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Join Tamir Aldad, a physician executive. We’ll explore the rapid growth of telehealth, the impact of venture capital investments, and the concerning trend of overprescription of medications like Adderall and benzodiazepines. Discover the risks associated with this phenomenon and the steps needed to prioritize patient well-being over profit-driven motives in the telemental health care industry.

Tamir Aldad is a physician executive.

He discusses the KevinMD article, “Venture-backed telemental health care companies are creating a new opioid epidemic.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Tamir Aldad. He is a physician executive, and today’s KevinMD article is “Venture-backed telemental health care companies are creating a new opioid epidemic.” Tamir, welcome to the show.

Tamir Aldad: Thank you for having me.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Tamir Aldad: So I’m an addiction psychiatrist by training. After residency and fellowship I was a researcher for a long time, doing behavioral health research, and along the way I felt that access to care was an issue for patients, particularly having to wait six to eight weeks to see a psychiatrist, especially if they have managed Medicaid.

And I thought that was unfair. Patients that are at high risk to themselves and others shouldn’t have to wait six to eight weeks, and I wanted to do something about that. So I ended up opening the first ever psychiatric urgent care here in New York, and now we’ve scaled that to New York, New Jersey, Connecticut, Michigan, Illinois, and Florida. So an exciting journey, and one that has great social impact and a mission that I really believe in.

Kevin Pho: All right, so tell me more about what psychiatric urgent care is. What are typical cases that you would see?

Tamir Aldad: So the goal of psychiatric urgent care is to see patients that otherwise would be inappropriate for the emergency room. So we’re not trying to replace an emergency room, but what we saw even during training is that there are patients that have nowhere else to go and, as a last resort, end up in the emergency room, and then we have to tell them to wait.

So these are patients that have passive suicidal thoughts, passive homicidal thoughts, don’t meet criteria for inpatient hospitalization, but also they’re at risk. They don’t have protective factors, and you’re taking a gamble by sending them home. But since they didn’t meet criteria, that’s really all you could do.

And what we wanted to do is create an environment where we could actually start care sooner, do a more thorough risk assessment, be higher touch along the way over the course of 12 weeks, to prevent that hospitalization. So it’s better for the patient in terms of clinical outcomes, it’s better for the health care system from a total cost of care perspective. You’re saving the health care system millions of dollars that otherwise would be spent on patients that don’t belong in high acuity settings. So it’s a win-win all around, and that’s what we’re committed to with our execution.

Kevin Pho: So I think that, especially during the pandemic, and we’ll talk about access to behavioral health services, it is at a premium where I practice. It’s sometimes very difficult to see a behavioral health specialist, and it’s probably prevalent all across the country.

Your KevinMD article is titled “Venture-backed telemental health care companies are creating a new opioid epidemic.” For those that didn’t get a chance to read your article, tell us what it’s about.

Tamir Aldad: So as you kind of mentioned, the pandemic created a vacuum for behavioral health, and access to care was an issue and then became even more of an issue. So I think it was wise for individuals in business to see this as an opportunity. There’s a very large market share that could be captured there, with a strong demand and a willingness to pay. So the environment was very fertile to build a successful business, and that part makes sense.

But I think where we have to be careful is, a lot of these telehealth companies, even though superficially everything sounds great, and this is coming from someone who runs a fairly large telehealth company, the clinical integrity of the organization needs to be at the forefront, and clinical decision making needs to really lead the business, and not have business decision making dictate the clinical care.

So in the article I talk about how some of these companies are very aggressive when it comes to prescribing stimulants for the treatment of ADHD. And a lot of that is driven from the value of prescribing stimulants in terms of metrics and the business. And we see this when it comes to patients coming frequently. Very rarely will a patient miss a visit when they need their stimulant prescribed. So you have them coming every month consistently, their no-show rates are lower, they stay with you longer because they need their stimulants.

So what you’ve essentially created is a habit-forming scenario, similar to what you saw a couple of years ago with Purdue and opioids. Now, calling it out as a comparable parallel scenario is aggressive, it’s pretty bold, and I don’t think I would go as far as saying it’s identical. But the purpose of my article is to sound the alarm, that we don’t need to wait until it’s too late to say, wow, here we are again. We need to learn from what happened with the opioid epidemic, and watch all the documentaries that are out, and start identifying some of the early warning signs and learning from them.

So these companies, sure, from a business perspective a lot of these practices make sense, but they will come back and haunt us in the future if we have a generation who cannot function without stimulants. So that’s basically the main takeaway, that we need to be really cautious here.

Kevin Pho: So give us an example of such a scenario. How easy is it for someone to obtain a prescription for a stimulant using one of these companies?

Tamir Aldad: Yeah, so I wouldn’t call out an actual company, but I could tell you that, for example, at Mindful Care we don’t give controlled substances. And even though stimulants are first line in terms of best practices for ADHD, we try second line treatments first, because I’m an addiction psychiatrist, so I have quite an aversion to habit forming medication, and I used to be the medical director here, so I definitely take that very seriously. But I also feel that in an environment where we are very high volume, it might be a risk of overprescribing if we use controlled substances as first line.

So a scenario where in other organizations it’s more of a problem is the time that’s spent to make the diagnosis, and the training that some of these individuals have in making the diagnosis and prescribing. A lot of these organizations make the diagnosis clinically, and the clinicians are only given a short amount of time to spend with these patients, so the psychiatric evaluation isn’t as thorough as it would be somewhere else. And if you put that together, and some of them also have very liberal criteria to make the diagnosis, if you put all that together it’s really, really playing with fire.

So if you think, you have less time with the patient because you have to meet your quotas, you have criteria that isn’t very, very strict, so more often than not people will meet the criteria and you’ll comfortably give them the diagnosis, and you’ve created basically a setting where it favors the diagnosis and favors prescribing. And that’s where it’s a slippery slope.

You know, if you told me an organization sends everybody to psychological testing, and you have children coming with psychological testing supporting the diagnosis, and then you’re writing stimulants, I can get behind that. I think that makes a lot of sense to me. But if you’re doing 40-minute psych evals, you have to do 10 a day, and if more or less someone sounds like they have inattention, they get a script for a stimulant, that’s aggressive, and that’s where I’m sounding the alarm.

Kevin Pho: Now, through your lens as an addiction psychiatrist, tell us about the dangers to patients if they’re prescribed a stimulant when they may not for sure have a true diagnosis of ADHD, because of a shallow evaluation process.

Tamir Aldad: Yeah, I think my biggest concern is developing a dependency, and then a lack of appropriate development of coping skills, and skills in general.

So depending on where you are when you start the script, I think it’s different. But if your inattention, for example, is rooted in something else, and you’re not given the opportunity to overcome that and learn how to deal with that, and basically you’re given this artificial crutch, you effectively can’t function without that crutch moving forward. So I think early on you’ve lost the ability to develop a skill. And I think by design, you being inattentive in a certain situation was there for a reason, and navigating that is actually going to yield a better long-term sustainable outcome, but you’ve removed that from the equation. So early on, that’s where I’m most concerned.

And then later on when it comes to adulthood, I think if you give even somebody with no inattention a stimulant, they’ll become very productive more often than not, depending on how much you give them. But the issue there is, now you’ve created an individual who has a dependency. It’s habit forming. When they don’t take it they experience withdrawal symptoms, if they take too much they’ll have cardiac symptoms, and now you’re dealing with a substance use disorder as opposed to medication management. So it’s a whole cluster of symptoms now with, for example, amphetamine use disorder, and now you have to deal with that. And it’s become an iatrogenic problem. And that’s where we need to be responsible early, not wake up when it’s too late.

Kevin Pho: Now, is it primarily with stimulants that this is happening? What about other controlled substances, like benzodiazepines?

Tamir Aldad: Anecdotally, I think we’ve done a better job with benzos, even a lot of these behavioral health companies. And again, I don’t have data to support this, but from what I’ve seen, and we see 30,000 visits a month, so anecdotally is kind of significant here, but what we’re seeing is an aversion to use things like Xanax, short-acting benzos, moving more towards the Ativans, the Klonopins.

I think with benzos, what we’re seeing is primary care doctors are a lot more responsible, and I think also in behavioral health we’re seeing people being a lot more responsible, prescribing longer-acting benzos for shorter periods of time. So I’ll see people who only got a 10-day script to bridge them until an SSRI or an SNRI kicks in, which I think is appropriate. So I haven’t seen as much of the careless, liberal prescribing of benzos as I’m starting to see with stimulants.

Yes, same thing with sedative hypnotics. I haven’t seen the Ambiens and the Lunestas being prescribed to everyone who can’t sleep, whereas we’re seeing a lot of inappropriate diagnosing of ADHD, and that’s where we’re really concerned.

Kevin Pho: I remember reading in mainstream media, could be last year, the year before, where one of these companies came under investigation for this exact scenario that we’re talking about here, inappropriate or shallow evaluation and then prescribing online or over an app a stimulant. So despite all that mainstream attention that shed light on this issue, this is still going on, to your knowledge?

Tamir Aldad: Yeah, I would say that company’s one of our competitors, but I would say that there has been a correction. But my concern is that it’s not good enough. I think the correction is a start, but a lot of the damage has been done, and the correction needs to start with a major reeducation across the board.

And the way we’re scaling these companies, one thing I talk about in the article is, we need to share the framing of these venture capital-backed organizations with the venture capital fund, with the private equity fund, so they also realize the risk. And I’ve noticed, even when on the boards that I sit on and the companies that I consult for, when they understand that the company and organization should be very clinically sound, everything is healthy and trickles down in a way that is protective. If you start with analyzing the business just through dollars and cents, you’re playing with fire.

So even that organization that a couple of years ago was in hot water, I think we need to continue working towards educating, and making sure that we’re not pressuring anyone to behave in a way that short term might make sense but has long-term consequences.

Kevin Pho: So specific to the telemental health space today, in April of 2024, are you seeing more of these companies practice more clinically sound methods? Are there fewer organizations just seeing things from the perspective of dollars and cents, or through some type of venture capitalist business model? What’s the situation like today?

Tamir Aldad: Yeah, I would say we’re starting to see a change in this tide. But it is like turning a ship around, and that’s my point. Maybe the ship started turning with what you saw in mainstream media two years ago, but if we don’t continue sounding the alarm and reinforcing this, we’re going to fall right back to where we were. There’s more inertia pushing us towards where we were than pushing us towards changing direction, because where we were makes a lot of sense for the people who hold the purse strings.

So if you course correct briefly to save face, that’s not sustainable. You need to reinforce the correction over and over again, which is the point of the article, in order to turn the ship fully around. So we are seeing it turning, we’re seeing people being more responsible, and that’s great, but we cannot stop sounding the alarm until it becomes the norm.

Kevin Pho: We’re talking to Tamir Aldad. He is a physician executive and addiction psychiatrist. Today’s KevinMD article is “Venture-backed telemental health care companies are creating a new opioid epidemic.” Tamir, we’ll end with some of your take-home messages to the KevinMD audience.

Tamir Aldad: So I think the most important take-home message here is to constantly look at your business and your organization and patient care through the lens of what is clinically sound and ethical, and the rest really will fall into place. And no matter the pressure in terms of metrics and KPIs and whatever management says, it’s really important we maintain our integrity.

Kevin Pho: Tamir, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Tamir Aldad: Thank you for having me.