Telehealth Linked to Quality as Extension Deadline Looms

Efforts to extend regulatory flexibilities for virtual care gained some wind in their sails from a new study in Health Affairs that linked telehealth use to significant quality improvements and a relatively modest bump in spending. 

Researchers assigned Medicare patients to health systems according to care patterns in 2019, then segmented the providers based on their telehealth adoption in 2020 (5.5M patients, 576 systems). They then analyzed outcomes for 2021 and 2022.

Patients at health systems in the highest quartile of telehealth use (27% of all visits) had an increase of 0.21 outpatient visits per patient per year, a relative increase of 2.2% compared to systems in the lowest quartile of telehealth use (9.5% of all visits).

  • These patients also had 14.4 fewer non-COVID ED visits per 1,000 patients per year, a 2.7% relative decrease.
  • Further, the patients at high-telehealth systems saw improved adherence to medications like metformin and statins, although there were no clear changes in hospitalizations.

Those improvements came at the cost of an additional $248 per patient per year at high-telehealth systems, a relative increase of 1.6% above the lowest quartile.

  • The authors noted that this increase was largely driven by inpatient admissions and pharmaceuticals, but offset by decreases in outpatient spending.

Where do we go from here? With many virtual care flexibilities set to expire at the end of the year – like allowing Medicare patients to receive telehealth in their homes – regulators are on the clock to create more permanent policies.

  • Policymakers have already proposed a bevy of bills to extend the flexibilities, but the debate carries on as the deadline looms.

The Takeaway

Given the access benefits, quality improvements, and modest increase in spending, this study only makes it harder to justify rolling back telehealth coverage for Medicare patients. The evidence is mounting, and it’s not too hard to picture a world where the arguments against telehealth only grow weaker as technology improves and providers optimize their virtual care services.

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.

Virtual Care is Table-Stakes, Now What?

There’s no catalyst like a pandemic to transform virtual care from a niche offering to a must-have service, at least according to the 8,000 people who responded to Rock Health’s latest Consumer Adoption Survey.

Virtual care has become table-stakes for both patients and providers, with a majority of respondents using it within the past year (63%).

  • A mature market doesn’t mean virtual care is for everyone. Almost a quarter of respondents still have never used it, citing preferences for in-person care (56%), quality concerns (18%), and lack of awareness (13%).
  • Rock Health doesn’t expect adoption to ever reach 100%, and anticipates always needing a spectrum of omnichannel offerings – traditional, virtual, and retail – to meet consumers’ preferences and capabilities.

There’s a growing share of respondents that prefer virtual care over in-person care for use cases like prescription refills (69%, up 8pp) and mental health services (41%, up 3pp). [Chart]

  • That isn’t too surprising given that refills are transactional care encounters, making them well-suited to low-touch virtual channels like app or portal messaging.
  • Virtual mental health on the other hand reflects a changing status quo, where consumers want to choose from a wider range of providers with different identities or treatment approaches (especially relevant in mental healthcare), and can conveniently access them for regularly scheduled visits.

Consumers are drawn to convenience, but virtual care innovators will need to invest in additional value drivers like data security and user-friendliness to stay competitive.

  • While convenience helped drive virtual care’s popularity, it also attracted competition from retailers, grocers, and CarePods that have the advantage of bundling healthcare with other routines like grocery shopping.
  • For virtual care players, continuing to compete on convenience involves considering both when and where virtual is really more convenient than the best in-person offering, and when it makes sense to partner with retailers as opposed to competing on other differentiators.

The Takeaway

Rock Health’s survey makes it clear that we’re in a new era of virtual care, one that brings its own set of market pressures. Those looking to succeed will have to navigate new value propositions (what defines the best virtual care), alternatives (virtual care doesn’t have a monopoly on convenience or access), and as always, the regulatory/reimbursement landscape.

Telehealth Linked to Physician EHR Burden

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

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

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 / 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, 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

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

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

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.

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