2024 Outlook: Despite hurdles, stakeholders bullish on VR in behavioral health

Though often associated with gaming, virtual reality (VR) is a technology rapidly evolving in healthcare. From pain management to enabling more efficient surgeries to gamifying physical therapy, VR use cases continue to proliferate. 

It especially holds promise in revolutionizing the behavioral health space, with substantial research supporting its effectiveness. VR is being used to treat a number of conditions, including anxiety, post-traumatic stress disorder (PTSD), substance use disorders and autism.

VR therapy is not a new concept. It was formally studied more than two decades ago, though it wasn’t until the last few years that the field became prominent, with new companies moving into the space. And as technology has improved and gotten more intuitive to use, it has also become less expensive. And in 2022, the American Medical Association approved the first-ever CPT code for VR-mediated therapy. 

“There is no question mark in my view about the clinical validity and clinical value the technology can bring to the market,” Eran Orr, CEO at XRHealth, told Fierce Healthcare, pointing out there are more than 15,000 published papers on VR’s efficacy across modalities.

Not only can VR expand a provider’s arsenal of treatment tools, Orr said, but it also offers a wealth of insights on engagement, biofeedback, wellness and other data. “VR is the technology for mental health,” Orr said.

Despite its potential, the technology still faces hurdles to adoption, like reimbursement, logistical challenges and regulatory pressures. 

‘Phenomenal’ outcomes from VR use

One area in which VR is often used is exposure therapy for conditions like social anxiety disorder, explained Max Teaford, Ph.D., assistant professor of psychology at the University of Tennessee at Chattanooga. Teaford opened a lab at the school to conduct research using VR on body ownership and spatial orientation.

“It allows us to create a relatively realistic situation where we can expose someone to a situation that may cause them to experience anxiety, or some other adverse symptom, but we can do it in a controlled manner,” Teaford said. 

The Department of Veterans Affairs (VA) is one major health system that aims to incorporate VR into its daily operations, from care delivery to training and education of staff. 

“VA is only scratching the surface of what VR and other immersive technologies can do,” Veterans Affairs Press Secretary Terrence Hayes told Fierce Healthcare in an emailed comment.

“We need to solve, now, all the non-sexy stuff." —Eran Orr, CEO at XRHealth

So far, the agency has documented decreases in perceived stress, acute and chronic pain, anxiety, depression and symptoms of PTSD, per Hayes. Patients also report increased perceived happiness and “a keen interest” in using more VR in the healthcare system and at home. AppliedVR is one immersive therapeutics company that works with the VA to expand military veterans' access to VR-based therapy for chronic lower back pain.

Where the VA uses VR for training and education, staff report increased engagement in the learning environment and increased empathy. Overall, it has seen “phenomenal engagement and impact” in patients and staff, Hayes said. 

Hoag Hospital in Newport Beach, California, was among the first to begin using Surgical Theater, a VR medical imaging platform helping surgeons visualize a patient’s brain and rehearse complex surgery. Though intended to help doctors prepare for surgery, Hoag staff were surprised to find a resounding positive response from patients, too. When they could see what was going to happen during the surgery, their confidence in the surgery and their doctors grew. 

After these results, Hoag became interested in other areas for possible VR deployment. It trialed VR and augmented reality (AR) across departments, from medical admissions to surgical admissions to acute and outpatient rehab. Leveraging Penumbra's REAL System, an FDA-approved VR rehab system, Hoag made VR a standard of care in its chemical dependency programs.

“The results were stunning,” Thomas Hutchinson, Hoag Hospital’s executive director of digestive health and experiential reality, told Fierce Healthcare. “It’s been a monumental change in how we monitor not just our patients, but our staff.”

The hospital recognized that its staff were burnt out after dealing with challenging patients, Hutchinson said. So it offered 20-minute sessions in headsets to clinical staff, seeing up to 60% reductions in stress and anxiety, as well as a notable increase in willingness to work. 

“Even just these little short interactions were enough to really change the mindset and reestablish their base as a healthcare provider,” Hutchinson said.

In 2024, Hoag Hospital plans to deploy VR to its palliative care population, particularly those at home and isolated, to see how their mental health might improve. “We’re really curious to see how that plays out,” Hutchinson said.

Establishing the value proposition

It is no secret that reimbursement for digital therapeutics broadly, not just VR, has historically stalled. The high-profile downfall of Pear Therapeutics earlier this year spread fear and doubt in the industry about whether these technologies can have a sustainable business model. Three of Pear’s digital prescription therapeutics had the FDA’s stamp of approval, yet it still struggled to secure reimbursement.

Because of these challenges, Orr sees a long road ahead when it comes to getting payers onboard. “I’m not optimistic,” he said.

“AI has a special opportunity for leverage in virtual environments." —Vijay Ravindran, founder and CEO of VR therapy maker Floreo.

AppliedVR's flagship product, the RelieVRx program, was granted marketing authorization by the FDA in 2021 for chronic lower back pain. Back in March, the CMS granted the company a unique Healthcare Common Procedure Coding System (HCPSC) Level II code for RelieVRx, and placed it in an existing benefit category: durable medical equipment. The CMS ruling was significant as it paves a reimbursement pathway, according to CEO Matthew Stoudt. 

Jumping those regulatory and reimbursement hurdles puts AppliedVR in a different category from prescription digital therapeutics, which are often app-based or prescription software, Stoudt told Fierce Healthcare earlier this year.

Unlike a few years ago, healthcare leaders today already know and understand what VR is and how it works, according to Aaron Gani, founder and CEO at RealizedCare (formerly BehaVR). The main focus now is operationalizing VR, Gani believes—that is, integrating it into provider workflows, reducing clinician burden and improving the patient experience. “We need to digitize more of the care delivery value chain,” Gani told Fierce Healthcare.

A strong value proposition, rather than just a solo digital therapeutic, is VR wrapped in a broader set of services to form a care management solution. Those services might be identifying at-risk members who would benefit from the intervention and doing the outreach, or providing downstream referrals for additional care. 

Broadly speaking, this is a value-based care approach, per Gani. For payers, the issue isn’t finding high-cost, chronic populations; it’s targeting them correctly, he said. Offering something that identifies patients, improves their outcomes and generates cost savings is where digital therapeutics have a real opportunity to shine.

Technology can scale quickly, and it gets cheaper over time. “That’s a really good place to lean in with digital therapeutics, is driving value and value-based care,” Gani said.

Artificial Intelligence in VR

One area likely to mature more in 2024 is artificial intelligence in VR, experts agree.

“AI has a special opportunity for leverage in virtual environments,” said Vijay Ravindran, founder and CEO of VR therapy maker Floreo. It can power characters that connect with users in more dynamic, engaging ways, for instance. 

Generative AI can also be leveraged to build 3D environments. These can create personalized experiences. For a skills-building lesson on crossing the street, for example, a rural clinic might want to simulate a big city if that is where the user is from. Neurodivergent kids could potentially benefit from interacting with characters who look like school staff or family members they know well.

“The fact that that environment doesn’t exactly resemble the environment of a specific provider serving a specific family can sometimes be an obstacle to the skill being learned,” Ravindran explained.

These capabilities can also help companies be less reliant on 3D artists who currently custom design environments by hand. “It could basically take something that required a tremendous amount of skill and make it so someone could relatively easily implement it,” Teaford said.

“These tools are coming,” Ravindran said, adding that Floreo is currently piloting an AI-driven character in its own software. 

Tech giants: competition or not?

The launch of the highly anticipated Vision Pro headset from Apple is reportedly set for February. It could revolutionize the way the mainstream public perceives VR, Gani believes, similar to what ChatGPT has done for generative AI.

“Apple is just so darn good at creating human-centered design and making things intuitive and kind of magical,” Gani said.

While it is hard to predict exactly how the Vision Pro will shape public opinion, it could potentially positively impact how providers and patients alike think of VR and its possible uses in therapy. “It really could blast things forward,” Gani said.

Since Big Tech, including Apple and Meta, develop the headsets that XRHealth’s platform sits on, the company does partner with the companies, Orr said. But right now, he doesn’t see them as a serious competitor.

“Healthcare is not a side gig, as a department in one of the tech companies,” Orr said. It is extremely complex with many barriers to entry. “Healthcare comes with a lot of baggage.”

A question of ‘when,’ not ‘if’

Orr is optimistic about the future. To accelerate adoption of VR, healthcare needs more awareness campaigns, more clinical trials and more partnerships with organizations and thought leaders with influence. “It's a team effort for all the ecosystem, but I do think we’re making very good progress,” Orr said

Certain things need to be worked out, like how to get a headset to a patient in different settings or how to connect it to WiFi or how best to integrate it into the clinical workflow. “We need to solve, now, all the non-sexy stuff,” Orr said.

Ravindran sees opportunities for the development of VR in more unregulated, non-healthcare spaces first. Floreo is fortunate, he said, because it works with the education sector as well as the healthcare sector. This means it can explore new experiences first in education, evaluate them without regulatory pressure and then decide whether to try the approach in healthcare settings.

Teaford doesn’t see eagerness about VR dying down. His lab at The University of Tennessee Chattanooga is often included in high school tours on campus. “High schoolers always get excited about trying out different virtual environments,” he said. 

“It’s just a question of 'when', not a question of 'if,'” Orr said.