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October 20, 2020
After a full workday at her makeshift home office, Sarah opens her browser for her last video meeting of the day, only this one is with her psychiatrist. Like many behavioral health patients, COVID-19 has shifted her whole life around. Work-from-home, socialize-from-home, and finally, heal-from-home.
On the other side of the screen, her practitioner has set up a pleasant, non-distracting background in her makeshift home office. The session begins and ends on time—a pleasing phenomenon of the new COVID paradigm, appointments are actually running on schedule.
Patients and practitioners along the behavioral health spectrum are adjusting to the new normal of virtual visits. According to Dr. Chris Morache, president of Psychiatric Centers at San Diego (PCSD) and practicing psychiatrist, COVID has caused a drastic increase in anxiety disorders among his patient population. He noted the comorbid occurrence of substance abuse has also risen, a sentiment echoed by Nick Mercadante, founder and CEO of PursueCare, a telehealth addiction recovery provider and virtual platform.
Both companies have seen a strong uptick in visit volume since the start of the pandemic in mid-March and are gearing up for a continued influx of virtual patient care in the foreseeable future as COVID’s implications linger and patients and providers become accustomed to telehealth’s convenience.
Many of PCSD’s practitioners were already incorporating virtual visits into their care delivery prior to COVID, but the use cases were for special circumstances like the homebound elderly population or existing patients who were traveling. That changed overnight when California’s governor initiated a lockdown in March, an order that quickly became the reality nationwide.
PCSD’s plans to expand telehealth offerings for their 200 clinicians over a scaled rollout shifted to onboarding everyone simultaneously. Like many practices, their visit volume initially dropped about 40% for two to three weeks, but then steadily increased as patients and clinicians adapted to the circumstances.
“People were terrified and didn’t know what to do. We were prepared from a tech perspective, but patients weren’t necessarily ready to make the shift yet,” Dr. Morache said.
Today, PCSD employs five telehealth platforms, which have created needed redundancy and flexibility for patients and practitioners. All of the platforms work on smartphones, tablets, or desktops.
“Having more than three platforms has been a lifesaver because they are never 100% reliable, and some patients are more tech-savvy than others. Before COVID, patients self-selected telehealth. After COVID, it didn’t matter, everyone was transitioned,” said. Dr. Morache.
Clinicians were trained on how to adapt their care delivery for the telehealth setting. Making sure their background is appropriate, remembering to look at the camera—not the screen, and frame themselves correctly… these considerations were all part of the telehealth learning curve.
With the quick shift to working from home, clinicians had to deal with hardware and software concerns as well. One unanticipated complication was the influx of forgotten password and sign-in issues—PCSD’s call center was crushed with non-clinical questions.
PCSD’s patients run the full gamut of the behavioral health spectrum. Mood disorders and anxiety disorders now represent 80% of diagnoses. They typically serve about 15% of patients with substance abuse disorders and 7-10% of patients living with autism. “Post-COVID, anxiety disorders have taken the lead by a measure and a half,” Dr. Morache said.
“Another phenomenon is people are a lot less likely to no-show their first or follow-up visit. Prior to COVID, we had under 5% no-shows, which is good for the industry. This went down during COVID because we were able to immediately follow-up with them. Demand has gone up as well,” he noted.
Their autism program, which relies heavily on in-person care delivery, virtually halted for the first three months of the pandemic. With the combination of these two factors, the practice’s leadership made a smart resource allocation move. They converted their idle autism care providers to in-house IT support. “We did not lay anyone off, which is great. They were able to offer the additional IT support patients needed and also speak to them on a clinical level,” said Dr. Morache.
Despite the added tech support, some issues that can disrupt a telehealth visit are outside of the provider’s control. Access to High-Speed Internet is not universal. For the patient population in metro areas, this isn’t typically an issue, but a growing number of patients live in rural locations. A moment of pixelation, skipping, or call dropping can interrupt the flow of a session. Dr. Morache developed a low-tech solution to a high-tech problem. “I have cue cards, so if I am frozen, I will hold up a sign that says, ‘I will call you.’ Patients have been understanding of the tech interruptions. It’s just the nature of the beast,” he said.
PCSD’s efficiency and timeliness of both appointments and documentation have improved with the shift to telehealth. Providers are not running behind as often, and patients are more keenly aware of their appointment start and end times. Patient outcomes, Dr. Morache noted, are the same.
“The efficacy of telehealth is undisputed,” he said. “The big question now is, what happens when COVID is over? Most patients want to continue telehealth. I think most of our clinicians will end up doing a hybrid practice, none will be exclusively practicing in-person—that is a relic.”
In addition to efficacy, access is also a factor in telehealth’s swift takeoff in the behavioral health space. PursueCare’s entire business model was based around this idea—they work with patients in underserved and under-resourced areas, leveraging community health partners to help bring to bear substance use treatment resources that otherwise might not be onsite, immediate, or comprehensive.
“We have physicians who can provide medication, like Suboxone for example. We have counselors and psychiatric medication management for co-disorders. Our pharmacy can ship medications directly to patients in 26 states. We offer at-home toxicology testing through a smartphone app that we developed and designed specifically for our patient population,” said PursueCare’s Founder and CEO Nick Mercadante.
“The app doesn’t require a lot of bandwidth because we work with patients that sometimes do not have access to WiFi or who have limited data available,” he said.
Before founding PursueCare, Mercadante worked as a healthcare attorney and saw an opportunity to improve the fractured care continuum for people with substance use disorders. His company combats barriers like lack of transportation, the inability to be quickly admitted, and the need to continue working versus taking time off to participate in a treatment program.
“We previously had to partner with hospitals to start a relationship with a patient in-person. The broader de-regulation of telehealth is now allowing us to start a care relationship with the patient directly, which increases access and adoption,” he said.
“When COVID hit, we started working on going directly to patients and finding them in their swim lanes, be it social media or TV ads, to raise awareness. The message was, ‘download the app, register, and get started.’ That was the biggest change for us,” he said. “Since then, the partnerships have come back 10-fold. The healthcare community started to acknowledge the longevity of the COVID paradigm and the need for new solutions. We can help reduce foot traffic, which facilities need badly, and there has been an incredible increase in demand in communities.”
COVID has indeed exacerbated PursueCare’s reason for existence. “Clinics have closed or are not accepting new patients, people are scared, and there is stigma. The pandemic has made people more isolated, and there has been a huge spike in overdose deaths,” Mercadante said.
After all, COVID’s disruptions didn’t just impact legal, above-board businesses… the drug trade has changed as well. “Drug use communities have been strained and the quality of drugs has changed. We are seeing an increase in Meth use and Meth spiked with Fentanyl. It is harder for drug users to get the more controlled-quality opioids because everything has been put on a freeze because of COVID. All of the prior issues have been taken to an extreme,” he said.
Many behavioral health providers initially opted for solutions that were quick and easy to implement given the urgency of the situation. As things evolved, pain points popped up. “This will eventually drive an increase in telehealth companies that are focused on a sub-specialty of care. Innovations in interoperability, features, and devices have all picked up steam faster in the past six months than in the past decade,” Mercadante said.
But as with technology innovations in any industry, there are some limitations. There is only so much a practitioner can do through a video session—some patients need a heightened level of care, a physical exam, or bloodwork, for example. Whether that type of care is episodic or chronic, providers must martial those resources and develop interoperable partnerships so the patient experiences a comprehensive care ecosystem.
PursueCare invested heavily on the frontend with care coordination and using triage and early assessments to determine individualized treatment plans. Their offerings sometimes serve as a stopgap between in-person treatments or a facilitator to ongoing treatment.
“In our space, there is a level of scrutiny and we have to be thoughtful about that, understand the regulations, know what we can and can’t do, and bring in additional resources as needed,” Mercadante said. “Toxicology screening is vital for the safety of the patient, so we developed partnerships to offer in-home toxicology screening where they do a swab on video, and then we DNA verify the results.”
Beyond the business and logistical considerations, behavioral telehealth is ultimately about connecting people with the care they need, something Mercadante has not lost sight of. “We are in a great position to help people. We could probably grow faster, but we want to ensure we have quality patient outcomes. Great things are happening with our patients, but there are always more improvements to be made and more people to serve,” he said.
“The most surprising thing is that it has taken a pandemic for this to take off in the way it has. The reality is, we are solving problems that existed before COVID. Nationally, we are meeting 16% of the mental health need in this country. Especially in middle America and rural communities,” he said. “But it is encouraging to see that the decision tree has gone from whether or not to adopt telehealth to how to make it most effective.”
During the first quarter of this year, 20 behavioral health companies conducted M&A transactions. Despite COVID’s temporary damper on M&A activity overall, investors are still interested in the sector. Disruption in the behavioral health market, predominantly borne via telehealth, will produce opportunities for savvy buyers with strong balance sheets—and the unexpected and dramatic rise in behavioral telehealth usage has actually provided new reimbursement opportunities for certain providers. These dynamics only add fuel to an already hot segment (from an investment perspective) of the overall behavioral health market.
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