Almost 10 years ago, I worked for a small startup that wanted to use technology to transform the healthcare system. The first slide of my pitch deck proclaimed that “Smartphones are becoming the digital diary of our lives,” while my second slide made the case that 40% of people actually had these devices. We regularly spent the first 10 minutes of every meeting debating whether those above 35, those under the poverty line, and even healthcare professionals themselves would actually own and use smartphones.
While this conversation may seem ludicrous today, the truth is that healthcare, up until the last month, wasn’t that far beyond those initial conversations. About 5 years ago, when I joined a mental health-focused organization, much of our innovation was site-based telehealth at our existing providers’ offices, with very little available at home or through an app. A maze of regulatory issues, provider skepticism, and consumer hesitation made the process of making healthcare digital simply slow.
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Over the last seven weeks, as we respond to the physical and mental health needs of those affected by Covid-19, that process has gone from slow to changing so rapidly providers can barely keep up. States are loosening licensing restrictions, health plans are agreeing to pay for care delivered remotely, and Medicare and Medicaid are reimbursing for many more telehealth services. Overnight, across the country, brick and mortar providers have taken their services online – and plans are finally paying for it. In California, one of the earliest affected states, Kaiser, already a leader in online care, more than doubled utilization, while neighboring health systems Sutter and Stanford have seen a 175x and 50x increase in video visits respectively.
This has particularly affected how we provide mental health and substance use care. A recent McKinsey report on resilience found that 63 percent of respondents to a National Consumer Survey in late March reported feeling anxious or depressed in the past week, and 1 out of 4 reported binge drinking at least once (more than 4 drinks for women or 5 drinks for men in a single sitting) in the past week (up from 1 in 6 in a recent CDC analysis). Leading digital coaching and therapy providers such as Talkspace as well as Meditation apps such as Calm have reported increases in utilization of more than 50% month over month.
There has been much coverage of how this expansion of telehealth has impacted substance use treatment, especially Medication-Assisted Treatment (MAT) for Opioid Use Disorder (OUD). Over the past two months, we’ve seen an amazing relaxation of the regulations that previously made it difficult to expand access to MAT, from data-sharing governed by 42 CFR to controlled substance prescriptions that have been strictly monitored through the Ryan Haight Act.
This is welcome news, but it also highlights the extent to which the conversation and coverage of how the U.S. is combating substance use disorder has become dominated by the discussion of OUD. In contrast, coverage of changes around telehealth related to alcohol has focused on things like the 243% increase in online sales in the U.S. The WHO actually had to publish a six-page guide to Alcohol and COVID-19 to remind us that alcohol impairs the immune system and that people should not be drinking during the workday just because they are at home.
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This is disappointing, given how much room there is for telehealth and changing regulations to have the same positive effect on treatment for Alcohol Use Disorder (AUD) as it has had for those with OUD. There has been a general bias towards in-person treatment for the most severe cases of AUD, given the dangerous nature of withdrawal and the risk of delirium tremens. This has been one of the arguments for keeping liquor stores open so that people do not go into involuntary withdrawal without access to Emergency Rooms and in-patient facilities.
In response to COVID-19, the American Society of Addiction Medicine rush-released a draft of their new Guidelines for Alcohol Withdrawal Management. Included in the draft is a protocol for ambulatory detox done at home, which has been common outside the U.S. but rare here. The policy allows for video or telephonic daily check-ins with a care provider if in-person check-ins are not possible, yet another sign of how telemedicine is quickly becoming part of the standard of care. Those who previously relied on in-person recovery meetings, weekly in-office therapy sessions and even in-patient care have quickly moved to technology to support their recovery. We need to do more to draw attention to these changes, so that those in recovery feel supported, and those who are only now realizing the extent to which alcohol may be impacting them have somewhere to go.
This rapid transition to online care may seem abrupt, but the evidence base for the change is there. Telemedicine is here to stay and is supported by data both on clinical outcomes and return on investment. According to the American Psychiatric Association, the evidence base is “formidable,” and may even be preferable for some populations and conditions. There is growing data as well that mental health telemedicine can reduce overall medical costs to the health system, even if utilization of services like therapy increases in the short term — which is in and of itself a good thing, since mental health is routinely under-treated (especially substance use issues).
There is also data that this transition is not just impacting those who are digital natives. As smartphone penetration has grown across income levels, Medicaid plans have become some of the more innovative adopters of telemedicine and digital health apps. The Covid-19 crisis has only accelerated this, as organizations like MassHealth, which manages Medicaid for Massachusetts, sign deals with digital health companies that may have seemed far fetched six months ago. I am hopeful that the acceleration of the rate of innovation in healthcare will be a positive effect that outlasts our immediate response to the pandemic.
To be sure, there will have to be work done to ensure that the long-term implementation of telehealth programs is done with an eye towards standardization between states and reducing both provider and consumer confusion. We do not want to just recreate existing system challenges online. Consumers should be able to understand what they have access to at what cost, and Providers should not be caught up in byzantine billing systems that overly emphasize coding for delivery modalities. In addition, much has been written on the infrastructure and data sharing challenges in our current system that persist online, as well as how bedside manner has to change when it’s now desktop manner. After the first wave of work to shift in-person care online occurred without much respect to the differences between face-to-face and virtual care, there has now smartly been a rush to create resources that help explain how to do things online effectively.
As we look ahead at the continuing weeks and months of degrees of isolation, it’s not enough to just push forward with this dizzying pace of change. We need to rebuild our strained healthcare system with virtual care embedded throughout. Now is the time, especially in behavioral health, to standardize things like billing codes, cross-state licensure rules, data-sharing agreement and prescription practices so that we can move forward in a coordinated way across the nation. These shifts will not only make it easier to practice telemedicine but also drive much needed broader structural changes across the healthcare system.The good news is we now have the regulatory changes, consumer support, and healthcare environment to start to build a more thoughtful structure to support this new era of telemedicine.
Julia Bernstein is the COO of Tempest, a New York-based startup creating a modern approach to recovery for alcohol use disorder. She is also an active angel investor and advisor to early-stage healthcare companies. In her career, Julia’s focus has been leading healthcare strategy and growth with a focus on changing the behavioral health system of care. She’s worked in sales roles for payers, growth roles for startups and strategy roles for nonprofits with deep experience in Medicaid, Medicare, behavioral health and digital health, as well as in operations, development and sales.
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