Category: Telehealth

Telehealth Linked to Physician EHR Burden

Posted on by Jason Barry

Telehealth is great for a lot of things, but reducing physician EHR burdens isn’t one of them, according to a new study in JAMA Internal Medicine. 

Researchers analyzed the EHR metadata of 1,052 ambulatory physicians at UCSF Health over 115 weeks straddling the onset of the pandemic, comparing usage from August 2018 – September 2019 to August 2020 – September 2021.

They found that telehealth use correlated to more time spent in the EHR both during and outside of patient scheduled hours (PSHs), although the extra work was mostly related to documenting visits rather than messaging patients.

  • Comparing the pre- and post-pandemic windows, telehealth use increased from 3.1% to 49.3% of all encounters.
  • Time spent working in the EHR during PSHs increased from 4.53 to 5.46 hours for every eight PSHs.
  • Time spent working in the EHR outside of PSHs increased from 4.29 to 5.34 hours for every eight PSHs.
  • Weekly messages received from patients increased from 16.7 to 30.3, and messages sent to patients increased from 13.8 to 29.8. Despite the spike, further analysis showed that documentation added the bulk of the extra time rather than messaging.

The authors give several explanations for why telehealth might be leading to more time in the EHR, including the fact it allows the physician to compose the note throughout the encounter (instead of a shorter burst afterwards).

  • That still wouldn’t account for the increase in EHR time outside of PSHs, which the authors believe might be because telehealth improves appointment adherence and reduces the time between visits that was previously used for documentation.
  • It could also be that telehealth requires more before-visit EHR review in the absence of a physical examination.

The Takeaway

There’s plenty of research suggesting that telehealth reduces provider burnout, but this study adds a wrinkle to the underlying explanation. These results make it clear that telehealth isn’t reducing EHR time, which points to other benefits like convenience driving lower burnout, such as more flexibility, autonomy, and even engagement with work.

Teladoc’s Mixed Q3, Starts Operational Review

Posted on by Jason Barry

Teladoc Health’s third quarter numbers are in, kicking off the earnings season with results that were “mixed” enough to weigh down the broader digital health sector despite an 8% increase to top line revenue.

Here’s Teladoc’s Q3 at a glance:

  • Total revenue up 8% to $660.2M
  • Net loss of $57.1M (an improvement over -$73.5M in Q3 2022)
  • Integrated Care segment revenue of $374.4M (up 9%)
  • BetterHelp segment revenue of $285.8M (up 8%)

Everything seemed to be trending in the right direction, especially considering that US Integrated Care membership reached 90.2M (up 10% YoY), driven in part by Chronic Care Complete enrollment hitting 1.1M (up 13% YoY).

So why did TDOC stock continue its multi-year dive despite the positive metrics? Without wading too far into the Wall Street weeds, the headline grabber from the investor call was that CEO Jason Gorevic is “disappointed” with Teladoc’s current valuation, and is initiating a “comprehensive operational review” to boost its bottom line.

  • The first component of the two-step overhaul involves a portfolio assessment geared toward sharpening Teladoc’s focus around solutions “prioritized in the direction of our integrated whole-person care strategy.”
  • Second, Teladoc is pursuing a comprehensive review of its cost structure, meaning that it’s tightening its purse strings and prioritizing profitability over revenue growth.

While margin improvement and focused offerings seem like they would be music to investors’ ears, more cuts are clearly on the way, especially for service lines outside of “whole-person care.” 

The Takeaway

One of Teladoc’s biggest advantages over point solution providers is its “whole-person care” bundling capabilities, and two-thirds of last year’s chronic care growth included bundles for multiple products like diabetes, hypertension, or weight management. That approach gives Teladoc a distinct edge with clients looking for an integrated platform, but right-sizing its offerings to fit the strategy means that some investors would rather avoid the short-term revenue pain even with long-term margin gain.

Amazon Clinic Expands to All 50 States

Posted on by Jason Barry

The same eCommerce giant that brought us one-click checkout is well on its way to bringing us one-click healthcare, with Amazon Clinic now available in all 50 states.

Amazon’s blog post sticks to the company’s roots by positioning Amazon Clinic as a “virtual health care marketplace,” allowing patients to compare treatment options for 30+ common conditions like pink eye or allergies.

The clinicians delivering the actual care appear to be from four partner networks: Curai, Hello Alpha, SteadyMD, and Wheel.

  • Users can see the cost of each provider, as well as the average wait time, although notably absent is any sort of care quality metric for the desired condition.
  • They can then select either an asynchronous chat or a live video visit delivered directly through Amazon.com / the Amazon app, and medications can be conveniently fulfilled by Amazon Pharmacy. Sounds great on paper.

It’s easy to picture this playing out the same way that Amazon’s eCommerce marketplace unfolded, with telehealth costs kicking off a race to the bottom that’s great for consumers and less great for margins. 

  • Amazon Clinic’s provider partners just got a massive boost to visibility (and probably volume), and we could see more traditionally B2B telehealth vendors enrolling to get the same perks.
  • Amazon also gains a treasure trove of user data, a new gateway to Amazon Pharmacy (One Medical referrals could easily be on the way), and it doesn’t seem far-fetched to think the Amazon Basics playbook of copying/acquiring outperformers is on the roadmap.

The Takeaway

Convenience is king with all consumers, and Amazon is hard at work blurring the line between patient and consumer. This probably wasn’t news that Ro or Hims loved to see, given that they offer overlapping services without the benefit of two billion website visitors every month. Case in point, Amazon.com publicized the Clinic expansion with a homepage banner reading “healthcare for those ‘can’t wait’ days,” possibly the single most valuable ad slot for a D2C telehealth launch of all time.

Teladoc Posts Solid Q2 Across All Segments

Posted on by Jason Barry

Teladoc Health just released its second quarter earnings, and the results were somewhere between a return-to-form and an absolute home run.

Here’s Teladoc’s Q2 by the numbers:

  • Revenue jumped 10% year-over-year to $652M
  • Net loss shrank to $65M from $69M in Q1 (last Q2 saw a $3B Livongo writedown)
  • Integrated Care revenue up 5% YoY to $360M
  • BetterHelp revenue up 18% YoY to $292M 
  • Full-year revenue guidance raised to $2.6B-$2.67B, up $25M at the low end

Those figures helped push Teladoc’s stock up over 25% on Wednesday, with the narrowing loss and improved guidance both welcomed by investors. The conference call didn’t hurt either, and the four main themes that Teladoc drove home in the analyst Q&A were:

  • BetterHelp customer acquisition costs are stabilizing after being a pain point over the last year. CEO Jason Gorevic said that consumer demand “has proven resilient through the first half of the year, even with the financial pressures that many households are facing.” BetterHelp now has 476k users, up 17% YoY.
  • The Integrated Care segment saw growth across all chronic condition management programs. Digital diabetes prevention got a special callout, and over a third of Teladoc’s chronic care members are now enrolled in multiple programs. Total chronic care program enrollment was 1.07M at the end of Q2 (up 7% YoY), and CFO Mala Murthy said the 45k new enrollees drove the Q2 revenue increase. 
  • GLP-1 drug costs landed a major spotlight, with Teladoc’s employer clients clearly scrambling for ways to keep them contained. Teladoc is launching a new weight management program in Q3, giving patients access to GLP-1 drugs and personalized care plans developed with a physician to help manage outcomes and costs. 
  • AI, AI, AI. It wouldn’t be a 2023 earnings call if they skipped it. Teladoc apparently uses over 60 AI models in its products, ranging from member engagement to its virtual care queuing system. Leadership also drummed up hype for the Microsoft partnership expansion, which will integrate Azure OpenAI and Nuance DAX into the Solo platform.

The Takeaway

All-in-all, Teladoc delivered a great second quarter, with every segment contributing to the revenue gains and proving that expanding within existing clients is a solid growth strategy. If there was something to harp on, it was the $200M worth of stock-based compensation that Teladoc is handing out this year, a pretty mind blowing total that’s a primary contributor to the company’s net loss.

Telehealth Only Effective For Some Conditions

Posted on by Jason Barry

New research out of the University of Texas added to the growing body of evidence that indicates telehealth’s promise of lower costs and utilization isn’t as straightforward as it appears – especially for certain types of diseases. 

Researchers looked at patient visits across all hospital-based outpatient clinics in Maryland from 2012 to 2021, finding that virtual visits reduced the overall number of 30-day follow-ups by 13.6%, bringing down costs by $239 per patient.

Patients with behavioral health, skin, metabolic, and musculoskeletal disorders saw an even greater 19% reduction in follow-ups (an equivalent cost reduction of $179), suggesting that virtual care serves as a true substitute to office visits.

  • Telehealth was also associated with a significant reduction in ER and specialist visits among patients in this category.
  • The common thread between those conditions is what the researchers coined as “high virtualization potential,” or the ability for physicians to effectively measure symptoms over telehealth.

The flip side of that coin is that conditions with “low virtualization potential” saw nearly zero benefit from virtual care in terms of lowering costs, follow-ups, or future ER visits.

  • These included circulatory, respiratory, and infectious diseases, where symptoms are difficult to observe over video and harder for patients to communicate.

These findings double down on the results from Epic Research’s study earlier this month, which found that 16 of the 24 specialties analyzed had fewer follow-ups after an initial telehealth visit.

  • That study saw nearly identical overlap with behavioral health and MSK, which both saw a 20%+ reduction in follow-ups after telehealth. Podiatry, OBGYN, and ophthalmology were the greatest exceptions, in line with the “low virtualization potential” theme.

The Takeaway

The difference in telehealth’s effectiveness between conditions caused the study authors to reach the conclusion that virtual care should be promoted in clinical areas where it is most beneficial, but it seems like there might be a bigger takeaway for our audience: There’s a huge need for innovative remote examination solutions, and circulatory, respiratory, and infectious diseases are a great place to start.

Trends Shaping the Health Economy: Behavioral Health

Posted on by Jason Barry

Trilliant Health published a new report that’s pretty close to required reading for anyone working in behavioral healthcare – Trends Shaping the Health Economy: Behavioral Health.

The report does a thorough job wrapping numbers around the biggest trend in the space: patient demand is outpacing the supply of providers.

  • Behavioral health volumes were 18.1% above pre-pandemic levels by Q2 2022, driven by a combination of stress-induced disorders and a 45X increase in telehealth utilization. Behavioral health visits accounted for 63.8% of total telehealth visits in Q2 2022.
  • Since 2019, the conditions that saw the sharpest rise in visit volumes were eating disorders (up 52.6%), anxiety (47.9%), substance-use disorders (27.4%), depression (24.4%), and bipolar disorder (12.2%).
  • Unlike many other areas of healthcare, behavioral health doesn’t appear to be a small group of high utilizers driving up volumes. In 2021, two-thirds of patients diagnosed with a mental health condition saw a provider five times or fewer.

Although telehealth was initially viewed as a way to expand access to therapy, the data paints a different picture of its actual impact. More prescriptions, treatments shifting away from behavioral health providers, and lackluster follow-up care.

  • The share of patients with a prescription for antidepressants increased 15% from 2017 to 2021, while patients ages 22-44 saw Adderall prescriptions spike 58.2%.
  • PCPs now prescribe the greatest share of behavioral health medications (42.3%), and NPs and PAs have also begun to account for a large share of prescribing volume (22%). Behavioral health providers account for just over a third of total prescribing volume.
  • Most patients initially diagnosed by their PCP with schizophrenia (70.2%) or bipolar disorder (62.8%) received subsequent treatment from a behavioral health provider, but the same was true for only 30.3% of ADHD patients.

The Takeaway

Trilliant’s data provides a strong foundation to start asking the right questions about the direction behavioral healthcare is heading.

  • Should high demand shift care settings for behavioral healthcare?
  • Should primary care be the first line of defense?
  • If PCPs are delivering this care, is more training needed to manage these conditions?
  • Is this the proper balance between therapy and medication?

While Trilliant’s report isn’t setting out to answer these questions, it’s a valuable tool for those that are.

Telehealth Rarely Requires In-Person Follow-Ups

Posted on by Jason Barry

Epic Research tied a nice ribbon on the end of 2022 with a study suggesting that telehealth is an efficient use of resources for most specialties, rarely requiring an in-person follow-up within 90 days.

The research appears to indicate that telehealth isn’t usually duplicative of in-person visits, adding weight to the argument that regulators should view it as an alternative, rather than an additional encounter.

After examining over 35M telehealth visits conducted between March 2020 and May 2022, Epic Research found a pretty wide spread between specialties for both the number of telehealth visits and in-person follow-up percentages.

The main finding was that high follow-up rates were present only in specialties that require regular in-person visits for hands-on care, such as obstetrics and surgery. 

  • Mental health and psychiatry had the highest telehealth utilization and some of the lowest need for in-person follow-up. No surprises there.
  • Only 15% of telemental health visits needed an in-person follow-up within the next three months.
  • On the opposite end of the spectrum, obstetrics (92%), fertility (54%), and geriatrics (50%) had the highest need for in-person follow-ups.
  • In specialties that could be consultations (e.g. genetics, nutrition), the researchers stated that telehealth might even replace the need for in-person visits.

The Takeaway

While the numbers certainly look good for telehealth at first glance, the pandemic itself might be doing them a lot of favors.

Many medical offices closed at the beginning of the study period, and most didn’t reopen to in-person appointments for several months. Plenty of patients also remain wary of in-person visits due to the risk of virus exposure. Both factors probably skewed the in-person follow-ups to a lower range.

Those details aside, Epic Research gave a great overview of in-person follow-up needs by specialty, and the more data we can wrap around telehealth’s impact the better.

Telehealth Startups Sharing Patient Data

Posted on by Jason Barry

An absolute firework show of a joint report between STAT and The Markup cast a spotlight on telehealth companies sharing sensitive patient information with advertisers, and it definitely wasn’t a good look for some of the biggest names in the space. 

Over the past few months, STAT and The Markup created accounts and completed onboarding forms on 50 telehealth sites (most major players, notably excluding Teladoc/BetterHelp), then tracked what data was being shared with advertisers such as Google, Facebook, and TikTok.

Of the 50 telehealth websites analyzed, advertisers received information from:

  • URLs users visited – 49 sites
  • Personal info (name, email, phone) – 35 sites
  • When user initiated checkout – 19 sites
  • User’s answers to questionnaires – 13 sites
  • When user added to cart – 11 sites
  • When user created an account – 9 sites

Yikes. One of the stats that stands out the most is the fact that 13 of the websites shared patients’ answers to medical intake questions, such as their migraine frequency or substance use history. All but one of the sites shared the URLs that users visited – gold star for Amazon Clinic – but most of the websites shared information with multiple advertisers. 

Here’s how many of the sites shared data with each advertiser:

  • Google – 47 sites
  • Facebook – 44 sites 
  • TikTok – 23 sites
  • Snapchat – 15 sites
  • LinkedIn – 9 sites
  • Twitter – 7 sites

You can find the full list of telehealth platforms and the information they shared roughly a third of the way down the report, and the authors were even kind enough to provide a cringe worthy round up of each company’s response. 

The Takeaway

Telehealth companies often act as middlemen between the patients and providers covered under HIPAA, rather than delivering care themselves, which results in limited protections for the sensitive information they collect.

Most patients probably assume that their health data is always protected, and many of them turn to online solutions for more privacy in the first place. The end of STAT and The Markup’s report included thousands of words from privacy experts and regulators, nearly all of them agreeing that protections like HIPAA need to be reformed for the telehealth era.

Only protecting sensitive information in certain settings is clearly starting to feel out of step with the times, especially when advertisers have the answers to your health intake forms.

Teladoc Reports Strong Q3 on BetterHelp Performance

Posted on by Jason Barry

Teladoc’s third quarter earnings report is in, and it’s looking like the company might finally be hitting its stride on its path toward profitability.

On its investor call, Teladoc told the only story that Wall Street wants to hear: cost management efforts and gross margins are both improving. The narrative helped push Teladoc’s stock up over 20% last week, although its $5B market cap still has a ways to go before getting back to its $45B peak.

Teladoc’s third quarter, by the numbers: 

  • Revenue of $611.4M, up 17% year-over-year
  • Net loss of $73.5M, earnings per share of -$0.45
  • Gross margin of 69.6%
  • Ended the quarter with 57.8M US members, up 10% year-over-year

CEO Jason Gorevic called out four main drivers behind Teladoc’s better than expected Q3 revenue, but its BetterHelp mental health business was definitely a standout.

  • BetterHelp grew over 35% compared to Q3 2021 and it’s now hitting a run rate of $1B annually. 
  • The direct-to-consumer mental health platform was specifically called out for contributing to Teladoc’s gross margin improvement, and its previously reported poor returns on advertising have begun to stabilize.
  • The efficiency gains were primarily due to higher utilization of group therapy sessions and the pivot away from a purely contractor model toward a hybrid model with more full-time employees.
  • Gorevic noted that next year’s outlook for BetterHelp depends in large part on macroeconomic conditions that could cause consumers to tighten their purse strings.

Other highlights from the quarter included 9% membership growth for Chronic Care Complete (now at 791k members), an expanded partnership with HCSC to bring Teladoc’s solution suite to employer groups, and high satisfaction among Primary360 users.

  • It was interesting that Teladoc stuck to NPS scores and some general utilization stats when discussing Primary360, and it’s probably telling that the actual membership count wasn’t deemed noteworthy.

The Takeaway

By all accounts Teladoc delivered a solid third quarter, and the margin improvement stemming from BetterHelp was music to shareholders’ ears. Despite the strong report, Teladoc lowered its full-year guidance to ~$2.4B in revenue, but even that was taken as good news by investors who viewed it as setting up an achievable growth target.

Telehealth Flexibilities Reduced Opioid Overdoses

Posted on by Jason Barry

A new study in JAMA Psychiatry attracted a lot of attention last week after finding that pandemic-era telehealth flexibilities significantly lowered the odds of medically treated opioid overdoses among Medicare patients.

Researchers from the CDC, CMS, and NIDA examined data from Medicare beneficiaries with a prior diagnosis for opioid use disorder (OUD), separating them into a pandemic cohort of 71k patients who initiated OUD care after telehealth flexibilities were expanded and 105k who sought treatment prior to the onset of the pandemic.

The differences between the two groups were stark: 

  • Roughly 1 in 8 beneficiaries in the pandemic group received OUD-related telehealth services, compared with just 1 in 800 in the prepandemic group.
  • The expanded access to treatment helped 12.6% of pandemic beneficiaries obtain medications for OUD (e.g. methadone, buprenorphine, naltrexone), compared with 10.8% of the prepandemic group. 
  • The pandemic cohort saw significantly lower odds of medically treated overdose (odds ratio: 0.67), as well as higher medication retention (OR: 1.27).
  • Pandemic beneficiaries were also far more likely to access virtual behavioral health services than the prepandemic group (41% vs. 1.9%).

The Takeaway

The study served as a boon to telehealth advocacy groups, which have been pushing to make pandemic-era telehealth flexibilities a permanent fixture. The American Telemedicine Association pretty much summed it up in their press release, touting the study as “a strong signal to policymakers that telehealth can and should be a permanent part of healthcare delivery.”

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