The federal government has extended COVID-era telehealth flexibilities twice since their implementation. Those flexibilities will now expire in December 2024, putting “life-saving” care at risk, behavioral health industry insiders warn.

Some substance use disorder (SUD) providers are currently planning to adapt their clinical models if flexibility is not available, partnering with local organizations or hiring clinicians who are willing to travel for in-person appointments.

“Telehealth care makes it easier to start treatment and is effective at keeping people in treatment,” said Gil Kochman, CEO of Workit Health, in an email to Addiction Treatment Business. “If these flexibilities are eliminated, the industry as a whole will lose its ability to reach a portion of the population that does not want or feel like they need in-person help.”

Ann Arbor, Michigan-based Workit offers virtual treatment for opioid use disorder (OUD) and alcohol use disorder using medication-assisted treatment (MAT), shared medical appointments and peer support. Before introducing these flexibilities, the provider saw patients in person at one of the company’s brick-and-mortar clinics before continuing care online.

When COVID-era flexibility rules eliminated the need for in-person visits, Workit patients who lived in rural areas or faced barriers to care for other reasons benefited “tremendously,” Kochman said.

What is at stake

The flexibility of telemedicine in the COVID era has dramatically improved access to MAT for SUDs, particularly for vulnerable populations.

Before the DEA implemented telehealth flexibility, virtual behavioral health provider Better Life Partners was able to connect most of its patients to buprenorphine treatment within two days while experiencing a treatment discontinuation rate of about 25%, according to Dr. David de Gijsel, the company’s top health official.

Better Life Partners provides mental health care and care coordination, as well as SUD treatment, to treatment providers, community organizations, and public health organizations, including Acadia Healthcare (Nasdaq: ACHC), Crossroads, and the New Hampshire Harm Reduction Coalition. In August 2023, Better Life Partners raised $26.5 million.

After the flexibility measures were introduced, Better Life Partners was able to start treating patients with buprenorphine within four hours. Almost 100% of the patients who come to us receive the treatment, Gijsel said.

Virtual SUD treatment eliminates some traditional barriers to treatment, including transportation, cost, time away from work, and child care—factors most likely to affect patients from rural areas or low-income areas. The private nature of a telehealth appointment can also benefit patients who struggle with stigma.

Virtual treatment also benefits people experiencing domestic violence, Gijsel said. Substance abuse is common in this population, and virtual treatment makes care more accessible for people with controlling partners.

The flexibility of telemedicine has also allowed SUD companies to grow quickly. Virtual care is also a “very scalable” business model, Kochman said.

“We’ve seen both positive and negative impacts of scalability over the past few years,” he said. “It’s easier than ever to get access to healthcare, but some companies have chosen to sacrifice quality and focus on rapid growth.”

An analysis published in April found that the virtual SUD treatment industry represents a market potential of well over $10 billion.

While the flexibility of telemedicine has expanded access and facilitated business growth, some providers question the wisdom of fully virtual prescribing models.

“It’s hard to get the spirit back into the model, but there have to be reasonable parameters in place,” Lee Dilworth, president and CEO of ReVIDA Recovery, told ATB. “Patients need to be seen in person from time to time, they need to get comprehensive care, which is difficult to do consistently and well in a pure telemedicine model.”

Nashville, Tennessee-based ReVIDA operates nine OUD facilities in Tennessee and Virginia, according to its website. Founded in 2019, the provider offers comprehensive care through medication-assisted treatment and individual and group therapy.

Increased access to MAT brings with it the risk of drug abuse, Dr. Steven Pratt, chief medical officer for employers at Magellan Healthcare, told ATB in an email. Drug abuse occurs when a patient takes a drug for a reason other than the one prescribed, or when someone other than the intended person takes the drug.

“Buprenorphine does have abuse potential,” Pratt said. “Easier access could lead to more abuse. (But) it appears that abuse is no longer a major problem under the relaxed regulations.”

Magellan Healthcare, based in Frisco, Texas, is a subsidiary of Magellan Health, a health insurance provider and provider of mental health and other services.

In-person care typically benefits most people, Gijsel said, and may be necessary in certain situations, such as administering injectable buprenorphine or conducting a health screening.

Some patients may not benefit from meeting with their doctor in person or simply do not want to, he said.

“Does it make sense to force these people to do something that doesn’t work for them and threaten them that a life-saving drug will be withdrawn if they don’t comply? No, that doesn’t make sense,” Gijsel said. “At least from a harm reduction perspective, it doesn’t make sense, but I think even from a ‘I want you to get the very best care’ perspective, it doesn’t make sense.”

Prepared for impact

If the DEA does indeed roll back Covid-era prescribing flexibility, providers and payers “would need months to plan how to get patients to providers who could perform an in-person exam before prescribing,” Pratt said.

Some SUD providers are planning early and developing strategies that could guide them through the adaptation process.

According to Dr. Suzette Glasner, the company’s chief scientific officer, Pelago has actively prepared for different scenarios and developed a hybrid model to prepare for possible requirements for in-person visits.

Pelago provides virtual care to patients with tobacco, alcohol, opioid and cannabis use disorders using cognitive behavioral therapy, motivational enhancement therapy and contingency management. The provider raised $58 million in a Series C funding round in March.

“At Pelago, when we hire physicians to prescribe medications, we ensure they are willing to travel to meet the necessary requirements and prerequisites for in-person visits,” Glasner said.

Some states where Pelago already operates currently require in-person visits, Glasner said, so the company has already established processes for in-person visits and identified facilities where its providers can see patients in person. The provider plans to roll out those processes in other states as needed.

Providers that operate some in-person facilities may be better prepared for potential in-person appointment requirements.

“Although we are now 100% virtual, we have always maintained a physical presence in every state we operate in,” Kochman said. “We have been monitoring this change for some time and are preparing for it. We have assembled a cross-functional working group that has developed plans based on several possible scenarios.”

The biggest challenge with these plans is uncertainty, Kochman said, which required Workit to prepare for several potential possibilities. The vendor has installed safeguards, including physical clinic locations and partnerships with local providers, to minimize disruptions to patient care

Better Life Partners is able to meet the demands of changing regulations without additional planning, Gijsel said. The provider has expanded its in-person offerings since the peak of the pandemic passed.

“We are in a good position to switch to face-to-face teaching if necessary,” said Gijsel.

Better Life Partners has evolved its technology and increased its community presence and number of providers, making its business more efficient than before the COVID-era flexibility reform, Gijsel said.

While most SUD providers are developing contingency plans, industry leaders remain confident that the DEA will largely preserve flexibility in telehealth drug prescribing.