Telehealth

The HHS finalized a rule in February 2024 that will allow opioid treatment programs to begin some medication treatment via telehealth.

Under the rule, these providers will be able to initiate treatment with buprenorphine through audio-only or audio-visual telehealth. They can begin methadone treatment via an audio-visual platform — but not through an audio-only option due to its higher risk profile, the Substance Abuse and Mental Health Services Administration said. The regulation makes permanent telehealth flexibilities that began during the COVID-19 pandemic to preserve access to care and tackle a worsening opioid epidemic. 

The rule marks the first substantial changes to treatment and delivery standards at opioid treatment programs in more than 20 years, SAMHSA said.

The updates — which also include expanding eligibility for patients to receive take-home doses of methadone and allowing more provider types to order medications — aim to reduce stigma and expand care access, which can be challenges to treating people with substance use disorders. 

Telehealth could be a significant aid on that front, experts say. Virtual care use soared during the COVID pandemic, helped by loosened regulations that allowed patients to receive care while maintaining social distance.

Some research has shown telehealth can expand who can access mental healthcare and opioid use disorder treatment, potentially preventing overdoses. Provisional data suggests drug overdose deaths reached nearly 107,000 during the 12 months ending in August 2023, according to the Centers for Disease Control and Prevention. 

“While this rule change will help anyone needing treatment, it will be particularly impactful for those in rural areas or with low income for whom reliable transportation can be a challenge, if not impossible,” Miriam Delphin-Rittmon, the HHS assistant secretary for mental health and substance use, said in a statement.

Regulators have made other changes that could improve access to substance use disorder treatment. During the pandemic, the Drug Enforcement Administration granted exceptions to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which required most practitioners to have at least one in-person evaluation before prescribing controlled substances.

The DEA and the HHS announced in the fall that they would extend pandemic-era prescribing rules through 2024. Advocates cheered the extension, arguing in-person requirements limited access, particularly for opioid use disorder care.

The pandemic forced health systems to rapidly shift to virtual care to preserve access, aided by loosened Medicare regulations that aimed to boost adoption and use of telehealth during the public health emergency.

But the shift also meant a spike in the number of electronic messages, including billing for patient messages, sent to providers, according to a study published in JAMA. 

Charging for e-visits, or asynchronous messages that require medical decision making and take at least five minutes of clinician time over the course of a week, spiked at the beginning of the pandemic as health systems shifted to virtual care. But billing fell after the early pandemic peak before beginning to steadily increase again in mid-2021. 

More than 470 healthcare organizations billed at least 50 e-visits in the third quarter of 2022, an increase of nearly 40% compared with the same period in the previous year. The upturn suggests organizations now see e-visits as a long-term source of potential revenue, researchers said. 

Clinicians argued the increase in messages overwhelmed their inboxes, pushing them to take on additional uncompensated work after-hours to handle the volume. 

Charging for messages is controversial, as patients are unsure what kind of questions could result in a bill. That could discourage them from contacting their clinicians, according to the study.

Many health systems began to bill for e-visits to bring in revenue from the growing number of messages. The study found an average of 103,127 e-visit claims per month in 2020, which sank to 77,164 in 2021 and rose again to 100,541 in 2022.

Nearly 45% of claims were billed for five to 10 minutes of provider time, while about 15% were charged for 21 minutes or more,  the research found.

The most common diagnoses for the five to ten minute code were acute sinusitis, urinary tract infection and acute respiratory infection. For the code that recorded the longer use of provider time, e-visits were usually linked to hypertension diagnoses. 

“This variation may suggest that shorter, lower-cost messages may substitute for synchronous acute care, whereas longer, more complex messaging is more often an additional care touch point,” the study’s authors wrote. 

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By Access TeleCare

While physician burnout existed prior to March 2020 and the onset of the COVID-19 pandemic, it has now become a larger problem that is deeply affecting the healthcare ecosystem. Physicians experiencing burnout increased from 38% in 2020 to 63% by the end of 2021, according to a survey co-authored by the American Medical Association. Today, physicians are twice as likely as workers in other industries to experience burnout symptoms.

Frontline providers, whose primary clinical workplace was a hospital, took a physical and emotional toll leading to significant rates of burnout and turnover. However, burnout is not limited to hospital-based physicians. Primary care physicians, too, are experiencing increasing workloads and administrative burdens, leading to increased stress, burnout and eventual departure from the practice of medicine.

The cost of physician burnout to the health system is staggering. Burnout is estimated to cost the entire healthcare system $4.6 billion annually, with much of those costs attributed to physician turnover and work-hour reductions.

To meet this growing crisis, healthcare providers need to innovate and adapt, leveraging technology advancements where appropriate. One area that is proving to be an immediate answer is specialty telemedicine, particularly in high-acuity settings. Telemedicine is a highly effective means of ensuring a reasonable and sustainable workload while enabling individual professional accomplishment and satisfaction—all factors that can reduce the likelihood of burnout.

Telemedicine’s effectiveness at reducing burnout is demonstrated for both in-person physicians and their virtual colleagues. Here’s how:

• Augment On-site Physician Capacity: High-acuity, specialty telemedicine can support hospitals in retaining more clinically complex patients to better serve their communities, all while augmenting, not burdening, existing physician capacity. TeleHospitalists, for example, can be relied on for the management of inpatient care managing gaps in coverage such as nights and weekends, and ensuring on-site providers can have a balanced schedule.
• Improve Physician Work-Life Balance: Telemedicine can alleviate unsustainable workloads resulting from the physician shortage, which erode career satisfaction and quality of life and increase the likelihood of burnout and early retirement, creating a vicious cycle of increasing shortages and burnout. TeleNeurologists^[1], for example, can supplement hospitals’ on-site capacity so that 24/7 coverage is always available and not burdensome for on-site neurologists allowing them to achieve better work-life balance.
• Alleviate the Burden of Managing Patients in Psychiatric Crisis: Telemedicine empowers hospitals to meet the increasing need for psychiatric care for patients experiencing a mental health crisis. Left unaddressed, the growing problem of emergency department boarding of psychiatric patients creates an untenable work environment for emergency medicine physicians and their clinical colleagues. By reducing ED boarding times by getting patients in psychiatric crisis seen, stabilized and placed in appropriate levels of care in a timely manner, virtual behavioral health not only makes the hospital emergency department more efficient and therapeutic for patients, it makes the workplace safer and less stressful for ED providers.
• Telemedicine as a Career: Telemedicine offers physicians a change of pace from the traditional hospital setting. It isn’t always the in-person stresses of the work that most affect physicians—sometimes it’s simply being away from family or missing kids’ bedtimes and special events that are most wearing. Working as a specialist via telemedicine allows physicians to maintain a high-level professional career and reduce time away from family. Dr. Jade Le, chief of the infectious disease service line at Access TeleCare, describes how a full-time telemedicine career gave her needed work-life balance, “I can be a mom to my kids and be a doctor taking care of patients, and I'm happy, and I feel fulfilled, and I'm not burned out.”

With the physician shortage only growing, hospitals cannot ignore physician burnout. Using specialty telemedicine within the hospital is an effective, proven and easy-to-deploy means hospitals can use today to begin to address some of the root causes of physician burnout, chief among them, overwork and unsustainable workloads. Having a meaningful telemedicine role also can support physicians who face a choice of continuing to feel burned out or leaving the workforce. With a specialty telemedicine role, they can stay engaged in meaningful patient care, have an impact on patient lives and continue to advance their professional knowledge.

A group of bipartisan senators reintroduced the Telemental Health Care Access Act in January that aims to remove barriers to telemental healthcare for Medicare beneficiaries.

The legislation, introduced by Sens. Bill Cassidy, R-La., Tina Smith, D-Minn., John Thune, R-S.D., and Ben Cardin, D-Md., would remove requirements that telemental health patients see an in-person provider within six months of receiving services via telehealth.

The senators warned the “arbitrary” requirement that patients be seen in person will limit access to needed care, particularly in rural areas.

The bill comes as a number of Medicare telehealth flexibilities that first went into effect during the COVID-19 pandemic are set to expire at the end of the year without congressional action.

Lawmakers have previously shown bipartisan support for making some of these changes permanent, arguing they improve access to care, particularly in rural areas where travel times to healthcare facilities can be long. 

“Especially for Minnesotans in small towns and rural places suffering from mental health challenges, long commutes to the nearest provider can mean virtual care is the only feasible option,” Smith said in a statement. “This bill is an important step in making it easier for mental health patients on Medicare to ask for help and get the care they need, without having to jump through administrative hoops.”

Legislators and witnesses at a Senate subcommittee hearing in November warned Congress should act quickly to address the temporary accommodations, as regulatory uncertainty could push providers away from virtual care. 

Telehealth use soared during the COVID-19 pandemic as regulators implemented these flexibilities and providers quickly pivoted to virtual care to accommodate social distancing. Though utilization has fallen since its peak, telehealth is still more common than it was pre-pandemic. 

Mental healthcare is a popular use case for telehealth, and an area where access challenges have long stymied who can receive treatment. In October, more than 67% of diagnoses from telehealth claim lines were for mental health conditions, according to FAIR Health. 

Teladoc Health is continuing to trim expenses in a bid to boost its bottom line, but the telehealth vendor could still look to make technology investments or pursue mergers and acquisitions, executives said on an earnings call in February. 

The company posted a net loss of $220.4 million for 2023, compared with a loss of $13.7 billion in 2022, a period that included several hefty non-cash goodwill impairment charges. Revenue increased 8% year over year to $2.6 billion in 2023. 

Teladoc generated “strong” free cash flow last year, and expects to continue this year, CFO Mala Murthy said on the earnings call. That could free the virtual care giant to pay down debt or acquire companies, she said. 

Teladoc missed Wall Street’s forecasts on revenue in the third quarter, and kicked off an operational review aimed at boosting the virtual care company’s bottom line. The vendor also cut jobs in engineering and data science earlier this year, according to a report from Endpoints News. 

The company has focused on cutting costs, including with automation, internal process improvements, organizational realignments and cutting spending on third party supplies, CEO Jason Gorevic said on the earnings call. The operational review will net about $43 million in expense savings this year, according to the company’s earnings report.

Teladoc could still make “sizable” investments, including in technology that could help the vendor stand out among its competitors, he added. The company is also considering tuck-in M&A deals, Murthy said. 

“It's important that we continue driving greater differentiation through investments in technology, such as machine learning and AI, improving our ability to engage with members on a hyper-personalized basis,” Gorevic said.

Teladoc reported mixed results in the fourth quarter of 2023, missing investor expectations on revenue, but beating Wall Street expectations on earnings per share. 

Revenue increased 4% to $660.5 million during the fourth quarter, compared with $637.7 million during the same time in 2022. Net loss was $28.9 million in the fourth quarter, compared with $3.8 billion in the prior-year period. 

Teladoc’s integrated care segment, which includes its business-to-business virtual care offerings, increased revenue 8% in the fourth quarter.

But revenue was flat in its direct-to-consumer mental health offering, BetterHelp, as the company saw lower yield on its marketing spend, especially on social media advertising.

The telehealth vendor expects between $2.64 billion and $2.74 billion in revenue for the full-year 2024, and a net loss per share from $1.10 and $0.80.

Telehealth utilization soared during the early days of the COVID-19 pandemic as regulators eased Medicare rules about virtual care and providers quickly pivoted to telehealth amid social distancing.

Providers generally followed Medicare rules when delivering care via telehealth at the height of the pandemic, according to a report by the HHS’ Office of Inspector General published in February. 

The rapid changes to the Medicare program might have risked fraud or waste, and it’s key for regulators to keep an eye on telehealth delivery to ensure quality of care, according to the report.

But the audit found physicians and other practitioners complied with Medicare requirements for 105 of the 110 sampled evaluation and management services provided from March to November 2020. Payments that didn’t follow requirements largely resulted from clerical errors or the inability to access records.

The audit found that 14% of the total amount Medicare paid for evaluation and management care — which doesn’t include services like diagnostic tests or procedures — during the early pandemic period was provided through telehealth, compared with less than 0.1% a year earlier.

Providers generally complied with Medicare requirements when delivering these services via telehealth, according to the OIG. The program paid just $446 for the five sampled services where providers didn’t meet Medicare requirements.

An earlier OIG report published in 2022 suggested telehealth fraud was rare in Medicare, and relatively few providers were billing for services that were never delivered or weren’t medically necessary.

The latest audit comes as legislators face a deadline to enshrine some pandemic-era Medicare flexibilities for telehealth. A number of the flexibilities are still temporary measures that could expire without congressional action. 

Bipartisan legislators have shown support for making some pandemic-era flexibilities permanent, arguing that telehealth could help people receive needed care, especially for rural patients or substance use disorder treatment.

Amwell has reduced its headcount by about 10% since the end of 2023 as the telehealth vendor worked to rein in expenses, executives said on a fourth quarter earnings call in February. 

The company posted a $679.2 million net loss for the full year, compared with losses of $272.1 million in 2022. Revenue declined nearly 7% to $259 million last year. It racked up non-cash goodwill impairment charges linked to sustained decreases in its share price and market capitalization. The charges totaled $436.5 million in 2023.

Nevertheless, leadership has “high conviction” about a path to profitability in the next few years, as Amwell completes migrations to its new Converge platform and deploys a contract with the Department of Defense’s Health Agency in partnership with technology firm Leidos, chairman and CEO Ido Schoenberg said on a call with investors.

The vendor faced headwinds as it transitioned customers from its legacy system to Converge, a new telehealth platform that aims to consolidate its offerings and include third-party tools.

But leadership believes the company is coming out the other side poised for growth, CFO Robert Shepardson said on the call. Total visits reached 1.6 million in the fourth quarter, with 52% taking place on Converge. 

Amwell wrapped up migrations for some large payer clients at the end of the year, so visits on the new platform approached nearly 70% at the end of last month, he said.

Completed migrations and a lessened need for research and development spending contributed to the recent headcount reductions across the company, according to Schoenberg. 

“Everything we do with Converge is dramatically more efficient. The deployment cycles are shorter, the support is easier. It's a very, very modern and very reliable platform,” he said. “The support tickets are a fraction of what they were in legacy.”

In the fourth quarter, Amwell beat Wall Street expectations on revenue and earnings per share, bringing in $70.7 million and posting a $50 million net loss. In the prior-year period, the company scooped up $79.2 million in revenue at a $61.6 million loss.

The company expects revenue between $259 million to $269 million in 2024, and Amwell plans to break even on an adjusted earnings before interest, taxes, depreciation and amortization basis in 2026.

Telehealth visits are more likely to result in a follow-up appointment compared with in-person care for most specialities, according to a study by Epic Research. 

But the gap in follow-up appointments between telehealth and office care narrows when looking at longer timelines. Seventeen specialties out of 24 had more follow-up visits within seven days after telehealth appointments, but only 14 specialties had more follow-ups within 30 days and 13 within 90 days of the initial visit.

Overall, the follow-up rates for both office and telehealth visits have held steady over the last three years.

Studies have shown telehealth could help patients more easily receive needed care, especially for mental healthcare and substance use disorder treatment. Rural patients could also benefit from using virtual care to cut down on long travel times to nearby healthcare facilities.

But some researchers have raised questions about whether telehealth leads to duplicative care, ultimately costing the health system more money in the long run. 

The latest Epic Research study follows earlier research that found most specialities had a greater rate of same-specialty, in-person follow-up care within 90 days after an initial office visit compared with virtual care. 

But the new study adds more time intervals, and included follow-up rates for both virtual and office visits. 

Overall, the follow-up rate was below 40% for both telehealth and office visits within 90 days of the initial appointment, under 25% within 30 days and below 10% within seven days, according to the research.

Specialties with the highest rates of follow-up after telehealth care across all time intervals were obstetrics and gynecology, podiatry and primary care. Specialities with higher follow-up rates after office visits include physical medicine and rehabilitation, mental health and sleep care. 

Digital health funding soared to record-breaking levels during the COVID-19 pandemic in 2021, boosted by the rapid uptake of telehealth and other digital health technologies that aimed to preserve access to care.

But investment began to decline in 2022, and dipped even further last year. U.S. digital health startups raised $10.7 billion across 492 deals last year, marking the lowest funding level in the sector since 2019, according to a report by Rock Health. The fourth quarter of 2023 marked the lowest investment quarter for digital health since the third quarter in 2019, with startups only bringing in $1.9 billion across 122 deals. 

But M&A activity and company shutdowns didn’t spike, even as startups seemed strapped for cash. Many companies were quietly raising funds from existing investors as well as seeking extension rounds and unlabeled raises, the venture capital firm and consultancy said.

Those measures likely won’t work again in 2024, forcing some companies to raise at a reduced valuation, look for M&A opportunities or shut down, according to Rock Health. 

The low levels of funding probably don’t fully explain what happened in the sector last year, report authors Madelyn Knowles and Mihir Somaiya wrote. 

Some startups likely looked to extend previous funding rounds, or turned toward unlabeled raises, where rounds aren’t assigned a letter like series A or B. Last year, 44% of deals were unlabeled, Rock Health found. 

Silent raises from existing investors also may have helped some startups stay afloat in 2023. But these strategies aren’t long-term fixes.

“For startups continuing forward, these creative financing measures are realistically one-time assists, and can’t be continuously relied upon if additional financing is needed,” Knowles and Somaiya wrote. “Startups that aren’t able to leverage funding to reach the requisite standards of their next deal stage will face tough decisions in 2024.”

Labeled raises could come back next year, as some startups will likely need more substantial raises than they could scoop up in 2023, the report predicted. 

M&A will likely pick up too, as startups run low on funds and buyers see opportunities to pick up assets on the cheap. Though industry watchers have been warning about impending consolidation in digital health, Rock Health tracked only 146 announced mergers or acquisitions last year, compared with 190 in 2022. 

The public markets may change in 2024 as well. Zero companies completed an IPO last year, but some late-stage companies could make the jump in the coming months.

Other companies that have struggled financially may delist. At least 17% of public digital health companies trading on Nasdaq or the New York Stock Exchange weren’t compliant with rules that require them to consistently trade above $1 per share. 

“We may see select startups that have eyed an exit and delayed their debuts finally take the plunge next year, especially those that have achieved strong financials,” Knowles and Somaiya wrote. “With the combined measures of delisting and new IPOs, we expect a recalibration of the private digital health market will result in a stronger and more stable publicly traded cohort in the years ahead.”

Though virtual care use has fallen back to nearly pre-pandemic levels in many fields of medicine, mental healthcare has remained elevated, a January study published in JAMA Health Forum noted. Diagnoses for mental health conditions made up more than 66% of telehealth claim lines in November, according to a Fair Health tracker. 

Telehealth availability for mental healthcare varies widely from state to state, suggesting some patients may face “several hurdles” when booking appointments for services, according to a January study published in JAMA Health Forum.

The analysis, conducted by nonprofit research institute Rand Corporation, found less than half of mental health treatment facilities in Mississippi and South Carolina offered telehealth care, while all facilities contacted in Delaware, Maine, New Mexico and Oregon did. 

Researchers were also unable to reach one in five facilities when attempting to inquire about telehealth options, the study found. 

Access challenges have long restricted how many people receive treatment for mental health conditions, and earlier research has shown telehealth could expand the number who receive care for common disorders.

In the latest study, researchers called nearly 2,000 facilities to ask about their current telehealth availability. They posed as prospective clients looking for care for major depressive disorder, generalized anxiety disorder or schizophrenia. They also randomized the names used, so they could determine if perceptions of race or gender affected the results.

Though they repeatedly called some clinics, the team could only reach about 1,400 facilities. 

“We tried to replicate the experience of a typical client seeking specialty care from a mental health treatment facility in the U.S.,” Jonathan Cantor, the study’s lead author and a Rand policy researcher, said in a statement. “The fact that we could not reach anyone at one in five facilities suggests that many people may have trouble reaching a clinic to inquire about mental health care.”

Of the facilities they could reach, 87% were accepting new patients, and 80% of those providers said they offered telehealth services. 

Nearly 97% of current telehealth providers reported offering counseling services, while nearly 77% provided medication management and almost 69% offered diagnostic services. 

But virtual care availability and the type of care offered varied based on facility type and location. Private facilities were nearly twice as likely to offer telehealth compared with public providers, which may reflect the different patient populations served by these facilities, according to Cantor.

Wait times also varied across states. The median number of days until a first appointment was 14, but callers in some locations would have to wait much longer before they received care. In Maine, the median wait time for a telehealth appointment was 75 days, compared with just four days in North Carolina. 

The researchers found some “encouraging” signs about telehealth access. Available services didn’t vary significantly based on the patient’s perceived race and ethnicity, their clinical condition or county-level sociodemographic details.

But the results suggest some patients could still struggle to find the services they need.

“[...] The patient must successfully contact the facility, confirm that the facility is accepting new patients and that it accepts the patient’s insurance, and must identify a facility that offers the specific telehealth services for their mental health needs,” the study’s authors wrote.