DTx, PDTs, and Cost Savings for Payers

EP: 1.Understanding DTx and PDTs

EP: 2.Considering DTx and PDTs as Part of Treatment

EP: 3.Monitoring Patients Through DTx and PDTs

EP: 4.Using PDTs Evidence to Explain the FDA Approval Process

EP: 5.Comparing PDTs With More Conventional Therapies

EP: 6.Durability of DTx and PDTs

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EP: 7.DTx, PDTs, and Cost Savings for Payers

EP: 8.Using Real-World Evidence to Advocate for DTx and PDTs

EP: 9.DTx and PDT Access

EP: 10.PDT Coverage: Pharmacy or Medical Benefit?

EP: 11.Closing Thoughts on DTx and PDTs

Scott Whittle, MD: I’ve been reluctant to say this because it’s an ugly truth, but the truth of the matter is that payers compare themselves with other payers in their marketplace in terms of costs. They don’t compare themselves with an ideal. When we say cost savings to a payer, they immediately look at what their cost is in the marketplace they’re in, and if they compare favorably, they shrug. They’re very focused on meeting the member’s need in a way that the member feels is appropriate. I hate to say it, but it’s about marketing. It’s about having the right benefit design that communicates to the providers you’re attempting to manage in your network and the members you’re attempting to sell policies to that what’s being offered to them is the best possible product at that price point at that point in time.

Quite honestly, I’ve watched the dominoes fall on this a number of times. They’ll use that language to defer decision-making until they see a change in the marketplace, and then they’ll respond to the change in the marketplace. That’s why [they’re asking for] more evidence. That’s when they say it isn’t durable. They’re really saying, “We aren’t positioned or ready to make a decision on this yet.” Quite honestly, they’re waiting for somebody to disrupt the marketplace by taking a step toward developing something that’s better that they then have to respond to. I have watched payers in each [geographic region consider], “Do I want to advance my position? Am I going to be an early adopter, an agent of change?” And once that company takes a step, the other companies recognize they need to take a step.

I apologize to put it so bluntly, but I’m a clinician first and I have been my entire career. When I present a therapeutic that I think is perfect with a great ROI [return on investment] and I propose it to my own system, the question that comes back to me is, “In that area, our cost is fine. Isn’t there something else you’d like to work on?” Who’s in the driver’s seat? This is with provider-based ACOs [accountable care organizations], where the providers are in charge.

As Arwen said, the providers need to clearly describe and say, “This is a solution to patient care that positions you in a place where you’re doing something better for your population. If you aren’t on board with this, you aren’t delivering.” Because that creates the anxiety that says, “I’m at a competitive disadvantage in my [geographic area]. I’m not delivering for my membership. Large employers are going to wonder why I’m asleep at the wheel. The folks I’m trying to sell policies to are going to ask why my product is second rate compared with somebody who’s decided to take a step toward doing the right thing clinically.”

I’ve said for a long time that providers are more in the driver’s seat in the discussion than they realize but not listening to what payers are saying and doing what we all want to do, which is provide excellent care and advocate at a systems level that our health care system thinks is what we need to do to be effective. If the payers don’t support us, they aren’t payers that are especially aligned with us.

Arwen Podesta, MD: I agree with all of that so much. You also mentioned that members, as in patients who are members of the health plan, definitely need to be advocates themselves. For those who don’t have coverage, I ask them to make the phone call. There are a lot of tools that I use in addiction that are probably a little different. There’s the FDA-authorized attention-deficit disorder video game. It’s for children, and Moms want it badly. That’s an area that we could probably make our mark quicker for those in the child and adolescence psychiatry space because that would be advocacy by the member’s mom. That’s where we’d see quicker movement.

The other ones that are FDA authorized are for PTSD [posttraumatic stress disorder], nightmares, IBS [irritable bowel syndrome], insomnia, substance use disorder, and a handful of others that recently came on the market. It’s important to get the patients to be advocates and working members of their MCO [managed care organization].

Scott Whittle, MD: Agreed.

John Fox, MD: One of the challenges is that health plans don’t necessarily hear the voices of those individuals unless it’s in a grievance process, which can be painstaking for provider and patient alike.

Transcript edited for clarity.