Text Nudges Show Potential in Primary Care

Even the simplest text messages can help patients get more out of their primary care visits, at least according to new research published in NEJM Evidence.

The study out of Ascension health system“A Digital Care Plan Nudge to Improve Primary Care Outcomes” – spanned 76 primary care practices and 29,000+ patients.

  • Patients were randomized to receive either usual care, or a digital nudge sent three days prior to their appointment.
  • The nudges were a simple text message highlighting up to three preventative care needs to address during the visit, such as cancer screenings or vaccinations.

The results speak for themselves. The digital nudge group saw:

  • An increase in appointment completions (+2.8 percentage points over usual care)
  • A decrease in appointment cancellations (-1.5 percentage points)
  • A decrease in appointment no-shows (-1.2 percentage points)

What about the care gaps? The digital nudge group addressed a care gap during 23.5% of visits, compared to 20.3% for usual care (P=0.08). In case anyone skipped stats class, that’s a bigger P value than we were going for, which basically means the jury’s still out on this one.

  • On the bright side, digital nudges did show a statistically significant improvement to care gaps closed at 90 days (+5.4 percentage points over usual care), specifically for breast and colorectal cancer screenings, diabetes testing, and flu vaccines.

Although the study didn’t meet the primary outcome of addressing gaps on the day of the visit, digital nudges showed promise as a scalable way to improve outcomes over time by encouraging patients to be proactive with their health.

  • Not a bad outcome considering that many patients arrive to primary care visits focused on immediate concerns, and springing new topics on them isn’t exactly a great way to inspire quick action.

The Takeaway

Patient activation works, and this study adds to the mountain of evidence supporting it. In the words of Ascension Chief Clinical Transformation Officer Mitesh Patel, “Most importantly, it reflects what’s possible when we combine behavioral science, digital tools, and a learning health system mindset.”

PHTI Gives High Marks to Virtual Mental Health Solutions

Virtual mental health solutions were the latest segment to fall under the piercing gaze of the Peterson Health Technology Institute, and in typical PHTI fashion the reviews were mixed.

The evaluation incorporated over 5,000 articles, input from clinical advisors, and interviews with depressed or anxious patients to evaluate three kinds of mental health solutions on their clinical effectiveness and economic impact:

  • Self-guided solutions – content that people can work through on their own, typically offered directly to employers or health plans (AbleTo, Dario, Headspace, Learn to Live, Meru Health, SilverCloud, Talkspace, Teladoc)
  • Prescription digital therapeutics – FDA-cleared interventions often used in conjunction with clinician-supervised outpatient treatment (DaylightRx, Rejoyn)
  • Blended-care solutions – build on self-guided treatment with integrated virtual care teams of therapists and psychiatrists (AbleTo, Brightside, Headspace, Koa Health, Lyra, Meru Health, Modern Health, Spring Health, Talkspace, Teladoc)

The good news? All 15 of the solutions produced meaningful improvements in symptoms of anxiety and depression, especially for patients not already in therapy.

The catch? While these solutions have the potential to improve access and outcomes, their net impact on overall spending varies by payor and category.

  • Self-guided solutions demonstrate clinically meaningful improvements in both anxiety and depression (6.9-point reduction in PHQ-9), with a relatively low cost (~$2 PMPM) that’s estimated to reduce spending in commercial settings by $0.30 PMPM.
  • Prescription digital therapeutics deliver equally strong symptom improvement, and because they’re expected to be reimbursed on a per user basis (~$280 per episode) rather than across all plan members, they save an estimated $0.72 PMPM.
  • Blended-care platforms show the strongest clinical outcomes, but with pricing models (~$6 PMPM plus $792 in annual therapy costs per user) that tend to increase overall health spending by an estimated $2.10 PMPM.

The Takeaway

PHTI gave virtual mental health solutions a glowing report card, and it seems like even the lone negative review – blended-care platforms – have their place for patients with severe symptoms.

Teladoc Adds In-Network Therapy With Uplift Acquisition

Teladoc wrapped up a bumpy Q1 with the acquisition of virtual therapy provider Uplift, a move that it hopes will help turnaround its persistently problematic BetterHelp segment.

UpLift provides virtual therapy, psychiatry, and medication management services – all crucially covered by most major commercial payors, as well as Medicare and Medicaid.

  • The deal adds over 100M covered lives and a network of 1,500 mental health clinicians, which Teladoc plans to integrate with BetterHelp to give its customers access to in-network treatment options.

The $30M acquisition shores up one of the most glaring weaknesses of BetterHelp’s cash-pay-only DTC mental health offerings, with Teladoc citing out-of-pocket costs as one of the primary barriers preventing potential customers from signing up.

  • UpLift generated $15M of revenue last year – a drop in the bucket compared to the $1B that BetterHelp brought in – but it’s anyone’s guess as to how much of a lift Teladoc will see from the “significantly higher conversion rates” it expects for new members.

In the wake of the pandemic, BetterHelp has eroded from one of Teladoc’s most promising assets to a constant pain point on investor calls, including a $790M impairment in Q2 2024.

  • Setting aside the scathing short report that accused BetterHelp therapists of using ChatGPT to respond to patients during sessions, the segment’s also been facing pressure from rising ad costs that have made it difficult to keep user growth steady.
  • Teladoc now expects BetterHelp revenue to fall between 7.5% to 11.25% next quarter, before returning to form later in the year thanks to stickier relationships courtesy of Uplift.

It’s also interesting to see Teladoc pick up another company at a 2X revenue multiple after paying the same rate for Catapult Health back in February.

  • Not exactly a lofty valuation for an established company with real revenue, especially considering the fairytale multiples we’re seeing startups command in AI Land.

The Takeaway

Acquiring Uplift’s existing payor partnerships should definitely accelerate BetterHelp’s ability to start accepting insurance, a much needed move given its recent difficulty wrangling new customers. Although an immaculate M&A track record isn’t something that Teladoc has going for it, this particular acquisition seems to make a lot of sense on paper.

Hybrid Care: Interest Outstrips Infrastructure

Provider organizations are hungry for more hybrid care, but new research in NEJM Catalyst highlights a notable gap between their interest and infrastructure.

A survey of the NEJM Catalyst Insights Council – made up of clinical leaders and executives from care delivery orgs across the globe – showed that a majority of the 730 respondents believe hybrid care improves overall quality (74%).

  • 55% of respondents’ organizations already offer hybrid care (68% for U.S. orgs)
  • 42% offer primarily in-person care
  • Only 3% offer primarily virtual care

Hybrid was ranked as the preferred mode of care delivery for the usual areas like primary care and chronic condition management, largely because of the convenience it offers patients, but several barriers still stand in the way of supplementing in-person care with virtual services.

Provider organizations are also facing their own set of challenges.

  • Only 58% report adequate technological infrastructure to enable hybrid care.
  • Even fewer report sufficient tech support for troubleshooting during virtual visits (27%).
  • Just 38% agree they give providers sufficient training to deliver hybrid care effectively.

Although technology barriers are a common scapegoat for limiting access to hybrid/virtual care, the authors point out that digital literacy and clinician support are the bigger culprits. They also suggest a practical solution: dedicated digital navigators.

  • Dr. John Torous, Digital Psychiatry Director at Beth Israel Deaconess Medical Center, believes embedding trained digital health navigators within health systems is “the missing link” to bridge the gap between clinical care and digital tools.
  • BIDMC has reportedly seen significant benefits from using digital navigators to help facilitate both patient engagement and clinical utilization, yet only 21% of organizations currently employ such specialists.

The Takeaway

Technology access is a constant barrier for hybrid care delivery, but this survey shows that digital literacy for patients and support for clinicians could be the actual limiting factors. Luckily, as the authors put it, digital navigators and training programs are also “low-hanging fruit.”

Teladoc Aims to Catapult Over Obstacles With Acquisition

Teladoc is looking to catapult over some of its recent obstacles with its first acquisition under CEO Chuck Divita, picking up Catapult Health for a lofty $65M.

The closing price is over three times what Teladoc shelled out for BetterHelp in 2015, which could be justified if Catapult’s at-home testing synergies pan out as intended. 

Catapult offers an at-home wellness exam called VirtualCheckup, giving members a diagnostic kit to collect blood samples, check their blood pressure, and screen for mental health conditions like depression or anxiety.

  • From there, members have a virtual visit with a licensed nurse practitioner to discuss their test results, review top health risks, and develop an individual health action plan.
  • If VirtualCheckup turns up anything that requires more intensive care, Catapult can now directly enroll eligible members into Teladoc’s chronic condition management programs or refer them to its virtual therapists and primary care providers.

Teladoc hinted that growing membership for its integrated care segment was a top priority during last month’s JPMorgan Healthcare Conference, with BetterHelp’s rising ad costs and dwindling user base prompting a change of course.

  • It was also reported that Teladoc will be a central component of Amazon’s efforts to move deeper into healthcare by allowing its customers to access chronic care programs for diabetes, hypertension, and weight management.
  • Revenue for Teladoc’s integrated care segment was up 2% year-over-year as of its Q3 earnings call in September, compared to a 10% dropoff for BetterHelp to $257M.

An immaculate M&A track record isn’t something that Teladoc has going for it. When it acquired Livongo at the height of the pandemic for $18.5B, the companies boasted a combined value of $37B. 

  • A few billions in write-offs later, Teladoc’s market cap now stands below $2B, but lessons learned from past experiences could set the Catapult integration up for more success.

At-home testing has historically been a significant limitation for many virtual care players, so Catapult could help Teladoc distance itself from the competition with an integrated platform that can tackle both.

The Takeaway

Teladoc is shifting its focus to chronic condition management with the acquisition of Catapult, and adding at-home testing to its diabetes and hypertension programs should be good news for their position in the market (assuming the integration avoids some past missteps).

Telehealth Prescribing Extended Through 2025

In a move that surprised basically no one, the DEA is extending pandemic-era telehealth prescribing flexibilities for controlled substances through the end of 2025.

The “Third Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications” was officially published on November 19th, ending a months-long stalemate among regulators.

The third time’s the charm (hopefully). The extension gives providers another year to prescribe Schedule II-V medications for conditions like ADHD and opioid addiction without first conducting in-person evaluations.

  • The move maintains the status quo that’s been in place since COVID hit, while effectively punting the decision on formal legislation to the new White House.
  • Both the DEA and the HHS will have fresh leadership, and it remains to be seen how the two agencies will work together to address the matter.

The policy hot potato just got passed to the Trump administration, so telehealth companies and patients will both have to prepare for another year of regulatory limbo.

  • By failing to issue a final rule, the DEA at least gains time to revise its most recent draft rules that sparked nearly 40k comments worth of industry pushback.
  • Those rules included requirements that half of a provider’s controlled substance prescriptions be written for patients seen in-person, and that every patient must be checked against drug monitoring programs in all 50 states. 

It’s a classic tension in healthcare: balancing legitimate access against potential abuse.

  • While the extension acknowledges the “urgent public health need” for access to addiction treatment meds like buprenorphine, the lack of legislation still leaves telehealth in a bucket of “stopgap measures” instead of “absolute necessities.”
  • Punting the decision should also mean better guardrails can be developed to prevent abuse at a time when the founders of pandemic-era pill mills are either fleeing the country or forking over millions in fines.

The Takeaway

The telehealth prescribing can has been kicked down the road for another year, and the industry will now be watching to see whether the Trump administration decides to repeal it. It’s more likely than not that the extension will stick – this isn’t exactly a hot button issue like raw milk.

Telehealth Doesn’t Lead to Low-Value Services

University of Michigan researchers just delivered some compelling evidence that telehealth doesn’t increase wasteful care, and may actually reduce it in several key areas.

This wasn’t a small study. The analysis in JAMA Network Open leveraged Medicare FFS claims data spanning 578k beneficiaries across 2,552 primary care practices between 2019 and 2022.

The researchers tracked eight measures of “low-value care” – services that provide little clinical benefit while racking up costs – across four categories: office-based, laboratory, imaging, and mixed-modality services.

The practices with the highest telehealth usage (top third) showed:

  • Significant reductions in unnecessary cervical cancer screenings (-2.9 per 1,000 beneficiaries)
  • Lower rates of low-value thyroid testing (-40 per 1,000 beneficiaries)
  • No increase in wasteful imaging or other diagnostic services

Low-value care costs the healthcare system close to $100B annually, and while wasteful services have been extensively looked at using Medicare data, this was the first study to do so within the context of telehealth.

  • On one hand, virtual visits eliminate chances for clinicians to perform low-value services that need to be performed in-person.
  • On the other, it’s hard to imagine that the inability to conduct a physical examination won’t lead to more clinical uncertainty and low-value diagnostic testing, although that’s exactly what this research seems to disprove.

The Takeaway

This study tackles one of telehealth’s most persistent criticisms head-on, and the lack of a clear link between telehealth and low-value care should reassure policymakers weighing how to finance and regulate the segment going forward.

Fabric Leans In On Virtual Care With TeamHealth

Fabric is back at it again with another acquisition, this time scooping up the virtual care business of physician practice juggernaut TeamHealth.

Here’s the updated timeline leading up to Fabric’s fourth acquisition in 18 months:

  • March 2023 – Florence launches with $20M to tackle ER capacity constraints
  • May 2023 – Florence nabs Zipnosis from Bright Health 
  • Jan 2024 – Fabric rebranding and GYANT acquisition
  • Feb 2024 – Fabric closes $20M Series A led by General Catalyst
  • June 2024 – Fabric acquires MeMD from Walmart
  • Sept 2024 – Fabric picks up TeamHealth VirtualCare

That’s an unusually hot start for a startup still looking forward to its second birthday, but Fabric CEO Aniq Rahman walked Business Insider through the method behind the madness.

  • After bringing a consumer mobile experience to the ER, Fabric acquired Zipnosis to add asynchronous telehealth capabilities and accelerate its roadmap to new sites of care.
  • That apparently worked like a charm, so Fabric picked up GYANT’s conversational AI to serve as a patient entry point to its other offerings, then followed that up by grabbing MeMD and its 30k corporate/payor partners.

The latest move with TeamHealth VirtualCare officially gives Fabric access to over 100M lives in managed care contracts with payers, as well as a 50-state network of clinicians.

  • TeamHealth also broadened Fabric’s medical group with multi-specialty experience, including cardiology, sports medicine, OB/GYN, and family medicine.
  • On top of that, the health systems working with TeamHealth VirtualCare will transition to Fabric, providing plenty of surface area to start cross-promoting other services.

Put it all together, and Fabric’s strategy of acquiring both capabilities and customers has led to it having a rare amount of each for such a young company – not to mention an eight-figure ARR (reported during the GYANT acquisition) that’s probably well on its way to adding another digit.

The Takeaway

Fabric is leaning in on virtual care at a time when massive players are bowing out completely, creating an ecosystem of solutions that pushes the telehealth economics in a positive direction that’s hard to achieve with narrower strategies. That M&A playbook isn’t a secret, and given where we’re at in the investment cycle, Fabric probably has quite a few companies knocking on its door looking to be the next solution in its portfolio.

Included Health Lunges Into Virtual Specialty Care

Where do you go when you’re already tackling primary care, behavioral health, and second opinions? If you’re Included Health, you swim straight upstream to specialty care.

The three bullet history lesson on Included looks something like this:

  • In 2021, Grand Rounds (virtual second opinions) and Doctor on Demand (on-demand visits for physical and mental health) merged to provide integrated virtual care.
  • The combined company entered care navigation, and now provides benefits guidance, financial support, and advocacy services to more members than possibly every other navigator in the country.
  • To make sure every patient felt this care was built just for them, the company acquired Included Health (culturally aware care for underserved communities), and here we are.

Specialty care is a natural continuation of that vision, starting with a trio of centers prepped for a 2025 debut: the Cancer Center, the Center for Women’s Health, and the Center for Metabolic Health. 

  • Members will have access to a specialist-led care team with integrated primary and mental healthcare, as well as in-home support for prescriptions, diagnostics, and monitoring. That all happens with a single member record, one central form of billing, a unified medical history, within the context of available benefits.
  • It’s a giant undertaking, but it’s made possible by roots in expert second opinions that helped grow a nationwide network of 4,000+ specialists and collaborations with over 40 health systems (not to mention a seriously well-rounded partner ecosystem) . 

The real strength of the expansion lies in the fact that it isn’t so much a new service line as a massive enhancement to a platform with all of the primary care, behavioral health, and navigation ingredients already baked in.

  • Outside of large orgs with the resources to try and coordinate the same breadth of offerings, few companies have had the scale, track record, and plain-old resources to cross the chasm into actual specialty care delivery. 

That means Included’s real competition will likely be Included. Can it scale without sacrificing quality? Can it deliver care for “all” that feels like care for “you”? Can it connect the dots between virtual specialists and the in-person care that will inevitably come into play?

The Takeaway

Included Health’s specialty care expansion hits the center of the bullseye with both patients seeking more cohesive care journeys and partners looking to right-size inflated portfolios of point solutions. That strategy also happens to be a good way to land on the shortlist of healthcare companies poised for a major IPO.

Brightside Raises $33M for Medicaid Expansion

Last week’s funding-heavy news cycle was punctuated by Brightside Health’s $33M Series C round, which added more momentum to the telemental healthcare provider’s recent expansion efforts.

Brightside provides full-range care for patients with mood disorders spanning anywhere from mild anxiety to severe depression. The “precision psychiatry” platform is built on a technology backbone that includes:

  • ActiveSupervision – a real-time care management solution that tracks patient progress and identifies situations that might require risk escalation.
  • PrecisionRx – AI clinical decision support that recommends medication and dose combinations most likely to be effective (resulting in a 70% response rate to the first treatment cycle, twice the industry standard).
  • Crisis Care – a national telehealth program for individuals with elevated suicide risk.

In the two years since its last raise, Brightside has scaled those solutions to the point where it can now provide in-network care to over 100 million covered lives, and it’s published close to a dozen peer-reviewed papers supporting its approach. 

  • A study from November showed that the Crisis Care program was effective at eliminating suicidal ideation in an average of six sessions.
  • Another study in the March 2023 issue of Psychotherapy Research found that supplementing teletherapy with video lessons helps address depression and anxiety.

Put all that together, and Brightside is uniquely positioned to serve not only the highest-acuity patients, but also the populations that often have the hardest time finding effective care.

  • The fresh capital will help it do just that, advancing its expansion into Medicare and Medicaid through recent payor partnerships with CareOregon, Blue Shield of California, BCBS of Texas, and Centene.
  • The Series C also put Brightside on a “comfortable path to profitability” in the next few quarters, with former Optum Behavioral Health Solutions CEO Trip Hofer joining the board to help oversee the next leg of that journey.

The Takeaway

Few telemental health companies have been brave enough to target the patients with the most severe symptoms, let alone those in the markets with the greatest need. Even fewer have been open to publishing their results. Brightside’s willingness to check all of those boxes makes it a must-watch in this space, especially considering that it’s tackling that checklist with soon-to-be positive margins.

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