Trends Shaping the Health Economy: Behavioral Health

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.

Teladoc Launches Integrated Health App

Unified experiences are the name of the game in 2023, and Teladoc just made its first play of the year by revamping its mobile app to cater to the whole-person care needs of its users.

The new app integrates Teladoc’s services for primary care, mental health, and chronic condition management, paving the way for more patients to reap the benefits of personalized navigation to all of their treatments with a single login.

  • The app includes all of Teladoc’s services that can be covered under employers and health plans (DTC solutions like BetterHelp remain separate), enabling users to view services covered by their health plan and review care plans across all their physicians.
  • An engagement component translates real-time data for clinicians and patients into “applied health signals” designed to improve decision making for all parties.
  • Teladoc is aiming to drive better health outcomes (and revenue) by steering patients toward a combination of its services when appropriate, giving the example of better A1C levels and blood pressure control for those enrolled in both its chronic care and mental health programs.

The other major highlight from the press release was that Teladoc’s full suite of services is now available in Spanish on the mobile app and website, welcome news for the 40M Americans that report speaking Spanish at home. 

  • Teladoc is clearly going out of its way to improve the Spanish-speaking member experience beyond the new language option, adding over 100 Spanish-speaking providers and expanding its nutrition plans to include cultural preferences.

The Takeaway

It was almost surprising to find out that Teladoc didn’t already have a unified experience for its various solutions given the clear benefits of bringing them under the same roof, but apparently it wanted to get the care coordination features dialed before the grand debut. The app is now available in select markets, but it’ll be interesting to hear how dialed the final product really is after the nationwide roll out later this year.

Telehealth Rarely Requires In-Person Follow-Ups

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

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

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

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.”

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.

Amwell Launches Comprehensive Behavioral Health Program

It’s officially #MentalHealthAwarenessMonth, making it a great time to show some genuine support to your friends and colleagues, and an opportune moment for virtual care providers like Amwell to launch behavioral health solutions.

Amwell recently debuted the Amwell Comprehensive Behavioral Health Program, combining the digital cognitive behavioral therapy programs of SilverCloud Health (acquired last year) with virtual care provided by psychiatrists from Amwell Medical Group.

  • Members undergo individual evaluations before selecting either self-guided or coach-supported care, and can then be referred to virtual therapy and psychiatry as needed.
  • The solution can be tailored to meet specific population needs, enabling payors and providers to deliver personalized experiences for various severities and care delivery preferences.

The new program extends Amwell’s growing suite of behavioral health tools, which includes Amwell Psychiatric Care for acute psychiatric needs and ED clinical support, as well as the SilverCloud Health Family Support Suite to help new parents and their children manage mental health concerns.

  • Behavioral health is one of healthcare’s most capacity-strained areas, and the pandemic has only exacerbated the problem.
  • Amwell cites research that 60% of US counties don’t have a single psychiatrist, and that 41% of adults have felt anxious or depressed during the pandemic.

The Takeaway
Amwell is clearly committed to quickly scaling its virtual behavioral health portfolio, which is a pretty natural direction to pursue given the huge need and telehealth’s ability to help address it. Behavioral health might also be one of the only clinical areas where telehealth represents a truly preferred substitute to in-person care, and Amwell’s recent investment in the area should go a long way toward making its services durable as patients begin returning to in-person care.

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.

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-- The Digital Health Wire team