The federal government has extended COVID-era telehealth flexibilities twice since their creation. These flexibilities are now set to expire in December 2024, putting “life-saving” care at risk, behavioral health industry insiders caution.
Some substance use disorder (SUD) providers are now making plans to pivot their clinical models if flexibilities are not cemented, partnering with local organizations or hiring clinicians who are prepared to travel for in-person appointments.
“Telehealth-only care makes it easier to begin treatment and is effective at retaining people in care,” Gil Kochman, CEO of Workit Health, told Addiction Treatment Business in an email. “If these flexibilities are removed, the industry overall will lose its ability to engage with a portion of the population who doesn’t want or feel they need in-person help.”
Ann Arbor, Michigan-based Workit offers virtual treatment for opioid use disorder (OUD) and alcohol use disorder using medication-assisted treatment (MAT), shared medical appointments and peer support. Prior to the flexibilities, the provider saw patients in person at one of the company’s brick-and-mortar clinics before continuing care online.
When COVID-era flexibilities eliminated the requirement for in-person visits, Workit patients who lived in rural areas or who faced other barriers to care benefited “hugely,” Kochman said.
What’s at stake
COVID-era telehealth flexibilities dramatically increased access to MAT for SUDs, especially for vulnerable populations.
Prior to the DEA’s telehealth flexibilities, virtual behavioral health provider Better Life Partners connected most of its patients to buprenorphine treatment within two days and had a treatment drop-off rate of approximately 25%, according to Dr. David de Gijsel, the company’s chief health officer.
Better Life Partners offers mental health and care coordination as well as SUD treatment to treatment providers, community organizations and public health organizations, including Acadia Healthcare (Nasdaq: ACHC), Crossroads and the New Hampshire Harm Reduction Coalition. In August 2023, Better Life Partners raised $26.5 million.
After flexibilities were instated, Better Life Partners was able to get patients started on buprenorphine within four hours. Almost 100% of the patients who reach out for care get it, de Gijsel said.
Virtual SUD treatment eliminates some traditional barriers to care, including transportation, cost, time away from work and child care, factors that are most likely to impact rural or low-income patients. The private nature of a telehealth appointment may also benefit patients who struggle with stigma.
Virtual treatment also benefits people who are exposed to intimate partner violence, de Gijsel said. Substance misuse is common among this population, and virtual treatment makes care more accessible for people with controlling partners.
Telehealth SUD flexibilities have also allowed SUD businesses to grow rapidly. Virtual treatment is also a “very scalable” business model, Kochman said.
“We’ve seen both positive and negative impacts of scalability over the past few years,” he said. “It’s easier than ever to access care, but some companies have chosen to sacrifice quality and focus on rapid growth.”
An analysis released in April found that the virtual SUD treatment industry represented a market opportunity of well over $10 billion.
While telehealth flexibilities expanded access and facilitated business growth, some providers question the wisdom of fully virtual prescribing models.
“It’s hard to put the genie back in the model, but there needs to be reasonable parameters,” Lee Dilworth, president and CEO of ReVIDA Recovery, told ATB. “Patients do need to be seen from time to time in person, they do need to receive comprehensive care, which is hard to do in a telehealth-only model, consistently and well.”
Nashville, Tennessee-based ReVIDA operates nine OUD facilities across Tennessee and Virginia, according to its website. The provider, founded in 2019, offers comprehensive care leveraging medication-assisted treatment and individual and group therapy.
Increased access to MAT does come with the risk of drug diversion, Dr. Steven Pratt, senior medical director for the employer segment within Magellan Healthcare, told ATB in an email. Drug diversion occurs when a patient takes a drug for a different reason than prescribed or when someone other than the intended person takes the drug.
“Buprenorphine does have abuse potential,” Pratt said. “Easier access could facilitate more diversion. [But] it appears that diversion has not become a major issue under the loosened regulations.”
Frisco, Texas-based Magellan Healthcare is a subsidiary of Magellan Health, a provider of behavioral health and other services.
In-person care usually benefits most people, de Gijsel said, and may be necessary in certain circumstances, such as when delivering injectable buprenorphine or completing a health screening.
Some patients may not benefit from seeing their provider in person, or simply prefer not to, he said.
“Does it make sense to force those people to do something that doesn’t work for them and threaten being cut off from a life-saving medication if they don’t comply? No, that doesn’t make sense,” de Gijsel said. “At the very least it doesn’t make sense from a harm reduction perspective, but I think even from a ‘I want you to get the very best care’ perspective, it doesn’t make sense.”
Bracing for impact
If the DEA does roll back COVID-era prescribing flexibilities, providers and payers would “need months to plan how to get the patients to providers who could do an in-person assessment prior to prescribing,” Pratt said.
Some SUD providers are getting a head start on their planning, creating strategies that could guide them through the adjustment process.
Pelago has been actively preparing for different scenarios and has developed a hybrid model to prepare for potential in-person visit requirements, according to Dr. Suzette Glasner, the company’s chief scientific officer.
Pelago offers virtual care to patients with tobacco, alcohol, opioid and cannabis use disorders using cognitive behavioral therapy, motivational enhancement therapy and contingency management. The provider raised $58 million in a Series C round in March.
“We have prescribing providers who, when we hire to Pelago, we ensure that they are ready to travel to meet the required demands and requirements of in-person visits,” Glasner said.
Some states in which Pelago already operates currently require in-person visits, Glasner said, so the company has already established processes for in-person visits and identified in-person facilities where its providers can see patients. The provider plans to deploy those processes across other states if necessary.
Providers that operate some in-person facilities may have a leg up on preparations for potential requirements for in-person appointments.
“Despite being 100% virtual now, we’ve always maintained a brick-and-mortar presence in each state in which we operate,” Kochman said. “We’ve been watching and preparing for this change for quite some time. We’ve assembled a cross-functional working group that has developed plans based on several possible scenarios.”
The main challenge associated with these plans is uncertainty, Kochman said, which necessitated that Workit prepare for several potential possibilities. The provider has installed safety mechanisms including physical clinic locations and partnerships with local providers to minimize disruptions to patient care
Better Life Partners is positioned to meet the demands of changing regulations without additional planning, de Gijsel said. The provider has been expanding its in-person offerings since the peak of the pandemic passed.
“We’re in fine position to switch to in-person if that’s required,” de Gijsel said.
Better Life Partners has evolved its technology and increased its community presence and provider headcount, so its business would be more efficient than it was before the COVID-era flexibilities, de Gijsel said.
While most SUD providers are drawing up contingency plans, industry executives remain hopeful that the DEA will largely preserve telehealth prescribing flexibilities.
