth services for children were Georgia (52 of 81 facilities [64.2%]), Vermont (9 of 15 facilities [60.0%]), Alabama (25 of 46 facilities [54.3%]), South Carolina (26 of 59 facilities [44.1%]), and Mississippi (22 of 62 facilities [35.5%]) (Table 2).
Figure 1. Map of County-Level Variation in Provision of Telehealth Services for Children With Mental Health Needs.
Facilities were asked, “Do you provide telehealth services for kids with mental health needs?” The numerator is number of facilities saying yes, and the denominator is total number of responding facilities that offered treatment to children. Gray areas do not contain facilities that took the survey.
Table 2. State-Level Differences in Telehealth Offering.
| State | No. of facilities offering treatment services to children | Facilities responding yes to questions, No. (%)a | |
|---|---|---|---|
| Do you provide telehealth services for kids with mental health needs? | Can you provide or prescribe medications through telehealth? | ||
| Alaska | 30 | 21 (70.0) | 13 (43.3) |
| Alabama | 46 | 25 (54.3) | 17 (37.0) |
| Arkansas | 78 | 59 (75.6) | 48 (61.5) |
| Arizona | 150 | 121 (80.7) | 95 (63.3) |
| California | 251 | 199 (79.3) | 154 (61.4) |
| Colorado | 85 | 79 (92.9) | 66 (77.6) |
| Connecticut | 70 | 45 (64.3) | 34 (48.6) |
| District of Columbia | 6 | 5 (83.3) | 4 (66.7) |
| Delaware | 22 | 15 (68.2) | 11 (50.0) |
| Florida | 136 | 99 (72.8) | 77 (56.6) |
| Georgia | 81 | 52 (64.2) | 43 (53.1) |
| Hawaii | 1 | 1 (100.0) | 1 (100.0) |
| Iowa | 54 | 48 (88.9) | 39 (72.2) |
| Idaho | 35 | 28 (80.0) | 13 (37.1) |
| Illinois | 177 | 121 (68.4) | 85 (48.0) |
| Indiana | 127 | 92 (72.4) | 61 (48.0) |
| Kansas | 84 | 70 (83.3) | 61 (72.6) |
| Kentucky | 131 | 103 (78.6) | 75 (57.3) |
| Louisiana | 59 | 43 (72.9) | 29 (49.2) |
| Massachusetts | 86 | 71 (82.6) | 55 (64.0) |
| Maryland | 116 | 105 (90.5) | 87 (75.0) |
| Maine | 48 | 34 (70.8) | 18 (37.5) |
| Michigan | 166 | 138 (83.1) | 85 (51.2) |
| Minnesota | 134 | 116 (87.3) | 78 (59.0) |
| Missouri | 78 | 52 (66.7) | 36 (46.2) |
| Mississippi | 62 | 22 (35.5) | 15 (24.2) |
| Montana | 33 | 32 (97.0) | 21 (63.6) |
| North Carolina | 92 | 72 (78.3) | 54 (58.7) |
| North Dakota | 19 | 15 (78.9) | 9 (47.4) |
| Nebraska | 69 | 55 (79.7) | 28 (40.6) |
| New Hampshire | 21 | 19 (90.5) | 16 (76.2) |
| New Jersey | 85 | 57 (68.2) | 41 (49.4) |
| New Mexico | 35 | 32 (91.4) | 26 (74.3) |
| Nevada | 43 | 34 (79.1) | 24 (55.8) |
| New York | 181 | 148 (81.8) | 119 (65.7) |
| Ohio | 266 | 211 (79.3) | 129 (48.5) |
| Oklahoma | 70 | 64 (91.4) | 38 (54.3) |
| Oregon | 52 | 45 (86.5) | 33 (63.5) |
| Pennsylvania | 168 | 131 (78.0) | 96 (57.1) |
| Rhode Island | 7 | 5 (71.4) | 4 (57.1) |
| South Carolina | 59 | 26 (44.1) | 21 (35.6) |
| South Dakota | 19 | 14 (73.7) | 9 (47.4) |
| Tennessee | 137 | 112 (81.8) | 88 (64.2) |
| Texas | 160 | 103 (64.4) | 81 (50.6) |
| Utah | 104 | 85 (81.7) | 52 (50.0) |
| Virginia | 106 | 80 (75.5) | 60 (56.6) |
| Vermont | 15 | 9 (60.0) | 6 (40.0) |
| Washington | 127 | 111 (87.4) | 81 (63.8) |
| Wisconsin | 143 | 109 (76.2) | 69 (48.3) |
| West Virginia | 62 | 51 (82.3) | 38 (61.3) |
| Wyoming | 28 | 23 (82.1) | 20 (71.4) |
The denominator for this table is mental health treatment facilities that offered treatment services to children.
We found that 2419 child-serving MHTFs (56.1%) offered medication management for children through telehealth (Figure 2). Hawaii (1 of 1 facility [100.0%]), Colorado (66 of 85 facilities [77.6%]), New Hampshire (16 of 21 facilities [76.2%]), Maryland (87 of 116 facilities [75.0%]), and New Mexico (26 of 35 facilities [74.3%]) had the highest proportions of facilities offering medication management to children through telehealth. The fewest offerings were reported in Maine (18 of 48 facilities [37.5%]), Idaho (13 of 35 facilities [37.1%]), Alabama (17 of 46 facilities [37.0%]), South Carolina (21 of 59 facilities [35.6.%]), and Mississippi (15 of 62 facilities [24.2%]).
Figure 2. Map of County-Level Variation in Provision of Medication Management Through Telehealth.
Facilities were asked, “Can you provide or prescribe medications through telehealth?” The numerator represents the number of facilities responding yes, and the denominator includes all facilities that reported offering treatment services to children. Facilities that did not report offering services to children were not included in this measure. Gray areas indicate regions with no facilities that completed the survey.
Multivariable Regression Analyses
Controlling for facility-level characteristics, county-level characteristics, and the state where the MHTF is located, non-CMHCs in a hospital or residential setting had markedly lower odds of offering telehealth services to children (adjusted odds ratio [aOR], 0.36; 95% CI, 0.25-0.52) compared with CMHCs or CCBHCs. No other facility-level or county-level characteristics were statistically significant variables associated with offering telehealth services to children.
In contrast, we found several notable statistically significant factors associated with offering medication management to children through telehealth. Facilities that did not accept Medicaid or private insurance as a form of payment were significantly less likely to offer medication management to children through telehealth (aOR, 0.46; 95% CI, 0.25-0.86) compared with facilities that reported accepting Medicaid as a form of payment (Table 3). In addition, non-CMHCs in outpatient-only settings had lower odds of offering medication management through telehealth to children (aOR, 0.46; 95% CI, 0.34-0.61) compared with CMHCs or CCBHCs. Compared with private for-profit facilities, public facilities had higher odds of offering medication management to children through telehealth (aOR, 1.86; 95% CI, 1.20-2.88).
Table 3. Multivariable Logistic Regression of Odds of Offering Telehealth Servicesa.
| Characteristic | aOR (95% CI) | |
|---|---|---|
| Do you provide telehealth services for kids with mental health needs? (n = 4341) | Can you provide or prescribe medications through telehealth? (n = 3344) | |
| Facility characteristic | ||
| Insurance (reference is accepts Medicaid) | ||
| No Medicaid or private insurance | 0.70 (0.47-1.03) | 0.46 (0.25-0.86)b |
| Private insurance only | 0.71 (0.51-1.01) | 1.20 (0.91-1.59) |
| Community mental health center and service setting (reference is CMHC or CCBHC) | ||
| Not CMHC or CCBHC and hospital inpatient or residential | 0.36 (0.25-0.52)c | 0.75 (0.49-1.13) |
| Not CMHC or CCBHC and outpatient only | 0.95 (0.74-1.20) | 0.46 (0.34-0.61)c |
| Ownership (reference is private for-profit) | ||
| Public | 0.69 (0.47-1.02) | 1.86 (1.20-2.88)d |
| Private not-for-profit | 1.10 (0.86-1.41) | 1.21 (0.86-1.71) |
| County characteristic | ||
| Mental health professional shortage area (reference is not a shortage area) | ||
| The whole county was designated as a shortage area | 1.14 (0.77-1.69) | 0.97 (0.66-1.44) |
| One or more parts of the county was designated as a shortage area | 1.08 (0.74-1.55) | 1.04 (0.72-1.49) |
| Quartile percentage of county Hispanic (reference is first quartile) | ||
| Second quartile | 0.90 (0.66-1.23) | 1.03 (0.72-1.46) |
| Third quartile | 0.78 (0.57-1.05) | 1.04 (0.71-1.53) |
| Highest quartile | 0.89 (0.62-1.26) | 0.97 (0.60-1.57) |
| Quartile percentage of county non-Hispanic Black (reference is first quartile) | ||
| Second quartile | 0.98 (0.73-1.30) | 0.79 (0.61-1.02) |
| Third quartile | 0.90 (0.65-1.24) | 1.11 (0.79-1.56) |
| Highest quartile | 1.17 (0.78-1.75) | 0.98 (0.63-1.52) |
| Quartile household income (reference is first quartile) | ||
| Second quartile | 0.89 (0.67-1.19) | 0.67 (0.48-0.93)b |
| Third quartile | 0.87 (0.58-1.29) | 0.66 (0.45-0.97)b |
| Highest quartile | 0.93 (0.64-1.35) | 0.67 (0.45-0.99)b |
| Pseudo R2 | 0.0694 | 0.0573 |
Abbreviations: aOR, adjusted odds ratio; CCBHC, certified community behavioral health clinic; CMHC, community mental health center.
Logistic regressions include state fixed effects, and clustering was done at the state level.
P < .05.
P < .001.
P < .01.
County median household income was inversely associated with offering medication management to children through telehealth. Compared with the lowest quartile of household income, MHTFs located in the second household income quartile (aOR, 0.67; 95% CI, 0.48-0.93), third household income quartile (aOR, 0.66; 95% CI, 0.45-0.97), and the highest household income quartile (aOR, 0.67; 95% CI, 0.45-0.99) were less likely to offer medication management to children through telehealth. No other county-level associations were statistically significant.
Discussion
In this cross-sectional study of MHTFs in the US, we found that 77.5% of children-treating facilities offered telehealth, and 56.1% offered medication management to children via telehealth. Telehealth availability varied broadly across states (ranging from 35.5% to 100.0% of reporting facilities within each state), contributing to persistent gaps in access to telehealth services for children in certain geographic locations.2,9,15 The likelihood of offering telehealth and telehealth-based medication management for children also varied by facility and county characteristics.
There are several potential explanations for the geographic variation in whether MHTFs offer telehealth.16,17 The policy environment, including state efforts to promote telehealth, may play a role in this variation.18 Another explanation may be facility-level barriers to implementation, including limited technological infrastructure (eg, inadequate broadband connectivity or telehealth platforms), staffing constraints and limited training in telehealth delivery, uncertainty around reimbursement policies, and variation in state regulatory requirements governing telehealth practice. Targeted policy initiatives—such as a permanent requirement that states reimburse mental health services delivered through telehealth,19 telehealth payment parity,20 improving broadband access,21 and strengthening support for safety-net facilities—are examples that may have increased the reach of telehealth services in some states compared with others.22
A second dimension of geographic variation pertained to income: Facilities located in higher-income counties were less likely to offer telehealth-based medication management for children. Possible explanations include higher-income counties having more psychiatrists, so facilities can meet demand more easily with in-person medication management, or higher-income counties having more commercially insured residents, leading facilities to lean into higher-profit in-person visits for medication management. Future research could test these (or alternative) hypotheses through additional data collection.
Facility characteristics were particularly important variables associated with offering telehealth to children. According to our results, facilities serving children who are Medicaid enrollees may be incentivized to offer medication management through telehealth, reflecting both policy incentives and greater population need.23,24,25 Previous research26 has shown large increases in telehealth mental health use by children covered by Medicaid during the COVID-19 pandemic, but these increases did not fully offset overall declines in mental health service use among Medicaid-enrolled children. Another possible explanation for this finding is that many mental health professionals do not accept insurance payments.27,28,29
Limitations
This study has several limitations. First, not all MHTFs completed our survey, so our results are limited to the respondent sample. Second, our survey responses may be subject to social desirability bias, as the person answering the phone may have wanted to encourage individuals to visit the facility for care. Third, our survey population includes only MHTFs listed in SAMHSA’s Behavioral Health Treatment Locator; facilities and office-based practitioners not listed in the locator are not represented in our results. Because the SAMHSA treatment locator does not include solo practitioners or small group practices, our findings do not capture services delivered in these settings, which may limit generalizability. Fourth, we excluded Alaska and Connecticut because of changes in county-equivalent geographic units during the study period. Fifth, the survey did not define the term kid, so facilities may have interpreted the age range differently when reporting services. Sixth, our measures did not assess specific eligibility restrictions (eg, requirements for prior in-person visits or diagnostic criteria), which may limit interpretation of service availability.
Conclusions
In this cross-sectional study, we found that telehealth has become an integral component of pediatric mental health care, yet its availability remains uneven across facilities and communities in the US. These differences may reflect variation in organizational resources and state-level policies. Policymakers and public health officials should continue to monitor telehealth service offerings for children to identify gaps in access. Addressing potential gaps in telehealth offering will be essential to advancing equity and ensuring that all children can benefit from emerging modalities of remote mental health care.
eAppendix. Secret Shopper Script
Data Sharing Statement
References
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