Prescription Digital Therapeutics: Reimagining Care in Behavior-Driven Conditions - Episode 5
Medical authorities detail how PDTs are compared with other, more conventional treatment modalities in behavioral health.
John Fox, MD: Arwen, you brought up the point that cognitive behavioral therapy [CBT] is an evidence-based intervention that all health plans, including Medicaid and Medicare, cover. Yet some payers have said, “We want comparative studies looking at the prescription digital therapeutics [PDTs] compared head-to-head with CBT.” How do you respond to that? You may not have had to. Scott and Tim, you’re welcome to chime in.
Arwen Podesta, MD: I have definitely had that conversation with colleagues, especially some of the therapists in my office, whether PDTs are being prescribed. We have studied this, and the CBT studies have to be academic, so I don’t see that we’re going to have this, but I don’t see the peril in using it in conjunction with therapy.
Part of the deal with PDTs, as Tim mentioned earlier, is that this is outpatient and in your pocket. With my patients with opioid or polypharmacy, polysubstance addiction, when does their addiction crop up and do push-ups and wake them in the middle of the night? Not when they’re in my office, when they’re sitting in front of me. It’s after a stressor happens at home or socially. It’s at 4 AM when they’ve awoken in the middle of the night because of a traumatic dream. Their therapist and their sponsor aren’t going to be there, but their PDT or any digital health app is going to be available for them. We know that these have very specific direction of the tools.
Scott Whittle, MD: That’s a perfect answer. I’ve seen you address it before. I’ve seen some of your work in this space, and I’m a fan. You speak to it very eloquently. I agree 100%. I’d just add that when payers say that, they aren’t speaking genuinely. Because as Tim indicated, they have approved and paid for many things that have far lower thresholds of evidence-based support. They’re really saying that they aren’t ready to make a move yet. I’ve experienced this on the payer side. I have people calling because of the desire to represent their interest. I receive 5 or 6 solicitations a week to look at and advocate for these strategies. Payers feel inundated.
I love your answer because I’d stay on that. It’s a mistake to say we need more evidence to support it, because I’ve looked at the evidence for the core products that are prescription digital therapeutics, and the evidence is there. Repeating that in a way to convince a payer and not to broaden our knowledge base and help us more effectively provide care is a mistake.
What I sense in the marketplace is that the major health care systems and payers around the country are all scrambling to create a digital strategy. They all want to manage it in a way that has a positive member experience, and the buzzword going around is the digital front door. When somebody working with them enters that digital front door, the experience of that patient has to feel consistent with the experience they’re having within the health care system as a whole. That fits exactly what you’re saying. That’s the way to address this with the payer community. Any time they talk about evidence, I hear, “We’re looking at this, we’re frightened, we don’t know where to go, and we need some support in making a decision.”
Timothy Aungst, PharmD: I want to jump on that, because trying to reap a lot of clinical evidence is going to be a big waste of time. In the end, you’re into pilotitis, and a lot of these companies can’t survive that. If every payer says, “Do me a pilot, do this thing,” they aren’t going to have the runway in capital to survive that market. We also need some financial evidence. How does this compare? Does this reduce the total cost of care? How does this compare with everything else? That’s where we have an opportunity: that scalability factor.
Scott Whittle, MD: In other therapeutics, that’s what they have to do. It’s interesting that we’re treating digital therapeutics differently. I truly believe that’s a lack of familiarity, which is why I love the way we’re talking about it. They should be talked about like other therapeutics in the space of broader therapeutics, and we’ll get there. We mentioned stigma too. The stigma is a part of that. That health care system has the same stigma to view these as somehow apart, but they aren’t. That’s part of my advocacy, to say that if you have an evidence-based strategy that’s targeted at a diagnosis that you’re responsible to treat, having an evidence-based FDA-approved strategy to address it is good medical care.
Timothy Aungst, PharmD: That’s it. Because with my patient group, my work is heavy Medicaid. If I want them to see a therapist, they could wait months. They can wait a long time, especially with this current environment. Do I let the patients by without care? What am I going to do? This is why we’ve seen some Medicaid programs come on. We know how many therapists are in our state. We know that we have health deserts. They aren’t going to say that digital therapy is the next best thing, but it’s a solution. It’s going to have the access scalability to meet your patients where they are. Because otherwise, they aren’t going to see anyone, and we don’t know if that’s going to lead to traditional end points of concern, such as ED [emergency department] visits, hospitalizations, and downstream cost.
Looking at that, considering that way of tracking the finances and establishing financial value, not just clinical value, is going to be key. It’s where a lot of digital health companies or digital therapeutics by and large are going to have to shift in terms of how they come back to a payer and say, “This is what we [learned].” It isn’t your traditional RCT [randomized controlled trial], such as hospitalization, but also leveraging all the data that they have to establish more value points than traditional pharmacotherapeutics can, at least at the end of the day.
Scott Whittle, MD: Agreed.
Arwen Podesta, MD: That’s 100% [true], because with traditional pharmacotherapeutics or recommended outpatient therapy, we don’t get data. The fact that these are collecting tons of data [is helpful]. Some of the companies are working with insurers to show efficacy and adherence, which we don’t get with pharmaceuticals, except for ones with a tracker, which are rare. But we get adherence information as well as some data about outcomes. That’s useful for insurance companies. I’m hopeful that will be in the mix of the discussion.
Transcript edited for clarity.