As the pandemic wanes, telepsychiatry companies are crossing their fingers that the virtual care market boosted by the pandemic can continue to thrive.
Talkiatry is one of the companies keeping a close eye on public health exemptions that allow stimulants like Adderall to be prescribed after a virtual visit. The telepsychiatry company released data this week reporting that if COVID-era exemptions were to end, 14,700 of its patients would lose access to their current treatment.
“We have hundreds of doctors who specialize and treat certain types of substance use disorders, and a lot of them in many states are being unfortunately delayed in getting the appropriate Drug Enforcement Administration licenses to be able to do the things that the Biden administration and the Consolidated Appropriation Acts want us to do, so there's confusion,” Talkiatry CEO Robert Krayn told Fierce Healthcare. “I think that anything that comes out that helps clarify those things would help move telemedicine forward and give people appropriate access to care.”
Before March 2020, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 (PDF) required a face-to-face visit before any control substance was prescribed—including stimulants used to treat attention-deficit/hyperactivity disorder (ADHD) like Ritalin and Adderall.
Post March 2020, a public health exemption went into effect suspending the Ryan Haight Act. The emergency is currently set to extend into spring.
Online third-party psychiatric platforms rushed to fill the space by blasting social media with ads. Their fast rise led to scrutiny from lawmakers and pharmacies over their prescription practices. There are ongoing investigations of Cerebral, telehealth provider Done and digital pharmacy Truepill, leaving many asking whether the rush into a gap in loosened restrictions invited sloppy practices and potentially put patients in danger.
More than 100 groups have requested that the DEA create a registry of providers permitted to prescribe drugs online for conditions including opioid addiction. This would ensure that those prescribing drugs like stimulants are providing high-quality, appropriate care, some healthcare leaders say.
“There are mental status exams, there is a framework, by the American Psychiatric Association and by other sources in terms of how you appropriately diagnose patients,” Krayn said. “There should be requirements to make sure that the providers who are prescribing these medications are doing it appropriately.
“You also have to take into account that there are new business models that have the potential to solve a lot of issues that we face today in terms of access and limited psychiatrists in rural settings. Telemedicine allows you to solve a lot of problems. You have to make sure that quality remains high when you do that.”
According to the New York-based company, 89% of patients on its platform do not live in the same city as their doctor, and 82% live in a county with a mental health care shortage.
Krayn says Talkiatry works to avoid the “red flags” that were a part of other companies' business practices, now under scrutiny by the Department of Justice as part of an investigation regarding possible violations of the Controlled Substance Act.
Talkiatry reports that 60% of its patients who came to the digital health provider for ADHD treatment were not diagnosed with ADHD. Of those who were diagnosed, 25% are not on a controlled substance.
Over time, the company claims that patients see a decrease in dosage and use of controlled substances averaging 48% for non-stimulants and 36% for stimulants.
“What you find commonly these days is a blurring of the lines between an online pharmacy and directly providing care to figure out what's best for the patient,” Krayn said. “It’s one thing to say, ‘I can sell you this medication,’ and you come here expecting that medication; it's another thing to say, ‘I'm here to help you determine what's causing your symptoms’ and try to figure out the best path forward.”
Some virtual care companies work with psychiatrists who are contracted employees, meaning they were only paid for appointments completed, possibly incentivizing prescribing medications. Talkiatry psychiatrists are W-2 employees. They also report to a chief, just as they would in a hospital setting, according to Krayn.
The company focuses on continuing education and is currently in the process of becoming accredited by the Liaison Committee on Medical Education to educate its own medical staff, the same accreditation academic institutions have. Krayn says this sets Talkiatry apart from the “1099 Uber for healthcare model.”
“All of our physicians are W-2 employees, we don't use 1099 contractors who can work one day and then be off for months at a time,” Krayn said. “What if you have a patient who you prescribed a controlled substance who needs to speak to you? You can't guarantee certain service levels.”
Despite investigations within the field, telepsychiatry is still seeing growth. A 2022 analysis by the Kaiser Family Foundation of 126 million patients showed that 39% of telehealth outpatient visits were for a mental health or substance use diagnosis. Digital mental health is being applauded as a necessary tool to address staffing shortages, especially in rural areas.
Yesterday, Array Behavioral Care scored $25 million in a funding round led by CVS Health.
“Our practice has always focused on helping provide patients the care they need, when and where they need it, without sacrificing quality,” said James Varrell, M.D., executive chief medical officer and co-founder of Array, in a press release. “It's clear that telebehavioral care is one of the most meaningful ways to address the clinician shortage and mental health crisis. As our practice broadens its reach, our patients and partners can rest assured in knowing that we lead with quality and clinical excellence first and foremost."
Iris Telehealth, a company that partners with providers to provide teletherapy services, scored $40 million in series B funding in April. Brave Health grabbed $40 million this fall to continue offering virtual therapy, psychiatry and medication management. Digital therapeutics provider Twill, formerly known as Happify Health, also now offers teletherapy.
New data from Blue Cross Blue Shield of Massachusetts showed that since 2019, in-person and virtual visits for mental health have doubled. With ongoing psychiatrist shortages and burnout, Krayn thinks the solution to risky practices is not ending telepsychiatry altogether but creating a new system to match a new model of care.
“I think that if the PHE were to end tomorrow without a special registration process for telemedicine, I think it's going to leave a significant number of patients without care,” Krayn said.