Teladoc’s Q2 Brings $3.1B Livongo Write Down

Teladoc shareholders can’t seem to catch a break, with the company’s second quarter results sending its shares plummeting 20% on the back of a heavy earnings miss and weak guidance for the second half of the year.

The telehealth services provider reported 18% revenue growth to $592.4M for the period, but the headline grabber from the announcement was a $3B impairment charge on its Livongo acquisition that drove a total loss of $3.1B.

Teladoc CEO Jason Gorevic shared some upbeat growth metrics on the conference call with investors, but also called out a number of headwinds that make it difficult to predict near-term performance.

  • Chronic care membership came in higher than expected, while member utilization improved year-over-year.
  • Teladoc’s BetterHelp virtual therapy business grew revenue by 40%, but continued to be hindered by competitors sacrificing margin to gain market share
  • Primary360 has been “a significant bright spot” for commercial momentum, but heightened economic uncertainty is delaying the decision making process in the employer market.
  • Teladoc is taking a look at its cost structure to maintain profitability, and will begin marketing bundles of services to expand its revenue sources.

The Takeaway
Although the market didn’t exactly react kindly to the Livongo news, the write down appears to be more of a symptom of wider market trends than the business itself, and Teladoc’s recently launched Chronic Care Complete solution is poised to be a core pillar of its long-term growth strategy. The near-term looks like a different story, as Teladoc now expects its full-year revenue to be at the lower end of its $2.4B to $2.5B guidance.

CVS Health Announces Virtual Primary Care

CVS Health’s push into omnichannel care delivery continued last week with its new Virtual Primary Care solution geared towards connecting the company’s clinical expertise and patient data on a single digital platform.

CVS Health Virtual Primary Care will provide eligible Aetna and CVS Caremark members with access to on-demand primary care, chronic condition management, and mental health services in either virtual or in-person settings.

  • The service’s physician-led care teams include nurse practitioners, RNs, and licensed vocational nurses. The care team will consult CVS pharmacists and help members identify appropriate in-network specialists and other services as needed.
  • An interoperable EHR will help patients transition between virtual and in-person care while allowing clinical data to be shared with other providers. A comprehensive data view will also enable providers to deliver personalized health alerts to patients.

The new program aims to enable timely access to care, and CVS cites reports that it currently takes 24 days to schedule an appointment with a primary care physician and twice that long to see a mental health professional.

  • Although the press release doesn’t go into too much detail on how CVS plans to staff the program, an active job listing for a virtual primary care provider indicates that they’re hiring two PCPs to cover the entire 17-state central US region.
  • If that ratio holds through next year’s launch it would suggest that CVS isn’t expecting significant patient volume through the platform, although it’s still early to make that call.

The Takeaway
The Virtual Primary Care launch continues CVS Health’s recent string of service enhancements designed to help it move beyond its corner drugstore image, including reimagining its stores as healthcare destinations and a strategic data partnership with Microsoft. The move also bolsters CVS Health’s overall care delivery strategy at a time when one of its most direct competitors, Walgreens, is doubling down on primary care by taking an ownership stake in VillageMD to streamline the launch of at least 700 connected clinics by 2027.

Measuring Telehealth Outcomes During the Pandemic

Since the beginning of the pandemic, few studies have investigated the association of telehealth with outcomes of care, including patterns of care use after the initial encounter. New research published in JAMA Network Open set out to do just that, using a cohort of 40.7M US adults with commercial health coverage to examine the difference in outcomes between telehealth versus in-person encounters.

The study assessed Blue Cross and Blue Shield members from July 1, 2019, to December 31, 2020. Outcomes of care were assessed 14 days after initial encounters and included follow-up encounters of any kind, ED visits, and hospitalizations.

The key finding of the study was that telehealth has the potential to result in duplicative care, depending largely on the patient’s condition type. Telehealth patients with acute conditions were more likely to have a follow-up encounter than in-person patients, while telehealth patients with chronic conditions were less likely to require follow-up. 

In the cohort with acute conditions, the odds ratios for patients with an initial telehealth encounter were 1.44 for a follow-up of any kind and 1.11 for an ED encounter.

  • Ex: Patients with an acute upper respiratory tract infection episode were 65% more likely to have a follow-up if their initial encounter was a telehealth visit, compared to in-person.

The chronic condition cohort showed contrasting results, with odds ratios of 0.94 for follow-ups of any kind if the initial encounter was via telehealth.

  • Ex: Patients with essential hypertension were 37% less likely to have a follow-up if their initial encounter was a telehealth visit, compared to in-person.

For those that like to dive into the data, this table breaks down patterns of subsequent care by the clinical condition.  

The Takeaway

The contrasting patterns of telehealth follow-up care for acute and chronic conditions are relevant to both policy makers and providers. Telehealth use for the management of chronic conditions appears comparable, or even more efficient, than in-person care, with the opposite looking true for acute conditions. This trend was strongest for acute respiratory infections, but that also feels like a pretty natural result for a study conducted during a respiratory-related pandemic.

The Telehealth Era Is Just Beginning

“The Telehealth Era Is Just Beginning” is a fitting title for the bullish stance on virtual care featured in this month’s issue of the Harvard Business Review. Although we cover plenty of articles outlining the benefits of telehealth, this piece was penned by a pair of especially qualified authors: former chief executive of the Permanente Medical Group, Robert Pearl, and Intermountain Healthcare’s executive director of telehealth services, Brian Wayling.

Pearl and Wayling shared an extensive deep dive on several key areas where telehealth can have a positive impact. It’s worth the read if you have 30 minutes and a big cup of coffee, but the key points are outlined here for those in search of the condensed takeaways.

Reducing unnecessary trips to the ER was the first focus area, due in large part to the heightened medical risks created by ER physicians frequently lacking access to patient EHR data and the low likelihood of follow-up care.

  • Kaiser Permanente addresses these issues by providing members with a telehealth center with physicians that can solve the problem and coordinate any follow-ups in 60% of cases, preventing unnecessary ER visits.

Reversing the chronic disease crisis was the second use case highlighted, with telehealth providing a better way to serve the 50% of US hypertension patients living with an elevated risk of complications due to poor management of the condition.

  • Pearl reported that KP consistently achieves a blood pressure control rate above 90% by replacing traditional office visits with EHR-connected blood pressure cuffs and virtual check-ins, enabling more frequent disease measurement and timeliness of treatment.

Other interesting examples revolved around improving access to specialty care and reducing geographical barriers to treatment, which help eliminate misdiagnosis and long wait times for patients with rare conditions.

  • Wayling laid out how Intermountain’s Neuro Fast Access Clinical Team virtual platform allows low-acuity patients to receive remote migraine treatment from an expert, which opens up clinical time for patients who require in-person care.

How to Spur Adoption

While these case studies are useful for anyone looking to replicate the success of KP and Intermountain at their own health systems, the article saves its most valuable information for last, exploring two changes required to usher in “the telehealth era.”

  • Integration – The organizations that consistently rank highest on quality are large multispecialty medical groups that leverage technology to coordinate care. As more doctors opt to work within health systems, they’ll be able to take advantage of shared EHRs, cross-specialty communication, and virtual care to help patients in ways unavailable to physicians in solo practice.
  • Value-Based Care – Doctors who are incentivized based on the quantity of services they provide will logically resist models that reduce specialty referrals and hospital admissions. It’s easier for KP and Intermountain to say this, but telehealth’s full benefits will only be realized after more organizations adopt value-based structures that promote the use of virtual care to create superior outcomes.

For best results, Pearl and Wayling suggest implementing value-based models within integrated organizations, driving the point home with a final example of how two large health systems (good luck guessing which ones) are finding success with this strategy.

Iris Raises $40M to Fight Mental Health Crisis

With much of the pandemic-driven adoption of virtual mental health services looking like it’s here to stay, Iris Telehealth recently closed $40M in Series B funding to help its telepsychiatry services keep up with a demand that’s “grown exponentially” over the past two years.

Iris’ telepsychiatry platform is designed to help US health systems and community health centers improve outcomes for patients with serious mental illness by intelligently pairing them with its staff of board-certified psychiatrists.

  • The company identifies best-fit providers for each unique organization based on practice philosophy, long term goals, and scheduling availability, then ensures a long-term commitment to addressing their partners’ needs.
  • These partnerships support healthcare organizations in creating their own sustainable telepsychiatry department by providing ongoing support, care model optimization, and triage assistance to help match patients to providers with appropriate licenses.

The latest funding will accelerate the scaling of Iris’ clinical operations team and the go-to-market strategy for expanding beyond its 200 current partner organizations.

  • Iris made it clear that developing long-term relationships will remain a priority throughout the expansion, and a core pillar of making this happen will be to extend the length of its contracts, which already average a four year duration.
  • The long term contracts are made to support what Iris reports is the number one need of its partners, which is the ability to optimize their throughput across the entire continuum between the primary care referral to discharge follow-up.

The Takeaway

Even as health tech funding cools off into the second quarter, mental health has remained the most resilient clinical area, with Rock Health reporting that the sector brought in a leading $1B during Q1 2022. The investor attention has catalyzed the creation of plenty of solutions targeting conditions such as anxiety or depression, and now Iris is looking to establish itself as the “escalation team” for when these situations require one.

Brightline Raises $105M for Adolescent Mental Health

Virtual mental health startup Brightline recently closed $105M in Series C funding to broaden its services as it tackles the nation’s “pediatric mental-health crisis.”

The two-year-old company is a poster child for the rise of behavioral health startups during the pandemic, with a valuation of $705M after a quick total raise of $209M.

Brightline offers adolescents and their families virtual services and educational content aimed at treating anxiety, ADHD, depression, and other behavioral issues.

  • The company staffs over 85 care providers (psychiatrists, speech-language pathologists, behavioral coaches) trained to support children with unique needs such as cyberbullying or wearing masks in the classroom.
  • The services are offered through employers and as in-network benefits with major health plans, including Blue Cross of California, Blue Cross Blue Shield Massachusetts, Aetna, and Primera.

The new funding will help Brightline triple the size of its care team by the end of the year while exploring additional ways to deliver specialized care through more modalities.

  • This includes upcoming services specifically for the caregivers of young children with Autism Spectrum Disorder and youth who identify as LGBTQ+ and/or BIPOC.
  • Brightline expects to serve over 30k children and teenagers by the end of 2022, while doubling the number of lives covered through its health plan contracts to 48M.

The Takeaway

Psychiatrists are among the most in-demand specialists, and adolescent psychiatrists aren’t exactly easier to find. Some research suggests that upwards of 75% of US counties don’t have access to a single one. If Brightline can address this supply-demand imbalance with its virtual services it could have a big impact on families affected by behavioral health challenges, and the company’s swift funding pace suggests that investors are eager to wager that they can.

Teladoc and Amazon Partner on Echo Voice Visits

Yesterday’s competitors are today’s collaborators, with Teladoc and Amazon inking a new partnership to bring voice-activated virtual visits to Alexa-equipped Echo devices.

  • “Alexa, I want to talk to a doctor” will now connect Echo users to a Teladoc call center to verify a patient’s medical history and health plan information ($0 if covered, or $75 direct-to-consumer). Within roughly 15 minutes, the patient will then get a call back from a Teladoc physician to treat mild needs such as colds, flus, or allergies.
  • The new service will initially be available in an audio-only format for supported devices such as the Echo Dot and Echo Show, but will add video functionality “soon” to make it easier to diagnose certain conditions.
  • The partnership greatly expands Teladoc’s consumer reach as part of its ongoing strategy to meet patients where they are. Amazon reports over 40M Alexa users in the US alone, and has delivered more than 200M Alexa-equipped devices globally.
  • This is the latest in a string of health-focused improvements to Amazon’s Alexa ecosystem, which have included capabilities for elder care coordination through Alexa Together, as well as medication management through the Care Hub… and those are happening outside of even bigger moves with Amazon Care.

Industry Impact

Despite the recent launch of Amazon’s own Amazon Care telehealth service, Teladoc’s virtual physician network is significantly larger, and this scale will be absolutely essential to keep up with what could be an insanely high call volume for the new service.

The Teladoc partnership marks Amazon’s first attempt at providing truly on-demand healthcare with Alexa devices, and if well executed, could go a long way towards breaking down barriers to care for many patients. Even though Amazon and Teladoc are now competing in the same arena, the collaboration shows that coordinated efforts are still on the table when there’s a clear benefit for both patients and the companies.

Teladoc Launches Chronic Care Complete

The big are getting bigger with the announcement that virtual care giant Teladoc Health is expanding its services with a “first-of-its kind” Chronic Care Complete solution targeted at the one in three US adults living with multiple chronic conditions.

  • Chronic Care Complete is now offered through the Teladoc Health app and provides a comprehensive experience that leverages connected monitoring devices in combination with personal coaches to help patients achieve health goals.
  • The program also provides access to physicians who can review medications or order labs as needed, as well as licensed therapists to provide mental health support for those dealing with difficult diagnoses.
  • Integrated proactive insights help Chronic Care Complete patients achieve better outcomes by applying personal health data and social determinants toward driving timely outreach.
  • According to Teladoc, chronic conditions such as diabetes, hypertension, and obesity account for 90% of all healthcare spending, driven in part by the confounding mental health challenges that are often ignored by other solutions but are a core component of Chronic Care Complete.

The Takeaway
Teladoc’s scale gives it unique positioning to address the intertwined physical and mental health challenges faced by polychronic patients. Chronic Care Complete is the latest in a string of new solutions launched following Teladoc’s 2020 merger with Livongo, each aiming to leverage this scale to provide better whole-person care, including the mental health offering MyStrength and the primary care service Primary360.

Online CBT Improves Depression Symptoms

Amid a recent flurry of reports calling into question the effectiveness of virtual cognitive behavioral therapy, a new study published in JAMA Network Open found that computer-assisted CBT (CCBT) does in fact improve depressive symptoms in primary care patients.

  • Methodology – The study included 175 adult primary care patients at the University of Louisville who had scored 10 or higher on the Patient Health Questionnaire-9 (27 point scale), indicating at least a moderate case of clinical depression. Nearly 62% of participants made less than $30k/year, while 74% did not graduate from college.
  • Interventions – Participants were randomly assigned to CCBT or treatment-as-usual groups (TAU) for 12 weeks of active treatment, as well as 3- and 6-month follow ups. CCBT included 9 online CBT lessons and weekly 20-minute teletherapy visits, in addition to TAU, which included in-office treatment at the primary care practices. 
  • Results – CCBT led to significantly greater improvement in PHQ-9 scores than TAU (mean difference: -2.5), with the positive results maintained at 3-month (-2.3) and 6-month follow-ups (-3.2). CCBT remission rates were more than double TAU at all time points.

Conclusions and Relevance

This study was particularly interesting because of the treatment’s sustained results and because its participants largely came from groups that are often underrepresented in CCBT research. Although the study had some limitations (treatment-as-usual as a control can’t compare CCBT to regular CBT), the results suggest that CCBT has the potential to be particularly valuable for patients in diverse primary care settings.

Amazon Expands Telehealth Services Nationwide

It’s never great to hear that a competitor with deep pockets and an army of engineers is pushing into your market, and this week Amazon gave companies in the employer telehealth space a lot to be nervous about.

After launching as an internal service in 2019, Amazon is now expanding its Amazon Care health offering to employers across the US amid “growing demand” for hybrid care.

Amazon Care’s hybrid model consists of two main elements:

  • Telehealth-based primary care delivered by a dedicated Care Medical doctor
  • Nurse practitioners dispatched to patient homes when medical needs can’t be resolved over video

Virtual services are now available nationwide to meet the needs of Amazon Care’s growing roster of employer clients, which now includes TrueBlue and Whole Foods Market (a fairly self-congratulatory announcement considering Amazon acquired the grocer in 2017).

In-person services are also expanding beyond the 8 existing locations (Seattle, Baltimore, Boston, Dallas, Austin, Los Angeles, Washington, DC, and Arlington), with Amazon planning to bring its nurse practitioner network to 20 additional cities by the end of the year, including San Francisco, Miami, Chicago, and New York City.

Industry Impact

The telehealth landscape is crowded with companies promising to improve outcomes with video visits, but Amazon Care’s in-person component could prove to be its biggest differentiator.

The hybrid model allows Amazon to keep patients within its ecosystem when in-person care is needed, building off the logistical expertise of its retail business to coordinate at-home and virtual care. Amazon is aiming to make ordering healthcare as seamless as ordering any other product off of, a patient experience that the company could be uniquely positioned to pull off.

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