Investor interest in telehealth surged during the Covid-19 pandemic. While the healthcare industry’s widespread adoption of telehealth was driven by necessity due to social distancing practices, such expansion would not have been possible without federal and state governments waiving many legal and regulatory requirements that had previously hindered such telehealth growth. Many of these waivers were temporary and tied to public health emergencies (“PHEs”) which either have already or will soon expire. In turn, the volume of telehealth investments has already begun to decline. In fact, 2023 is projected to be the lowest telehealth funding year since 2019. This begs the question – is the slowing telehealth investment due to the tightening credit markets and an expected economic downturn, or should the telehealth industry expect the trend of decreased investor interest to continue in a post-PHE world?
A review of federal, state, and private payer activity indicates interest in telehealth remains strong. As such, as the credit market stabilizes and fears of a recessions begin to recede, we expect investor interest in telehealth to return.
Background on pandemic telehealth coverage policies
Prior to the Covid-19 pandemic, payers had created numerous policy and coverage barriers that served to limit widespread telehealth adoption. For example, Medicare had requirements preventing patients from receiving telehealth services from their homes, as well as the frequency limits of certain telehealth services. Many state Medicaid programs and private payers had similar telehealth restrictions. On January 31, 2020, a PHE was first announced at the Federal level. Pursuant to the PHE, the Department of Health and Human Services, Centers for Medicare and Medicaid Services (“CMS”) waived many of the key Medicare telehealth requirements that had previously limited widespread telehealth adoption, with state Medicaid programs and private payers quickly following CMS’ lead.
Insights on telehealth interest from federal, state and private payer action
The federal telehealth waivers were set to end when the federal PHE expired on May 11, 2023. Although CMS was supportive of continuing expanded telehealth coverage, many restrictions on telehealth were set by statute, and therefore congressional action was required to permanently change policies. Under heavy industry pressure, on December 29, 2022, Congress temporarily extended many of the telehealth flexibilities afforded by the PHE to Medicare beneficiaries through December 31, 2024. Given the current gridlock in Congress, legislative efforts to further codify telehealth coverage expansion are unlikely to be revisited until late 2024. While budgetary pressures may continue to lead to temporary rather than permanent extensions, with CMS, industry, and public support, Congress is unlikely to force a return to a pre-pandemic telehealth world.
When it comes to making coverage determinations, states often follow the lead of Medicare. However, given the expectation that Congress will not act further on telehealth solutions until late 2024, state action provides helpful insight into the strength of the telehealth industry post-PHEs.
Many state Medicaid programs offer more generous telehealth coverage policies that have continued to broaden in the last couple of years. States have long removed geographical restrictions imposed on where telehealth services take place. In fact, Hawaii, Montana, and Maryland are the only state Medicaid programs that still restrict reimbursable telehealth services to rural areas. Furthermore, 37 state Medicaid program plus Washington, D.C. allow patients to receive telehealth services in their home. Removing geographical restrictions and increasing the types of eligible originating sites means that more patients, including previously underserved populations, can access telehealth services.
With respect to the delivery method of telehealth services, all state Medicaid programs reimburse for live video and 36 state Medicaid programs and Washington, D.C. also reimburse for audio-only telehealth services. Moreover, 28 state Medicaid programs reimburse for asynchronous telehealth services, also referred to as store-and-forward policies, which allow providers and patients to directly share information with each other before and after telehealth appointments. This movement by state Medicaid programs beyond the historical live video requirements provides reimbursement opportunities for telehealth providers and technology. The success of such programs could also lead to further adoption from Medicare of store-and-forward services (which are covered only covered by Medicare in Hawaii and Alaska as part of a telehealth demonstration project).
States have additionally taken legislative action to address private payer reimbursement for telehealth services. The majority of states have passed service parity laws, requiring telehealth services to be covered if they would otherwise be covered if rendered in-person. Payment parity laws, which 24 states have passed, require telehealth services to be reimbursed at the same rate as in-person services.
Beyond the flexible telehealth policies provided by state Medicaid programs, states are demonstrating commitment to telehealth services by announcing their own investments into telehealth offerings. For example, Minnesota’s Department of Health released a report in June 2023 detailing how telehealth services have filled in the gaps of healthcare access and delivery. Other states, like Ohio and New Mexico, are expanding broadband access to remove the technological barriers to telehealth access. Ohio is concentrating its broadband expansion efforts to providing telehealth access to K-12 students and Governor Grisham of New Mexico recently announced that a part of the state’s $675 million federal grant to expand broadband access throughout the state will be allocated to improving access to telehealth services. In March 2023, Governor Roy Cooper of North Carolina issued a $1 billion investment plan to address the state’s mental health and substance use crisis, which includes $225 million for raising Medicaid reimbursement rates for behavioral health services and allocates $50 million towards facilitating access to mental health treatment including through telehealth for rural communities.
Private payer action also offers valuable insight into the strength of the post-PHE telehealth market. Although private payers have always had the flexibility to determine coverage for telehealth services (within the boundaries set by law), their partnerships and newly added services demonstrate commitment to coverage and reimbursement for telehealth services. For example, BlueCross BlueShield of Massachusetts’s expanded network of mental health providers recently expanded its mental health network include telehealth partners with Headway and Talkiatry, (and has correspondingly increased its mental health spend from $610 million in 2019 to $1.3 billion in 2022). Aetna provides its members access to CVS Health Virtual Primary Care, which expanded this year to include telehealth mental health care appointments with licensed therapists and psychiatrists. Similarly, Humana continues to grow its mental health telehealth platform with the addition of Array Behavioral Care in February 2022 and Valera Health in July 2023 as in-network providers.
Notwithstanding the end of PHEs and corresponding loss in many waivers and policies that allowed for increased telehealth adoption during the pandemic, the recent actions of state governments and private payers indicate that interest in telehealth remains strong. We therefore expect investor interest in telehealth providers and technology to similarly stay strong as economic headwinds recede.
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Eating disorders often start at a younger age, but they don’t solely affect this population. Recognizing this, virtual eating disorder support company Equip announced Tuesday that it is now treating adults as well as adolescents. The company also announced an investment from General Catalyst, which helped expand its platform to adults. The amount was not disclosed.
“There is a very pervasive, really dense stereotype that eating disorders only affect 15- to 25-year-old thin, White girls,” said Dr. Erin Parks, chief clinical officer and co-founder of Equip, in an interview. “That is true, it does affect them. But it is not only them.”
She added that because so few people have access to treatment, many older adults have had their eating disorder for a very long time and need support.
San Diego-based Equip, which was founded in 2019, previously focused on those ages 6 to 24. The startup is now expanding to serve people of all ages. The virtual company operates in all 50 states and is in-network with several insurance companies, including Aetna, Elevance, Optum, Cigna and UnitedHealthcare. It connects patients with a care team that includes a therapist, dietitian, physician and peer and family mentor.
Different ages require different kinds of treatment, according to Parks. With its younger patients, the company uses family-based treatment, in which the family is brought in to help care for the patient. For adults, the company is using a method called enhanced cognitive behavioral therapy, which is a highly individualized treatment that addresses thoughts, feelings and behaviors affecting the patient’s eating disorder.
Parks said that when it comes to adults, individual treatment is often the best way to go because they may not have a support group. Sometimes when adults have been sick for a long time, they’ve “pushed away” a lot of their family and peers, or they may be too busy with work to build that support group.
There are other virtual solutions for eating disorders as well, including Arise and Within. Arise offers coaching with a care advocate who has lived experience with an eating disorder, therapy, nutrition counseling, group support and psychiatry. Within provides access to a care team that includes dietitians, therapists, nurses and peers.
The expansion to adults was powered by a recent investment by General Catalyst. In total, Equip has raised more than $75 million. With the funding, the company brought on a new president, Nikia Bergan. It also updated its technology and trained its providers in treating adults. In addition, it’s planning to use the funding to gain more Medicaid contracts, Parks said.
Equip considers itself an alternative to brick-and-mortar eating disorder treatments, which often require patients to stay at the treatment facility for a certain period. Parks said the benefit of a virtual program is that patients can be treated as they live their normal lives.
“[If you take] someone out of their life and give them a bunch of skills, then all of the sudden they plop back into their life and have all these triggers that they aren’t equipped to deal with,” Parks argued. “One of the great things about getting treatment while still being able to go to school, still being able to go to your job, still being able to parent your kids, is that you get to work with your providers on your real-life triggers as they come up.”
Parks is likely looking to replicate the positive results it claims to have achieved in the adolescent population in this new, adult population. In its annual outcomes report published earlier this year, the company cited that 81% of its adolescent patients reached or maintained their target weight within one year.
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The commercial market has been slower to adopt value-based care than the public market, but there are ways to move the process along successfully, executives said Monday.
During a panel at the Oliver Wyman Health Innovation Summit 2023 held in Chicago, healthcare leaders discussed the challenges and opportunities in advancing value-based care in commercial health plans. The panelists were Mark Hansberry, senior vice president and chief marketing officer of HealthPartners; Ellen Kelsay, president and CEO of Business Group on Health; and Tiffany Albert, senior vice president of health plan business at Blue Cross Blue Shield of Michigan.
Bloomington, Minnesota-based HealthPartners, which is an integrated healthcare organization serving more than 1.8 million members, has had some success with value-based care in the commercial space, Hansberry claimed. He shared five rules for scaling value-based care in the commercial market:
1. Payers and providers in a value-based arrangement need to have a shared understanding of what value is for patients, Hansberry said.
“You have to have a universal definition of what value means so that when clinicians look at you as a payer … they need to acknowledge that what you’re saying a clinical outcome is is actually a good clinical outcome, a good measure of performance,” he stated.
2. It’s important to ensure that the providers in the value-based arrangement are able to and willing to take the risk associated with value-based care.
“Most care systems weren’t built to actually manage risk,” Hansberry said. “That wasn’t their job. Their job was to take care of sick people. Now we’re asking them to do something else. How do you actually support those individuals on that journey?”
3. Payers need to support providers engaging in value-based care with “real-time, actionable data and consultation,” Hansberry said.
“It’s not just a data dump or a big Excel file that you pass over and you say good luck with it,” he stated. “Because, by the way, if they perform well in those value-based contracts, you do too as a payer. You want them to perform well. So you want to provide them with good, insightful, actionable data that’s risk-adjusted, that is connected to their practice — not just an amorphous health system — but to their practice so they can take action on those insights. But then you also want to supplement that with that consultation along the way.”
4. The incentives in the value-based contract must be aligned to “enable that [provider] to reap the benefits of the value that they’re creating for those members,” according to Hansberry.
5. Ultimately, a value-based contract comes down to trust between all the parties. But Hansberry noted that this is easier for HealthPartners as an integrated health system.
“We’re fortunate because we’re both a health plan and a care system,” he said.
He added that success in value-based care doesn’t happen overnight, which is partially why it’s difficult to scale.
“It takes time to build trust,” Hansberry stated.
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It’s no secret that hospitals and health systems have been facing severe financial woes in the past couple years. These money problems have forced many providers to make what they likely felt were tough but necessary choices — such as shuttering underperforming service lines, laying off staff and using debt collection agencies to obtain payment from patients.
Some of these tactics have even invited negative scrutiny
. However, a new report argued that commercial payers should shoulder some of the blame when it comes to how hospitals are managing their dire financial circumstances.
Compared to government payers, commercial payers take significantly longer to pay hospitals and deny claims at a higher frequency — often without a justifiable reason to do so — according to the report published by consulting firm Crowe. These delays mean that hospitals are waiting longer than they need to receive commercial payments — during a time when they need cash flow to be expedited, not needlessly delayed, the report said.
Crowe analyzed data from the more than 1,800 hospitals that use its revenue cycle analytics platform and found that about 45% of a typical hospital’s patient population is covered by a commercial health insurance carrier.
Commercially insured patients have conventionally been thought of as hospitals’ preferred population. This is because hospitals can negotiate prices with commercial payers, and these payers usually pay higher rates than government payers like Medicare and Medicaid. For the average net revenue per inpatient case, commercial plans pay $18,156.50 compared to $14,887.10 from Medicare. For outpatients, commercial plans pay $1,606.86 for the average patient case, compared to $707.30 paid by Medicare.
Reimbursement rates may be higher among commercial payers, but getting them to pay in a timely manner is an entirely different story, per the report. During the first quarter of this year, commercial payers initially denied 15.1% of inpatient and outpatient claims compared to 3.9% for Medicare over the same period, according to the report.
Crowe analyzed the claim denial category of prior authorization and precertification denials. These occur when a payer denies a claim based on their decision that a provider did not get prior approval for care before it was delivered or that the care rendered wasn’t necessary based on the patient’s medical diagnosis.
Last year, the prior authorization/precertification denial rate for inpatient claims among commercial payers was 2.8%, up from 2.4% in 2021. This rate increased to 3% during the first three months of 2023, but the denial rate for traditional Medicare was just 0.2% during the same period.
Another claim denial category that the report examined is the request for information (RFI). RFI denials happen when a payer decides not to process a claim because it is missing some type of required documentation, such as a signature or copy of the medical record. In this category, commercial payers’ denial rate is 12 times higher than Medicare, the report found.
Most of the claims that commercial payers deny eventually get paid. However, the administrative effort required for hospitals to turn an initially-denied claim into a payment costs a good deal of time and money — two things in short supply at hospitals
To obtain payment from a denied claim, a provider must investigate the claim, determine what they have to do to rectify the problem and resubmit the claim — a process that can take weeks — said Colleen Hall, the managing principal for Crowe’s healthcare consulting group, in a recent interview. This process creates “an aging accounts receivable situation” for the provider and delays them from receiving much-needed cash.
“There certainly are several for-profit insurers out there. I won’t name names, but I think that those for-profit entities are in direct conflict with the nonprofit hospitals. I don’t know what goes on in the for-profit payer side of things, but could there be actions that they’re deploying to delay payments? Potentially. There have certainly been denials that our clients, as providers, have to manage only to find were denied for no reason,” Hall declared.
In the first quarter of this year, about a third of the claims that providers submitted to commercial payers took more than three months to get paid, the report found.
It’s difficult for hospitals to gain steady financial footing when the payers that have the best reimbursement rates are holding onto a third of their claims payments for more than 90 days, Hall pointed out.
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Oshi Health — a virtual care provider for patients with digestive disorders — announced its first contract with a commercial insurer on Thursday. The New York-based company has entered into a value-based contract that provides Aetna members with in-network access to its specialized treatment.
Founded in 2019, Oshi built a virtual-first care platform designed to help patients achieve lasting control over chronic digestive conditions. The company hires gastroenterologists, nurse practitioners, dieticians and GI-specialized behavioral healthcare providers to quickly reach a diagnosis and guide individualized treatment. Patients are also assigned a care coordinator, who can help them find in-network providers if they need services like a colonoscopy or endoscopy.
The startup prides itself on providing whole-person care, which includes often-neglected dietary and psychosocial interventions, Oshi CEO Sam Holliday said in a recent interview.
“Over the past decade, there’s been a recognition that many gastrointestinal disorders are actually triggered by the signaling between your gut and your brain. A whole class of GI conditions has actually been renamed as disorders of the gut-brain interaction, or DGBIs,” he explained. “Things like gut-directed cognitive behavioral therapy can really reframe patients’ thought patterns and dampen the brain signaling that causes their symptoms, making symptoms feel less severe.”
Dietary interventions and behavioral therapy are proven methods to alleviate GI patients’ symptoms, and they’re often more effective than medication, Holliday pointed out. But these services are rarely available to GI patients because they haven’t been reimbursed historically, he added.
That’s why these interventions are a core part of the care patients receive under Oshi’s new contract with Aetna.
“One of the challenges in GI is that there aren’t very good quality measures. Really, the main things we focus on as a country is getting people screened for colorectal cancer, But we don’t really have measures for what matters to patients, who are the people suffering. What we think is the best measure to use is symptom control,” Holliday explained.
The root cause of GI symptoms usually stems from dietary or behavioral health reasons, and traditional, medication-centric GI care does not address those underlying causes, he declared. Patients end up continually seeking care — and driving costs up — because their symptoms are still bothering them. Through Oshi’s value-based contract with Aetna, “the value aspect being measured is Oshi’s ability to reduce that utilization downstream,” Holliday said.
Oshi will measure its care teams’ ability to sustainably control patients’ symptoms through a mix of medication, dietary adjustments and gut-brain psychology interventions. The company will track metrics such as reductions in emergency department visits and patients’ reported symptoms.
“We get paid a certain amount as we’re providing the care. Then, if we’ve gotten to a good level of patient satisfaction, symptom control and reduced utilization at the end of the measurement period, we have a bonus opportunity. And if we don’t achieve certain levels, there is a downside,” Holliday explained.
Aetna shares in the upside if Oshi hits its goals, but the payer is protected against potential downside. If Oshi doesn’t achieve as good outcomes as the partners had hoped, Aetna won’t have to pay the startup the full amount for care, Holliday declared.
The partnership is in its first phase, meaning Aetna members can access Oshi’s services in the following six states: Florida, Maine, Massachusetts, Ohio, Pennsylvania and Texas.
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Paragonix Technologies — a company that launched in 2010 as a response to the lack of innovation in the donor organ preservation and transport process — closed a Series B funding round on Tuesday. The $24 million round was led by Signet Healthcare Partners.
The Cambridge, Massachusetts-based company provides transplant centers and organ procurement organizations (OPOs) with medical devices designed for the preservation and transportation of donor organs.
The traditional method of preservation requires the organ to be transported in a cooler of crushed ice. Due to unstable temperatures, many facilities that receive organs preserved in this manner report that they arrive frozen and damaged, said Paragonix CEO Lisa Anderson.
“Paragonix determined there was an opportunity for a more scientifically reproducible, measurable and reliable solution to transporting an organ from a donor to recipient,” she said. “We set out to create a new standard for organ preservation and transport that would provide the care and quality of handling commensurate with transporting such a valuable gift and improve patient outcomes worldwide.”
Paragonix’s devices are made from a series of interconnected systems that work together to provide a cool and sterile environment within a consistent range of 4-8° Celsius. The company sells three devices, each designed for a different organ (heart, lung and liver). All have been cleared by the Food and Drug Administration.
Each device works slightly differently based on specific user needs related to the organ type, Anderson said. For example, the heart preservation device has pouches filled with proprietary cooling solutions that keep the organ at optimal temperatures during transport. The heart is contained within a nested canister and is then housed in a wheeled shipper container that works to protect and insulate the inner contents.
All of Paragonix’s devices display the organ’s temperature while it is being transported. They also use bluetooth monitoring and tracking technology to allow surgeons to track the organ’s exact location throughout its journey, even in flight, Anderson pointed out.
Paragonix markets and sells its devices to transplant centers and OPOs across the U.S. and Europe. Last year, over one in five thoracic donor organs transplanted in the U.S. were preserved using a Paragonix device, Anderson declared. She also said that 19 out of the 30 largest U.S. heart transplant programs rely on Paragonix devices to safely preserve, track and transport organs to their intended recipients.
“Most other organ preservation devices are extremely complicated, labor intensive and require special personal or extensive training, while Paragonix’s devices are lightweight, user friendly, and a user can be trained in less than an hour,” she declared.
Anderson explained that her company’s main competition is the legacy way of transporting organs, as many organizations still receive damaged organs that were transported using the over-ice method. The medical industry needs to move away from this method of organ preservation because devices like the ones that Paragonix sells are clinically proven to improve patient outcomes and reduce the risk of post-surgical complications, she declared.
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The American Hospital Association (AHA) survey, released Wednesday, found that 78% of hospitals and health systems said their relationship with commercial insurers is getting worse. Less than 1% said their relationship is improving and the rest said it has stayed the same.
The survey included 304 respondents representing 772 hospitals. All of the respondents are members of AHA.
One of the main culprits behind the worsening relationship appears to be certain practices of commercial insurers, such as prior authorization. The report found that 95% of hospitals and health systems said staff time spent seeking prior authorization approval is increasing. Meanwhile, 62% of prior authorization denials are eventually overturned, the report found.
Aside from time spent on administrative procedures, costs may also be a factor in the relationship souring. A whopping 84% said the cost of complying with insurer policies is also increasing.
“Misuse of utilization management tools like prior authorization has several negative implications for patients and the health care system,” AHA said in the report. “Prior authorization denials can result in delays of necessary treatment for patients and ultimately lead to unexpected medical bills. The extensive approval process that doctors and nurses must go through adds wasted dollars to the health care system through overuse of prior authorization, inefficient submission processes, excessive requests for unnecessary documentation and the need to reprocess inappropriate payment and coverage denials.”
AHA also takes issue with claims denials, stating that commercial health insurers are “increasingly delaying and denying coverage of medically necessary care.” However, 50% of claims denials that are appealed are overturned, AHA said.
There are financial consequences to these delays and denials, AHA stated. The survey found that 50% of hospitals have more than $100 million in accounts receivable for claims that are older than six months, totaling $6.4 billion in delayed or potentially unpaid claims among the 772 hospitals in the survey. Another 35% of respondents said they’ve lost $50 million or more in revenue because of denied claims.
“These payment delays and denials for medically necessary care have serious implications for the financial stability of health care providers and compound fiscal challenges plaguing our health care system,” AHA said.
The report also provided several policy recommendations, including streamlining the prior authorization process and increasing oversight on insurers. Additionally, the organization sent a letter to the Department of Health and Human Services and the Department of Labor, calling for action against commercial payers.
“Health care coverage must work better for patients and the providers who care for them. We urge you to take additional steps to ensure adequate oversight of commercial health plans, including those offering Medicare Advantage plans, this open enrollment season,” the letter stated. “Individuals and families should feel assured that the plan they choose during open enrollment will actually be there for them when they need care.”
America’s Health Insurance Plans (AHIP) declined to comment publicly on AHA’s survey, but previously told MedCity News that commercial insurers’ practices are needed to reduce expenses for patients.
“Health insurance providers advocate for the people they serve by ensuring that the right care is delivered at the right time in the right setting — and covered at a cost that patients can afford. Prior authorization prevents waste and improves affordability for patients, consumers, and employers,” Kristine Grow, AHIP spokesperson, previously said. “Health insurance providers have a comprehensive view of the health care system and each patient’s medical claims history and work to ensure that medications or treatments prescribed by clinicians are safe, effective, and affordable for patients. This results in better outcomes and lower costs for patients.”
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