"DTx offer solutions in a number of very challenging spaces and access to care."
Digital therapeutics (DTx) have the potential to expand access and to provide options to patients, as well as improve treatment feedback, agreed panel members in the recent Payer-Provider Perspective: Prescription Digital Therapeutics custom video program.
When discussing DTx, whether with patients or colleagues, it is important to stress that these products are evidence based, the expert panel members said. This is especially true considering the number of options and tools available, added Timothy Aungst, PharmD, associate professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences in Worcester and a clinical pharmacist at a home health care agency.
“You open up your smartphone, and you look up something in the app store, and you are going to get hit with a lot,” Aungst said. “There are 300,000-plus health and medical apps out there, and no curation. So, how do we know this stuff actually works? How do we go from the consumer model where we say, ‘Sign up for a subscription, download this thing, it is going to do something for you’? Well, how do you know it is actually going to do something for you? And here is the key thing: We want evidence to show. We want to be able to say in which patients they do work, or how much time do you need to achieve is a set outcome.” Having that information—efficacy evidence—is important, he said.
Some apps and DTx are approved by the FDA, the group noted, which lends additional credibility. Yet, lack of FDA approval may not necessarily mean a particular DTx is not worthwhile, the panel agreed. This further complicates matters, as there are discussions among payers regarding what level of evidence or approval is needed for coverage and reimbursement. The more evidence, the better, they all agreed.
According to the panel, DTx improves access to care in several ways: It improves care availability when the support is most needed; it makes care more convenient; and it extends care despite a shortage of clinicians.
One of DTx’s strengths is that it can reach patients where and how they are most comfortable, explained Aungst. Just as ease and convenience have influenced people in other areas of the economy, point of care matters, he added. He posed the questions patients may ask themselves: “Do I want to spend time driving to someone to provide the care, or do I want this on my own time?... Do I have to go to a clinic to get this done? Does it mean I have to ask for time off in the day, and will my employer get angry? What am I going to do about childcare? Versus the alternative: Can I do this on my own, and guide it in a way?” The flexibility and convenience of DTx allows patients to fit the care into their schedules as they need it, he said.
Panel moderator John Fox, MD, principal of Foxworthy Healthcare Consulting, agreed, noting that need can occur outside of normal office hours. By having DTx as an option, patients can access the care and support as they need it. “Often, patients use these [DTx products] when they need it the most, and when you need it is not 8:00 scheduled on a Tuesday morning appointment with your psychiatrist,” he said.
Arwen Podesta, MD, a board-certified adult psychiatrist in New Orleans with subspecializations in addiction medicine, forensic psychiatry, and integrative medicine, uses DTx primarily for opioid use disorder, alcohol use disorder, polypharmacy use disorder, and insomnia. When she introduces DTx to patients, she provides them with an overview, then suggests they delve further at home. This encourages its use at home when busy patients find it most convenient.
Health Care Inequities
Convenience is not the only access issue. The challenges of health care disparities were “painfully underscored” by the COVID-19 pandemic, said Scott Whittle, MD. A child and adolescent psychiatrist by training, Whittle is a physician at Intermountain Healthcare and medical director at SelectHealth in Salt Lake City, Utah.
“At least to some extent, health care equity is nowhere where we thought it was, and the gaps between who has access and who does not, who has access to engagement and who does not, have been made painfully clear,” Whittle added. “Beyond that, I think that [the lack of equity has] accentuated the human resource crisis we are facing nationally in terms of just simply having the human resources to apply to the problem as a whole.”
Not surprisingly, Whittle estimated that access to care for behavioral health conditions ranges between 10% and 40% to 50%. As an example, Whittle said that Intermountain Healthcare recognized that if they “didn’t double access to behavioral health care services within the next 3 to 5 years, we would be seeing a further deterioration of our ability to meet these needs. Not just hold steady—further deterioration.”
Not only are there not enough resources in some areas, but the panel also agreed there are health care deserts—areas of the country that completely lack behavioral health care clinicians—that would especially benefit from the use of DTx.
Although some people do not believe DTx is the next best thing in health care, it is hard to deny its potential, Whittle added. “It is going to have the access scalability to meet your patients where they’re at, because otherwise, they are not going to see anyone. And we do not know if that will lead to traditional end points of concern, like [emergency department] visits, hospitalizations, and a downstream cost.”
In fact, in a recent meeting, a senior medical director of a behavioral health care system said to Whittle, “We need to be putting DTx at the front end of care, not at a carefully guarded back end, because the access crisis is real.”
Alternative, Discreet Options
DTx also can offer patients additional or alternative support to psychopharmacological options. Some patients do not fully remit with psychopharmacology alone, and other patients may be reluctant to rely on medications. This is especially true in child and adolescent populations; parents often have concerns about their children using psychopharmacological agents. For these patients, DTx provides access to care via a safe and effective alternative.
“As a pediatrician, I knew that a lot of parents did not want to treat their kids’ ADHD [attention-deficit/hyperactivity disorder] symptoms with medication,” said Whittle. “So the fact that this is a therapeutic without being a medication has appeal, either as a stand-alone or as an ancillary approach.”
This may be especially true of the latest FDA-approved video game indicated for addressing symptoms of ADHD, added Podesta. She noted that parents of children with ADHD “want it badly.”
Additionally, the stigma attached to receiving psychiatric care can prevent patients from seeking it. DTx can provide discreet, convenient care and support, Whittle said.
According to Fox, another advantage of DTx is “getting real-time or near real-time feedback, both to the provider and the patient.” Most DTx have both patient and clinician portals, allowing clinicians to monitor DTx use and symptom improvement.
Podesta agreed. “What we do not get with traditional pharmacotherapeutics or with other prescribed or recommended therapy, such as outpatient therapy, is numbers—data,” she said.
Not only do data help to show adherence, but they also shed light on outcomes, Podesta added. This benefits her, as the clinician, as well as her patients. Podesta always tells her patients that she will be monitoring the clinician platform of the DTx, an arrangement she finds that most patients like. “They tend to be more excited and feel more accountable,” she explained.
The lack of similar engagement with psychopharmacological options could be driving the failure of treatment as usual, said Whittle. From a claims-based perspective, “Starting a prescription for medication-assisted treatment or asking somebody to go to therapy usually fails between 7 and 9 times before [the suggestion] sticks. Seven to 9 times,” he emphasized. “Somebody’s struggling with, say, the condition of depression, opiate use, or alcohol use disorder, and when somebody’s struggling with that, it is not the moment in the therapist’s office that we are trying to manage. It is that individual feeling connected enough to build recovery capital on a longitudinal basis. And quite frankly, nothing accomplishes that better than the digital strategies that are available.”
Podesta agreed about the need for engagement and how DTx can help improve that, especially through text messaging. Plus, DTx empowers patients and gives them an extra degree of support. Patients, she has found, appreciate “the use of the apps to augment and overcome specific disease states and symptoms.”
In addition, the DTx programs Podesta uses most often leverage contingency management, which has been proven to be very effective. This gives patients 2 support systems rolled into 1. “At 4:00 am, they wake up thinking that they want to go get drugs to help them go back to sleep or to calm their nerves. And then they use that app that I have been so clear is part of their care. [After using the app], they get an Amazon gift card or whatever it is, and then more salience occurs to get them to do it again. So, it is forward-thinking.”
The panelists expressed hope that their colleagues, patients, and payers recognize how DTx can be a powerful tool in behavioral health care. Specifically, Podesta said she would want her colleagues to know “prescription digital therapeutics are evidence-based, research-based, effective tools to improve outcomes. We have new technology coming down the pipeline every day—why not use it therapeutically to actually better help patients?…Their safety is beyond [that of] almost any prescription that I have ever written as a psychiatrist. And, with a lot of my patients not wanting to be on medicines, using these tools is a game-changer.”
“DTx offer solutions in a number of very challenging spaces and access—access to care is incredibly challenging,” added Whittler. “DTx offer the engagement element that traditional treatment has really struggled to provide, [plus] they offer [the data and support showing] the treatment being provided is actually evidence based.”
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