T he opioid epidemic claimed over 47,000 American lives in 2017,1 with a total economic cost of over $78 billion in 2013. 2 Medication-assisted treatment (MAT) combines the use of FDA-approved medications — methadone, buprenorphine, and naltrexone — with behavioral therapy and is recognized as the most effec- tive treatment method for lasting recovery from opioid use disorder (OUD). The Innovation Opportunity The widespread adoption of MAT is hampered by a number of systemic barriers. The most notable difficulty is the significant shortage of authorized prescribers for these medications caused by regulatory hurdles requir- ing a license to prescribe, limits on patient panel sizes for buprenorphine prescribers, and reimbursement limi- tations. As a result, access to this life-saving treatment is limited. Telehealth offers a promising approach to reducing bar- riers to access to MAT. This brief provides an overview of telehealth for MAT. Eleven interviews were conducted with 11 organizations directly offering telehealth services nationally. Many are not yet expanding into MAT. Others are part of a developing, but nascent, telehealth MAT environment. Complex Regulatory Environment Evidence shows that using telehealth to deliver MAT is an effective alternative to in-person treatment and is grow- ing in acceptance and demand across the US. Still, the regulatory and reimbursement environment is complex, and barriers hinder widespread adoption of telehealth for MAT. At the federal level, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 requires an initial face-to-face encounter between prescriber and patient, followed by an additional in-person visit at least every 24 months. 3 In 2016, the 21st Century Cures Act directed changes to this law to drop the barrier of in-person visits. 4 But at the time of publication, the Drug Enforcement Administration has yet to issue the needed regulations to implement this change, leaving physicians justifiably concerned about violating federal law in their provision of telehealth-based MAT services. At the state level, broad adoption — particularly by Medicaid provid- ers — is limited by complex and often unclear policies around what specific services are covered and by which entities. For more context, see “Opportunities and Challenges to Utilizing Telehealth Technologies in the Provision of MAT in the Medi-Cal Program.” 5 Despite these barriers, there has been incremental progress to expand the use of telehealth MAT. A few forward-thinking states have adopted regulations to expand its use. Maryland explicitly covers telehealth for the prescribing of buprenorphine,6 and Wisconsin has been covering substance use disorder services deliv- ered via telehealth in its fee-for-service program since 2004. In California, reimbursement remains fragmented and regional overall. But specific programs like the Drug Medi-Cal Organized Delivery System and the hub-and- spoke system 7 provide funding to increase the number of buprenorphine-prescribing clinicians and the flexibility to create new models of care that may include telehealth MAT programs. Outside of Medicaid, commercial health plans in California and elsewhere across the nation are increasingly covering MAT delivered through telehealth. Telehealth MAT INNOVATION LANDSCAPE SERIES ST Advisors Outsider Perspective with Insider Knowledge® About the Author With extensive experience in equity research, corporate strategy, and investment banking, ST Advisors is a bou- tique consulting firm providing its strategic and financial advisory expertise to health care IT and services firms, as well as to investors in those sectors. JUNE 20192 California Health Care Foundationwww.chcf.org $$ Telepsychiatry providers adding MAT services. These companies, such as Genoa Healthcare (acquired by UnitedHealth in 2018), Regroup, and e-Psychiatry, have different models. Some provide a network of independently contracted physicians and other mental health professionals and offer a broad array of outsourced psychiatric services, with MAT being just one. Others have individual remote psychiatrists who can partner with local PCPs. In these cases, the psychiatrists provide the MAT expertise, while the buprenorphine-waivered PCPs write the prescription under their state and DEA licenses. $$ University-focused pilots. This research identified a handful of university pilot programs throughout the US. These tend to be state-based only (none found were in California), with the pilots primar- ily funded through grants, making scalability and longevity a concern. Although identified as pro- viding telehealth MAT, these organizations were not a focus of this landscape. Some examples include the Medical University of South Carolina, University of Maryland School of Medicine, and West Virginia University. Telehealth for MAT as a tool to address the opioid addiction is an emerging frontier. While regulations and reimbursement remain challenges and have histori- cally restricted the ability to provide MAT via telehealth, the crushing weight of the opioid epidemic is creating momentum across the country to remove these barriers. The nascent market of telehealth MAT provides a new care delivery model for OUD treatment. The 11 organizations presented on page 3 were identi- fied as either providing telehealth MAT services currently or planning to. This is not intended to be a compre- hensive list of organizations providing telehealth MAT. Rather, the goal was to give a sense of how this market is shaping up and the types of organizations stepping up to address this unmet need. For more information, please see Table 1 (page 4) or contact each organization directly. The Solutions Landscape Most health systems, health services organizations, and brick-and-mortar addiction treatment organizations are not yet expanding into telehealth MAT. While the benefits of telehealth for MAT are well recognized, it’s often not a high-priority business area for these organizations. The existing market opportunities they see in their core busi- ness outweigh the risk of entering this complex regulatory environment. For example, Teladoc, the nation’s largest general telemedicine provider, does not prescribe Drug Enforcement Agency–controlled medications (e.g., opi- oids, sedatives, or buprenorphine) through its platform. One health system that serves large rural areas and offers in-person substance use treatment had no concrete plans to provide telehealth MAT services, choosing instead to focus its emerging telehealth initiatives on marketing teletherapy directly to significantly lower acuity patients. A large multisite treatment center thought it had enough volume with its existing traditional programs, using tele- health MAT only for a pilot program with incarcerated patients, a program that has since ended. The handful of organizations nationally that have embraced telehealth for MAT typically take a technology- first approach and are in effect betting that regulations and reimbursement policies are on the cusp of change. They are racing to be among the first movers in tele- health MAT. The organizations evaluated fell into three categories: $$ Addiction or MAT-specific telehealth providers. Recognizing the need and opportunity, a number of early-stage start-ups have sprung up. These companies have taken several approaches to staff- ing, ranging from full-time hires to independent contractor relationships with prescribing provid- ers. Several of these companies are working with existing providers, such as primary care providers (PCPs), to provide a virtual wraparound service and support providers in treating patients with OUD. Other emerging addiction treatment companies like Groups offer face-to-face outpatient services with telehealth for prescribing and have started to expand their care models to include more tele- health for MAT directly to patients. 3 Telehealth MATwww.chcf.org Telepsychiatry Providers Adding MAT Services Addiction or MAT-Specific Telehealth Providers4 California Health Care Foundationwww.chcf.org Table 1. Organizations Providing Telehealth MAT Services – Current or Pending, SERVICES OFFEREDKEY CUSTOMERS YEAR FOUNDEDSTATESPAYMENT*MEDICAID Telepsychiatry Providers Adding MAT Services e-Psychiatry www.e-psychiatry.com General telepsychiatry Health care facilities — currently provides outsourced telepsychiatry to complementing medical care. Direct to consumers and payers — provides direct treatment to patients and requires a yearly in-person visit. 2007NationalVendor bills health care facil- ities for blocks of provider time. Self-pay and accepts some insurance. Depends on the needs of the health facility purchasing services. Genoa Healthcare (subsidiary of UnitedHealthcare) www.genoatelepsychiatry.com General telepsychiatry Health care facilities — currently provides outsourced telepsychiatry to complementing medical care; will add telehealth MAT by 2020. 2000NationalVendor bills health care facil- ities for blocks of provider time. Depends on the needs of the health facility purchasing services. Piedmont Behavioral Services www.piedmontbs.com General psychiatry, including telepsychiatry Health care facilities — provides outsourced telepsychiatry services to complement medical care at health facility. Direct to consumers and payers — provide direct treatment to patients, both in person and virtually. NRCA, FL, NC, NY, TX, VA, WV Self-pay and accepts most major insurance. NR Regroup www.regrouptelehealth.com General telepsychiatry Health care facilities — currently provides outsourced telepsychiatry to complementing medical care; will add telehealth MAT by 2020. 2011AK, AL, AR, AZ, CA, CO, IL, IN, MI, NC, NY, OH, OR, PA, SC, TN, TX, WA, WI, WV Vendor bills health care facil- ities for blocks of provider time. Depends on the needs of the health facility purchasing services. Addiction or MAT-Specific Telehealth Providers Bicycle Health www.bicyclehealth.com OUD treatment, virtual MAT Direct to consumers — provides direct treatment to patients, requires initial in-person visit. 2017CASelf-pay and accepts some insurance. Medi-Cal pending. Boulder Care www.boulder.care OUD treatment, virtual MAT Payers — provides direct treatment to patients. Currently partnering with provider partners to do prescribing, which includes in-person visits. Plans to offer fully virtual care once legal to do so. 2018NH, ORSelf-pay and accepts some insurance. Medicaid in OR. * Payment models are still evolving in many cases. Several of these organizations are participating in local hub-and-spoke programs, enabling them to receive grant funding for the care of patients participating in these programs regardless of their ability to pay. Note: NR is not reported.5 Telehealth MATwww.chcf.org Table 1. Organizations Providing Telehealth MAT Services – Current or Pending, continued SERVICES OFFEREDKEY CUSTOMERS YEAR FOUNDEDSTATESPAYMENT*MEDICAID Addiction or MAT-Specific Telehealth Providers, continued Bright Heart Health www.brighthearthealth.com Addiction (opioids, tobacco, alcohol) treatment, and pain management; all virtual services Direct to consumers and payers — provides direct treatment to patients, requires initial in-person visit. Also partners with health systems (especially emergency departments) and payers as a refer- ral base for initial and ongoing care. 201530 states, includ- ing CA Self-pay and accepts most commercial insurance, Medicare, and Medicaid. Medi-Cal Groups www.joingroups.com OUD treatment, delivered in person and supplemented with digital tools Direct to consumers and payers — direct treat- ment, currently in person only (with virtual prescrib- ing). Currently piloting telehealth MAT in CA; will add by 2020. 2014CA, IN, ME, MI, NC, NH, OK, WV Self-pay and accepts some insurance. Medicaid in ME and NH. Medicaid pending in all other current states. PursueCare www.pursuecare.com OUD treatment, virtual MAT, and mail-order pharmacy services Health facilities — managed service organization providing supportive services to organizations that want to create addiction treatment programs for patients. Direct to consumers — direct treatment, includes prescribing, counseling, and mail-order pharmacy. 2018CT, KY, ME, NH, VT, WV; national expan- sion antici- pated Vendor contracts with health facility for a set of services that enable the health facil- ity to provide telehealth MAT. Self-pay and accepts or will accept most major insurance. Medicaid in KY and WV start- ing 7/1/2019. Medicaid pending in ME and VT. Thrivee www.thrivee.com OUD treatment, virtual Direct to consumers and commercial payers — provides direct treatment to patients, requires initial in-person visit. Exploring an outsourced model to work with providers and health care facilities. 2018NY Coming to: CT, FL, IN, KY, MI, NH, NJ, OH Self-pay, and accepts some insurance. Not currently, will be offering services to commercial Medicaid. WorkIt Health www.workithealth.com Addiction treatment (opioid and alcohol use disorder), virtual Direct to consumers, commercial payers, and employers — provides direct treatment to patients, requires one in-person visit. 2014CA, MISelf-pay and accepts some insurance. Medicaid in MI. Medi-Cal pending. * Payment models are still evolving in many cases. Several of these organizations are participating in local hub-and-spoke programs, enabling them to receive grant funding for the care of patients participating in these programs regardless of their ability to pay.6 California Health Care Foundationwww.chcf.org Endnotes 1. Lawrence Scholl et al., “Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017,” Morbidity and Mortality Weekly Report (MMWR), Jan. 4, 2019, 67(5152):1419–1427, dx.doi.org. 2. Curtis S. Florence et al., “The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013,” Medical Care 54, no. 10 (Oct. 2016): 901–6, doi:10.1097/ MLR.0000000000000625. 3. Ryan Haight Online Pharmacy Consumer Protection Act of 2008, H.R. 6353, 110th Congress (2008), www.govtrack.us. 4. 21th Century Cures Act, H.R. 34, 114th Congress (2016), www.govtrack.us. 5. Opportunities and Challenges to Utilizing Telehealth Technologies in the Provision of Medication Assisted Therapies in the Medi-Cal Program, Center for Connected Health Policy, June 2018, www.cchpca.org (PDF) . 6. “Drug Medi-Cal Organized Delivery System,” California Dept. of Health Care Services, last modified April 17, 2019, www.dhcs.ca.gov . 7. “CA Hub and Spoke System: MAT Expansion Project,” UCLA Integrated Substance Abuse Programs, www.uclaisap.org. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemak- ers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org . About the Innovation Landscape Series As part of its efforts to help promising products and services succeed and scale in California’s safety net, the CHCF Health Innovation Fund conducts high-level landscape analyses of issue areas espe- cially ripe for tech-enabled innovation. The Fund publicizes the findings of these landscape analyses to inform other funders and customers seeking scalable solutions to challenges in the safety net. Readers should note that these reports are not intended to be exhaustive, nor are they endorse- ments of the companies included in them. Finally, because solutions landscapes can evolve quickly, these reports may not fully reflect the current market. www.chcf.org/innovationfundNext >