Telehealth can be an important component of facilitating access to care for Medicaid enrollees, particularly the nearly four in ten enrollees with behavioral health needs (mental health conditions and/or substance use disorder (SUD)). During the COVID-19 pandemic, states took advantage of broad authority to expand Medicaid telehealth policies, resulting in high telehealth utilization across populations. In particular, states report that telehealth has helped maintain and expand access to behavioral health care during the pandemic. Indeed, in state fiscal year (FY) 2022, behavioral health, especially mental health, remained a top service category with high telehealth utilization among Medicaid enrollees. Similarly, CMS data indicates that behavioral health services delivered via telehealth increased dramatically during the pandemic; this finding is consistent with other analysis of outpatient visits (including but not limited to Medicaid patients). However, CMS also notes that this increase was not enough to fully offset the decline in the rate of in-person utilization of mental health outpatient services.
Given ongoing provider workforce challenges that present barriers to enrollees’ access to behavioral health care, Medicaid telehealth policy may continue to serve as an important tool for extending the workforce and facilitating improved access to behavioral health care, even beyond the COVID-19 pandemic. The 2022 Bipartisan Safer Communities Act requires CMS to issue guidance on Medicaid and telehealth by the end of 2023. The Consolidated Appropriations Act passed in December 2022 authorized additional telehealth provisions, including requirements or funding related to provider directories, crisis services, and virtual peer mental health supports. In the future, Congress could pass additional legislation suggested in a Senate Finance Committee draft on mental health and telehealth.
Against this backdrop of state and federal policy activity, KFF surveyed state Medicaid officials about policies and trends related to telehealth delivery of behavioral health services. These questions were part of KFF’s Behavioral Health Survey of state Medicaid programs, fielded as a supplement to the 22nd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA). A total of 44 states (including the District of Columbia) responded to the survey, but response rates varied by question. This issue brief utilizes this survey data to answer three key questions:
- How have states expanded behavioral health telehealth policy in response to COVID-19?
- What trends have states observed in behavioral health telehealth utilization?
- What are key issues to watch looking ahead?
How have states expanded behavioral health telehealth policy in response to COVID-19?
States have broad authority to cover telehealth in Medicaid without federal approval. Prior to the pandemic, the use of telehealth in Medicaid was becoming more common; in particular, most states offered some coverage of behavioral health services delivered via telehealth, and the majority of telehealth utilization was for behavioral health services and prescriptions. However, Medicaid policies regarding allowable services, providers, and originating sites varied widely, and telehealth payment policies were unclear in many states. To increase health care access and limit risk of viral exposure during the pandemic, all 50 states and DC expanded coverage and/or access to telehealth services in Medicaid. We asked states to indicate specific behavioral health Medicaid policy actions taken to expand telehealth in response to COVID-19 and any implemented or planned changes to these policies.
Nearly all responding states took at least one specified Medicaid policy action to expand access to behavioral health care via telehealth (Figure 1). States most commonly reported adding audio-only coverage of behavioral health services, which can help facilitate access to care, especially in rural areas with broadband access challenges and for older populations who may struggle to use audiovisual technology. Also, nearly all states reported expanding behavioral health services allowed to be delivered via telehealth, such as to newly allow telehealth delivery of group therapy or medication-assisted treatment (MAT). Many states noted that virtually all behavioral health services were eligible for telehealth delivery during the pandemic. Finally, most states reported expanding the provider types that may be reimbursed for telehealth delivery of behavioral health services, such as to allow specialists with different licensure requirements (e.g. marriage and family therapists, addiction specialists, and peer specialists). A small number of states noted additional behavioral health Medicaid policy actions beyond those specified; for example, Washington reporting providing technology to enrollees and providers to improve access to behavioral health care during the pandemic.
As of July 2022, states were more likely to allow audio-only coverage of behavioral health services compared to other services. As reported on KFF’s 2022 Medicaid budget survey, nearly all states added or expanded audio-only telehealth coverage in Medicaid in response to the COVID-19 pandemic. As of July 1, 2022, a majority of states reported providing audio-only coverage (at least sometimes) across service categories, with mental health and SUD services the most frequently covered categories (Figure 2).
Many states reported permanently adopting some or all of these behavioral health Medicaid telehealth policy expansions. Consistent with responses to KFF’s 2022 Medicaid budget survey, many states reported permanent (i.e. non-emergency) adoption of telehealth policy expansions that were initially enacted during the pandemic on a temporary basis. In particular, states frequently noted that all or most expansions of behavioral health providers and/or services allowed for telehealth would be maintained after the public health emergency. However, some states also reported limiting or adding guardrails to pandemic-era behavioral health telehealth flexibilities. Most commonly, states reported that they would limit coverage of audio-only telehealth for behavioral health services, consistent with concerns about the quality of audio-only telehealth reported on the budget survey.
What trends have states observed in behavioral health telehealth utilization?
To better understand the impacts of behavioral health telehealth policy changes during the pandemic, we asked states to indicate whether they monitor behavioral health telehealth utilization in Medicaid and, if so, to report utilization trends by geography, demographics, and other factors.
Nearly all responding states monitored utilization of behavioral health services delivered via telehealth in FY 2022 or plan to begin doing so in FY 2023 (Figure 3). Telehealth utilization data can help states assess the impacts of expanded telehealth policy. These assessments may inform future quality and other analyses. Some states that already monitor behavioral health telehealth utilization reported future plans to increase this monitoring and/or to stratify utilization data by additional demographic or other factors.
Many states reported high utilization of telehealth for behavioral health care across all or most Medicaid populations, though some states noted utilization trends among certain subgroups of Medicaid enrollees, such as:
- Geographic trends, with states most commonly reporting particularly high behavioral health telehealth utilization in rural areas compared to urban areas. Telehealth could be an important tool for facilitating access to behavioral health care for Medicaid enrollees in rural areas with fewer provider and hospital resources.
- Demographic trends, which were most commonly captured by race/ethnicity and age. These trends generally mirror overall data indicating that behavioral health conditions are most prevalent among young adults and White people. In particular, some states reported that younger enrollees (including children and non-elderly adults) were most likely to utilize telehealth for behavioral health care. Several states reported higher telehealth utilization among White individuals compared to people of color. A small number of states reported that female enrollees were more likely to utilize telehealth compared to male enrollees.
- Temporal trends, with states frequently reporting that behavioral health telehealth utilization has declined from its peak earlier in the pandemic, but remains high compared to the pre-pandemic period. Future policy changes, such as to further expand or to limit telehealth flexibilities, may impact ongoing utilization. For example, South Carolina reported anticipating an increase in behavioral health telehealth utilization among children in FY 2023 as part of an initiative to increase access for school-based mental health services.
The trends summarized above are generally consistent with overall Medicaid telehealth utilization trends reported on KFF’s 2022 budget survey. Additionally, several states reported that telehealth utilization was higher for mental health services compared to SUD services (this trend likely reflects the higher prevalence of mental health conditions compared to SUD conditions among Medicaid enrollees). A few states reported that demographic utilization trends varied by service or provider type. For example, New York indicated that female enrollees were more likely than male enrollees to receive psychological and psychiatric services via telehealth, but that male enrollees were more likely to receive SUD services via telehealth. Colorado reported that utilization trends by race/ethnicity were related to provider type, as community mental health centers are likelier to use telehealth and are also likelier to serve more racially/ethnically diverse populations.
What are key issues to watch looking ahead?
Key issues that may influence states’ future behavioral health Medicaid telehealth policy decisions include analysis of utilization and other data as well as federal guidance:
- Data and quality: As states continue and expand their monitoring of behavioral health telehealth utilization, the results of these analyses may provide information that can inform policy decisions. Also, the Government Accountability Office (GAO) has recommended that CMS collect information to assess the impact of telehealth on quality of care for Medicaid enrollees, and most states report questions and/or concerns about the quality of services delivered via telehealth that may be addressed through ongoing data analysis.
- Federal guidance and legislation: States also report watching for further guidance from the federal government related to Medicaid telehealth policies. The Bipartisan Safer Communities Actsigned into law in June 2022 directs CMS to issue guidance to states on options and best practices for expanding access to telehealth in Medicaid, including strategies for evaluating the impact of telehealth on quality and outcomes. CMS must issue this guidance by the end of 2023. The Consolidated Appropriations Act passed in December 2022 authorized additional telehealth provisions, such as requirements for Medicaid provider directories to include information on telehealth coverage and for CMS to issue guidance on how states can use telehealth to deliver crisis response services. The Act also authorized grants for nonprofits to expand and improve virtual peer mental health support services, as well as other non-Medicaid telehealth provisions (such as telehealth policies for veterans and for Medicare enrollees). Several of these federal Medicaid telehealth policies passed in 2022 follow from a Senate Finance Committee discussion draft on ensuring access to telehealth, released by the Committee in May 2022 as part of a series of drafts associated with its mental health care initiative. Looking ahead, Congress could take up additional policies suggested in the draft, such as to require public aware
As states emerge from the COVID-19 pandemic and grapple with behavioral health workforce shortages, the continuation of expanded telehealth policy—informed by data analysis and federal guidance—may be an important component of maintaining access to behavioral health care for enrollees.
This work was supported in part by Well Being Trust. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.
This brief draws on work done under contract with Health Management Associates (HMA) consultants Angela Bergefurd, Gina Eckart, Kathleen Gifford, Roxanne Kennedy, Gina Lasky, and Lauren Niles.
However, you won’t achieve muscle as fast as you’ll have accomplished had your diet put you in a calorie surplus,
with everything set up for the sole function of adding mass.
Don’t attempt to enhance multiple physical qualities on the similar time.
To make progress as quick as your genetics will permit, you’ll need to
concentrate on one major fitness objective to the exclusion of every thing else.
Even if you’re following one of the best full physique exercise ever devised in all of human historical past,
including muscle to your frame takes persistence, hard work and patience.
(Yes, solely three days per week.) Every workout should take you about minutes, door
to door. Rest a minimal of ninety seconds between workout routines similar to bicep curls and Romanian deadlifts,
and as a lot as 3-4 minutes in your heavier units of bench presses and squats.
A good guideline is to relaxation lengthy sufficient to
maneuver heavy weight, however not long enough to cool down.
The broad grip entrance lat pulldown hits the
back and biceps. If you like pull-ups (which are done along with your palms going through forwards, not like chin-ups the place your palms face you) and you’re
capable of do three units of 5-10 pull-ups using good type, do pull-ups as an alternative.
The dumbbell hammer curl is completed with your thumbs up and palms facing one another like you’re holding
a hammer. Doing the train this way, somewhat than together with your palms going
through up, still hits the biceps, however brings the brachialis,
one other muscle in your higher arm, into play.
Being unable to train places the break on your quest to
construct muscle quick like nothing else. Injuries not solely harm but in addition sideline you,
and you can’t build muscle from the sofa. In this article,
you’ll discover the 15 most vital, no-nonsense tips to beefing
up. Whether you’re a gym newbie or a seasoned lifter, these insights
will turbocharge your routine and catapult your outcomes.
Another huge benefit to this type of set-up is the
reality that it’s going to permit you to embrace extra isolated workouts.
If you want to specifically goal one of the smaller muscle
groups (biceps, triceps, lateral deltoid, etc), you can do so extra easily.
Some individuals could select to only employ the FST-7 precept in one of their exercises for a particularly lagging muscle
group, whereas others may strive it by way of all exercises in the course of the week.
There are superior variations with German Quantity Training that convey the rep vary lower
to allow for more weight.
This usually means compound urgent workout routines like
the bench press, overhead press, and push-ups, but also isolation workout routines for your push muscle
tissue, like tricep extensions and lateral raises.
The rep ranges in our 5 day workout cut up programs can additionally be slightly altered.
For instance, if it says 8-12 reps for any given train, but you prefer reps, that’s
nice. As Quickly As you decide on the change you need, simply maintain the same rep range over the course of
the coaching period so you’ll have the ability to give consideration to
the aforementioned progressive overload methodology.
When it comes to weight reduction, any workout split may be effective so long
as your food regimen is in examine. To shed pounds,
you should eat fewer energy than you burn and incorporate cardio or HIIT after your workouts.
Implementing a 5 day cut up with loads of cardio can be extremely advantageous for fat loss, as it helps protect muscle mass.
However, a workout routine that works for me does not mean it actually works for all.
It is as a outcome of everyone’s physique responds another
way. Shoulder presses also enhance sports activities efficiency and different actions requiring overhead movement, corresponding to throwing and climbing.
They have interaction your shoulder stabilizer muscles, which help improve
shoulder stability and reduce the risk of injury. However, you need to take
those results with a couple of grains of salt, especially regarding
long-term positive aspects and power progress.
Commit to attempting ONE of these movements in the subsequent week.
Use 20 seconds of courage, recruit a good friend who has lifted or
trained earlier than, and try your best.
Every day, we burn a sure number of energy just present, which known as our BMR (basal metabolic
rate). We then factor in our day by day activity level, and get a number that known as our “total daily energy expenditure.” You can calculate yours below.
As we stated above, gaining weight comes all the means down to
thermodynamics and science. No must call for assist to get that 50lb bag of dog food off
the highest shelf, or carrying an air conditioner unit up a flight of stairs.
Break this down into simple steps and objectives that aren’t scary, and get began. If you battle to get
enough calories in your system, spacing out your meals would possibly assist
you to really feel much less full, or offer you more
opportunities to achieve your calorie goal for the day.
I hate to say it, but constructing endurance and getting bigger concurrently
is brutally difficult.
Nevertheless, you’ll not lockout at the high of every
rep. Locking out offers you with a mini pause at the
high of every rep. That just isn’t what we want.
Stopping simply in need of lockout and going
straight into the next rep will keep the stress on your thighs.
That will provide your physique with 48 hours to relaxation, recover and develop between every training session.
You don’t essentially have to use all of those weight coaching
techniques in the identical or every exercise. You can select which ones you need to do and you can alternate them.
That’s one other thing about building muscle at any age; it’s always good to change up your workouts every now
and then, even when they’re simply subtle modifications (anywhere from every 4-8 weeks).
Full-body workouts can be made to work for newbie, intermediate and advanced trainees alike.
In truth, some advanced lifters choose a high-frequency
(4-5 instances per week) full body workout plan over extra standard body part split routines.
As a rule, I’d counsel resting for longer between sets
of compound workouts that work a large amount of muscle mass, corresponding to squats, rows, deadlifts, leg presses and so
forth. Think of it as a video game; you want to degree as a lot as make your
stats enhance.
Life could be unpredictable, and generally you might need
to adjust your coaching days. Having a versatile cut up permits you to adapt with out dropping momentum.
Nevertheless, particular person factors such as
training intensity and quantity ought to dictate how
typically you train each muscle group. If you feel fatigued or sore, it might be
useful to cut back the frequency temporarily. Many lifters make errors when selecting or following
a training split.
In contrast, a Push/Pull/Legs split might permit for decrease volume per session but higher overall weekly volume as a
result of increased frequency. If a muscle group is
fully recovered however you wait too long to train it again, you might miss out on potential gains.
This information helps you train more effectively and see better outcomes.
Non-training days require slightly larger fat as there is
less need for carbs. If your physique responds well to fat go
for the higher end of the ranges prescribed below and vice versa if
it performs better on carbs. You will discover ways to measure progress and reply to plateaus, so you’ll be able to continue to enhance well
past Week 12. Workout splits differ in frequency, intensity, and restoration calls
for. Push/Pull/Legs balances frequency and restoration properly, while Bro Splits allow high-volume concentrate on individual muscle teams but
with lower frequency.
After one other day or two, your muscle tissue are normally fully recovered and prepared to be skilled once more.
How shortly you achieve muscle is dependent upon several
components, corresponding to your coaching expertise, genes, diet,
and sleep. As talked about, I will not go into an extreme quantity of
depth however present enough so that you simply can understand the basics to nutrition and supplementation when constructing muscle.
Equally to weight reduction, muscle development is
extremely dependant on your food plan. For all of my fellow beginner lifters, I advocate watching the
video beneath as I go over some helpful tips about this
exercise program.
Our Mass-Attack coaching routine is a 12-week, three-phase plan consisting of four, six, and
two weeks, respectively. The first part is adhering
to a hybrid size/strength routine, one which helps prepare your
physique to endure the stresses to observe. In the second section, you’ll be following a plan resembling that
of a powerlifter, with a give consideration to constructing uncooked power, while paying
much less consideration to muscular hypertrophy (growth).
The third part is as quickly as again a hybrid, for two
distinct reasons. One is to reacclimatize your physique
to the usual bodybuilding program you’ll go back to on the end of the
12-week cycle.
However there are another techniques to pressure your muscular tissues to work
more durable. And that is going to provide the advantage
of constructing quality muscle in addition to burning extra body fats during your workouts.
When you’re controlling that weight, you’re making your muscles work harder which equates to constructing extra muscle.
This easy double progression technique can work nicely for most exercises,
and will produce first rate features in muscle mass
over a quantity of months, just so lengthy as you keep consistent and work onerous.
Do the identical workouts, for the same number of units
and reps, whereas lifting the same amount of
weight, for the next 5 years. No matter how your training
week is ready up, it’s essential to coach onerous and concentrate on bettering your workout performance over time.
Subsequent up is the reverse grip lat pulldown, which targets your again and
biceps.
Cardio acceleration movements must be used between occasions of supersets,
or as a substitute of supersets between workouts.
This will help optimize your physique composition, even further in between your supersets.
The coaching triggers growth, but your food provides the means.
If you don’t eat enough, your physique won’t have the constructing blocks
to add muscle dimension. As for health degree, obviously the more skilled you’re and the better
form you’re in, the extra your muscles can deal with.
Keep Away From utilizing momentum or swinging the load up utilizing your hips, as that can take
away work from the supposed working muscle tissue. That means it’s worked to a point
in rowing workout routines just like the bent-over row, however you presumably
can target it even further with exercises like the reverse
dumbbell fly, pictured above. The upright row is a barbell
train that works not only your side delts, but additionally your higher trapezius.
Transferring again to a compound train, the behind-the-neck press is
a variation of the usual overhead press.
Before I write this, please understand that I’m an advocate for lifting heavy weights with decrease
rep ranges to build size, strength, and dense muscle mass.
However, I’ve discovered that training legs require a unique method.
And in this publish, I’m going to share why I do high reps
for legs…. For a newbie new to the world of power training, jumping straight right into a
PPL routine might be too much. Instead, a full physique exercise program where you train your complete body two or
3 times weekly is a good idea to prepare for the
high volumes of a PPL cut up. An upper-lower break up routine where you divide your muscle groups into
one exercise in your higher body muscle tissue
and one for your decrease physique is also an ideal coaching program for the newbie.
This seven-day challenge is designed that will assist you build strength, improve
endurance, and push previous your limits in a sustainable method.
Each day, you will give consideration to
a key movement pattern, dialing in kind and control.
Sleep provides quite a few advantages, however
it’s additionally the time when your muscles have the biggest alternative to repair
themselves and heal from all of the work they’re doing
in the course of the day. Set your self up for fulfillment by growing a bedtime routine and allowing your self
to get a full night’s sleep.
And when your muscular tissues aren’t sufficiently challenged, they’ll stop to adapt.
Then, within the subsequent workout, you must attempt to carry more
than the last time. In contrast, a triceps train just like the tricep pushdown, where you
principally maintain your higher arm next to
your torso, primarily works the lateral head of the triceps.
With the barbell lying triceps extension, it’s time to work the
long head of the triceps (which makes up 50% of your triceps volume) and the medial head
(which makes up one other 12%). Make changes as essential, whether its discovering the
correct kind or finding the proper weight.
While you can use this for a 3-day cut up, you probably
can actually use it for 4, 5, or even 6. We additionally want to quickly compare a PPL break up to a Push-Pull Break Up.
This is because it divides the muscle teams into
three training classes. These three classes permit a nice blend of frequency, quantity, and restoration. The greatest break up for you will finally rely in your
choice.
For the newbie lifter, this sort of training will help maximize muscle achieve until your health stage
is prepared for more superior workouts. This 4-day superior
full-body workout plan is made for individuals who have been lifting weights for no much less than a 12
months. The routine lasts for 3 months and focuses on building muscle mass.
The main objective is to gain dimension and energy by lifting
heavier weights with fewer repetitions in every set.
So, make sure you get sufficient quality sleep – snooze like a champion, and your muscle tissue will thanks.
You can get creatine from food (primarily animal proteins
like meat and fish), but not sufficient for the effects you’re after.
Finally, unfold your daily protein intake fairly evenly all through the day,
and you’re golden. Complete proteins containing all important amino acids are your best wager.
We’re speaking lean meats, fish, eggs, dairy like
cottage cheese, and for the plant-powered, beans, lentils, quinoa, tofu, and
different soy-based meals. Protein shakes
utilizing a high-quality protein powder like soy or whey
protein are good, too.
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