Contributed: Digital health and opioid use disorder

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The alarming scale of the opioid use dysfunction (OUD) epidemic has resulted in unprecedented human and financial devastation, and there may be important alternative for digital instruments to change the gold commonplace of care to at least one that’s ongoing and on-demand.

The epidemic has solely worsened because the onset of COVID-19, given heightened financial instability, social isolation, disruption to transportation and decreased entry to in-person help companies.

We’ve got begun to see elevated proliferation and adoption of data-driven, on-demand telemedicine options by suppliers. The pandemic particularly has accelerated the normalization of nearly enabled care and familiarization with digitally delivered remedies amongst clinicians, pharmacists, caregivers and sufferers alike.

The convergence of all these components – the stunning damaging influence on human life, an uptick in digitally pushed innovation within the OUD house and a willingness by suppliers and sufferers to undertake such options – makes investments by all key stakeholders all through the healthcare ecosystem within the OUD digital well being house each engaging and well timed.

Though there was a major quantity of digital disruption within the OUD market, lingering unmet wants exist, as many present options require a mixture of in-person and app-based interactions. Leisure of in-person go to necessities and reimbursement parity for a lot of telemedicine companies amidst COVID-19 bode effectively for continued use of those digital interventions.

To ensure that telehealth and telemedicine to actually allow expanded entry to take care of geographies missing skilled suppliers or neighborhood well being sources, we might want to see elevated innovation in digital-first, direct-to-consumer instruments, in addition to an extension of reimbursement.

Till then, extra built-in and complete tech-enabled options that incorporate medication-assisted therapy (MAT) whereas minimizing in-person interactions shall be more and more necessary. Within the subsequent few years, we are going to seemingly see:

  • Elevated normalization of digital or app-based packages as the usual of care.
  • On-demand and ongoing distant care, reasonably than episodic supply.
  • Decreased stigma and way of life disruption as a consequence of accessible digital options.
  • Employers bundling digital OUD companies in advantages to enhance worker wellbeing and cut back complete medical expense.
  • Payers shifting in direction of value-based outcomes for OUD packages, with digitally enabled companies to watch compliance and incentivize retention.
  • Acceleration of partnerships between know-how and healthcare suppliers.
  • Massive techs partnering with extra ‘conventional’ healthcare corporations to increase entry to companies and enhance supply of digital OUD therapy choices.

Human and financial influence of opioid misuse – and the influence of COVID-19

Opioid abuse ends in large destruction, each by way of cascading monetary penalties in addition to lack of life. By way of the financial influence, the opioid dependancy epidemic prices $200 billion yearly. Given the magnitude of loss attributable to opioid abuse, in addition to the pressure on an already overburdened healthcare system, the necessity for more practical OUD remedies is each dire and time delicate.

Explicit demographics are at heightened threat. Rural communities face a myriad of social and financial components, compounded by an absence of availability of in-person therapy. Moreover, the variety of expectant moms fighting OUD has quadrupled over the previous 20 years.

Youths are additionally disproportionately affected, with almost 4,100 deadly overdoses in 2017 alone. Moreover, the VA has printed research discovering veterans at increased threat of opioid overdose or suicide dying, highlighting the necessity for ongoing digitally enabled sources and follow-up care.

The 2020 COVID-19 pandemic has accelerated the depth of the opioid disaster and wish for improvements in care. American Dependancy Facilities stories that the financial influence of COVID-19, with 20.5 million jobs misplaced in April alone based on the Bureau of Labor Statistics, has exacerbated the hyperlink between substance abuse and unemployment.

Despair and nervousness fueled by social isolation have led to upticks in relapse numbers, and social distancing has lowered capability for in-person therapy amenities and help teams. Even by June 2020, relapses had been rising considerably within the Appalachian Mountains area, which has traditionally been flagged by the CDC for inordinately excessive numbers of opioid overdoses and deaths. Nationwide, overdose deaths elevated by ~15% between March and June 2020.

With a turbulent path ahead relating to state rules, public well being and financial circumstances, the utility of digital instruments to offer ongoing take care of OUD sufferers is vital.

Coverage adjustments and implications driving digital

Exterior of population-specific and COVID-19 associated considerations, broader U.S. coverage adjustments in current months and years are conducive to wider adoption of digitally enabled OUD care. Within the wake of the COVID-19 public well being emergency, CMS quickly expanded Medicaid and Medicare reimbursement to incorporate parity for in-office and telehealth visits.

Previous to March, solely 14,000 Medicare beneficiaries had acquired a telehealth service in a given week, whereas over 10.1 million utilized telehealth from mid-March to mid-July 2020. The huge spike in utilization demonstrates each a necessity for and willingness to undertake telemedicine throughout each sufferers and suppliers.

The same silver lining of the pandemic-induced public well being emergency was the relief of the 2008 Ryan Haight Act, which amended the federal Managed Substances Act to impose a prohibition on prescribing managed substances with out having first performed not less than one in-person medical analysis, with some exceptions.

In March of 2020, the DEA confirmed that the general public well being emergency as a consequence of COVID-19 certified as an exception, thereby enabling suppliers to prescribe managed substances through telemedicine. A affected person can subsequently full your entire course of, from screening and prognosis to acquiring a prescription and starting therapy, solely through digital means.

Additional, in early August 2020, President Trump signed an govt order to increase rural well being entry to telemedicine, whereas CMS launched the proposed doctor free schedule for 2021, which included bolder telemedicine allowances, together with the extension of reimbursement parity.

These actions by the political and healthcare authorities bode effectively for each telemedicine and OUD therapy, signaling a broader motion in direction of increasing entry to and reimbursement for nearly enabled well being companies. Based on their founders, corporations like Ophelia and Bicycle Well being have taken benefit of the versatile laws to launch solely digital OUD packages and seen optimistic enrollment outcomes.

Digital OUD therapy panorama: Alternatives and predictions

The present therapy panorama combines a mixture of digital and in-person companies. A small variety of opponents supply complete, built-in options incorporating MAT – albeit requiring in-person interactions in the beginning and/or at outlined intervals, although waiving the in-person go to requirement – has allowed innovators (e.g., Bicycle Well being, Halcyon Well being, Ophelia, Workit Well being and Eleanor Well being) to pursue a digital mannequin aggressively, if not solely, from the outset.

Nonetheless, nearly all of gamers within the digital well being OUD house deal with participating with customers to complement MAT: connecting customers to therapy amenities, help teams, digital steering and training, or in any other case appearing as a companion device to allow ongoing and on-demand entry to the overarching therapy program (e.g., DynamiCare, Pear Therapeutics, Boulder Care, Teams, BUP app, Assist Close to and Now app, Marigold Well being, and Path).

Supplier-focused instruments additionally exist, akin to scientific choice help instruments and built-in care platforms, which allow clinicians to higher assess threat, monitor compliance and replace therapy plans accordingly (e.g., Quartet Well being and WeConnect Well being Administration).

COVID-19 has additional exacerbated the opioid epidemic and demonstrated each the necessity for extra accessible options, in addition to the chance for telemedicine and digital well being to bridge gaps in care, increase entry to companies and support in destigmatization. CEOs of a number of main healthtech corporations have famous that COVID-19 has modified the therapy panorama, as relaxed regulation and elevated want gasoline nearly enabled care.

“[COVID-19] modified issues massively, with extra overdoses and other people unable to entry a neighborhood physician or group,” Ankit Gupta, CEO of Bicycle Well being, stated. “Unemployment and psychological well being points have worsened … pointing in direction of a worse opioid epidemic. We try to … see sufferers as shortly as attainable. … Due to this extra demand and changes to regulation, we elevated our month-to-month enrollment price 20x and [have grown] geographically.”

Dr. Corey McCann, CEO of Pear Therapeutics, which presents prescription digital therapeutics for OUD and SUD, famous that COVID-19 has pushed the world “… right into a distant care setting, accelerating the mixing between telemedicine and PDTs.”

He identified that this creates a possibility for seamless person acquisition and engagement, whereby a affected person can “self-identify with an internet advert after which click on via to obtain a prognosis and prescription.”

In an identical vein, Zack Grey, CEO of Ophelia, pointed to the necessity for comfort and accessibility.

“If you consider it, folks can textual content their drug seller, so therapy must be higher and simpler,” he stated. “It must be simply as discrete … persons are extra incentivized if they will begin and obtain therapy at residence.”

There is a chance for know-how to construct on present capabilities and tackle persistent unmet wants referring to lack of care coordination, obstacles to therapy initiation and modification, and a supplier’s capability to judge affected person threat and monitor compliance. Business sources, together with Rock Well being, have said that know-how can mitigate points round shopper habits and gaps in therapy.

Within the coming years, we are going to seemingly see:

Elevated normalization of digital or app-based packages as the usual of care. 

With nearly all of people not receiving evidence-based remedies and empirically supported packages, 40-60% of those that obtain therapy for SUD in any respect will relapse. Tech-centric options that depend on evidence-based packages enable for frequent knowledge seize, affected person engagement and elevated adherence.

Sufferers are more and more acquainted and comfy with wearables and different linked apps to watch well being, and worth the empowerment that coincides with real-time and correct well being metrics referring to a therapy plan. App-based options can leverage continuous knowledge assortment and bodily metrics, enhancing the flexibility of sufferers and suppliers to judge MAT dosage or signs and modify care routine accordingly.

“Sure sufferers have interaction with know-how in a manner that’s an order of magnitude higher than in individual or through telephone,” McCann stated, “Distant however synchronous care … offers alternatives to take care of sufferers between month-to-month visits with suppliers. It actually plugs the gaps.”

The necessity to implement nearly pushed main and pressing care amidst COVID-19 has accelerated supplier consolation with tech-enabled options and affected person willingness to obtain care on this method, significantly when care has been proven to be equal in high quality with elevated comfort.

On-demand and ongoing distant care, reasonably than episodic supply.

Reasonably than guaranteeing continuous observe up care and a seamless affected person journey, the reactive nature of dependancy care traditionally manifests in bursts of intensive therapy with no ongoing help.

Within the subsequent few years, sufferers will demand the identical stage of on-demand entry to care that they expertise with different app-based companies. Such constant updates are preferable on the supplier aspect as effectively, since data-driven apps enable care managers and sponsors to watch and talk over the course of a affected person’s journey in a scalable method.

“The current legislative adjustments permitting for us to ship companies solely over telemedicine makes it simpler for sufferers to have interaction, particularly for folks in rural America who weren’t in driving distance of the proper docs earlier than,” Grey stated. “Now, persons are extra incentivized to have interaction if they will begin therapy from residence.”

The on-demand nature of telemedicine is complemented by distant testing, which additional addresses problems with episodic care supply and noncompliance.

“DynamiCare does distant substance testing, which works effectively amidst COVID-19. The overwhelming majority of in-person suppliers don’t have a great way to do [that],” Eric Gastfriend, CEO of DynamiCare, stated.

Provided that about two-thirds of sufferers in OUD packages don’t obtain correct ongoing urine testing and that noncompliance stays a difficulty, the flexibility to make the most of know-how to boost testing and compliance is vital.

“Making use of optimistic incentives with the proper paradigm of care improves each retention and outcomes,” Gastfriend stated. He additional identified that “with MAT, we frequently see a giant drop-off at six months, whereas you might want to be in therapy for not less than a 12 months to considerably decrease your possibilities of relapse.

“We are able to’t completely automate MAT with know-how, so we use contingency administration and motivational incentives as a part of our digital care program designed for use alongside therapy. It’s a troublesome illness to overcome, and you might want to use all of the instruments you may.”

Decreased stigma and way of life disruption as a consequence of accessible digital options.

One of many main alternatives for digital well being is to cut back the related stigma and perceived burden associated to opioid abuse therapy, permitting people to hunt care with out drawing consideration to the problem or disrupting their each day routines. Apps can present on-ramps to extra intensive or in-person interventions as wanted, with the additional benefit of steering via the care course of.

Grey pointed to fashions and types that make sufferers be ok with therapy or being in restoration.

“Manufacturers like Hims and Roman actually deal with destigmatization,” he stated.

Moreover, lowering bodily and psychological obstacles to entry shall be vital in catering to subgroups akin to youths, pregnant girls, veterans or rural populations which face nuanced and extremely particular challenges.

“These people haven’t all the time been handled effectively by the well being system,” Corbin Petro, CEO and cofounder of Eleanor Well being, stated. “They wish to be handled with respect, in addition to profit from the comfort of know-how.”

Eradicating the geographic roadblocks or the social repercussions of publicly searching for take care of dependancy through app-based options will considerably enhance adherence and cut back relapses.

Gupta famous that he began the corporate after seeing power ache sufferers fighting problematic opioid use, lots of whom “weren’t a inhabitants he would have related to dependancy, proving that anybody can get depending on opioids. If opioids are probably the greatest instruments to beat acute ache, we have to enhance therapy for dependancy. It must be handy, inexpensive and stigma free,” he stated.

Employers bundling digital OUD companies in advantages to enhance worker wellbeing and cut back complete medical expense.

Employers can companion with digital therapy suppliers and/or well being plans to supply nameless and sponsored OUD teaching, therapy help and care navigation advantages for his or her workers, justifying the price of offering these instruments to workers with the cost-savings from prevented in-person care or hospital visits for OUD/SUD associated points.

This has been a standard pattern with psychological well being and wellness advantages, with employers growing recognizing the cascading advantages of investing in worker’s psychological wellbeing. Adoption of OUD advantages for workers would equally enhance office morale and retention.

Innovators have expressed enthusiasm for a future the place OUD packages are integrated into employer well being plan advantages, however name out a hesitancy to have interaction with dependancy and stigmatized circumstances.

“Some employers really need this. … Labor unions too, since [OUD] hurts productiveness,” Gupta stated. “It’s a large downside in each business. We’d like to work extra with employers sooner or later.”

Grey shared related sentiments.

“We positively see a path ahead with employers,” he stated. “Blue collar employees can get hooked on opioids wanted for on-the-job accidents. Telecom or development industries are additionally potential companions.”

Petro identified that COVID-19 could current a possibility to reframe the problem, “Traditionally, employers have recognized it is a want, however haven’t wished to the touch it [due to stigma],” she stated.

“[COVID-19] is a chance to vary the panorama and framing to extend employer curiosity. The pandemic has created nervousness and uncertainty, and plenty of are utilizing substances to manage, probably resulting in misuse. This concept of treating these with ‘rising threat’ of substance misuse resonates extra with employers [more than treating ‘addicts’].”

Payers shifting in direction of value-based outcomes for OUD packages, with digitally enabled companies to watch compliance and incentivize retention.

Given problems with compliance and retention referring to OUD therapy packages, particularly when threat of relapse is considerably lowered after one 12 months of therapy, it’s vital that value-based care preparations incentivize long-term restoration and lowered overdose readmissions or relapses.

Eleanor Well being champions value-based care, which their CEO Petro stated is “about effectivity of useful resource use.” They’ve designed a service that could be a “longitudinal mannequin and fee construction that incentivizes retaining sufferers” together with each digital and in-person care to handle all varieties of obstacles.

“We strive to not consider sufferers based mostly on black-and-white measures like damaging urine drug screens,” she stated, “since this incentivizes cherry choosing of sufferers additional alongside in restoration and does not acknowledge the influence of enhancements in substance misuse, like we do in different power circumstances.”

She famous that they particularly attempt to keep away from fee-for-service reimbursement, which incentivizes relapse over restoration, and have been “pleasantly shocked on the handful of payers who wish to transfer into the value-based care house for psychological well being and substance use therapy.”

Alongside the vein of incentivizing longitudinal involvement and extended engagement, DynamiCare presents a digital well being program that enhances therapy, with CEO Eric Gastfriend noting that “getting main payers to announce partnerships with incentive-based dependancy therapy packages is a serious breakthrough for the sector” and has even resulted in further NIH funding for dependancy therapy analysis and trials.

Gastfriend added that it has discovered success in modeling itself after gamers like Omada, combining know-how, {hardware} and training.

Massive techs partnering with extra “conventional” healthcare corporations to increase entry to companies and enhance supply of digital OUD therapy choices.

Whereas there was a major uptick in digital exercise within the dependancy house, with startups targeted on neurological circumstances (together with SUD) elevating over $193M in enterprise capital funding in 2018 alone, gaps in entry to know-how pushed by socioeconomic standing, geographic obstacles and an absence of historic partnerships between Web and broadband suppliers and healthcare corporations have prevented adoption.

A key barrier to broadly implementing telemedicine or telepsychiatry options for OUD lies in an absence of connectivity for rural communities, which is more and more prime of thoughts given the 2019-2020 COVID-19 pandemic and the necessity to increase Web entry for telehealth extra broadly.

Even previous to the pandemic, Web service suppliers, in addition to these providing {hardware} and software program parts, have develop into more and more vital and unlikely gamers within the digital transformation for OUD care.

In recent times, Microsoft has been working to carry broadband connectivity to a few million rural People through their Airband Initiative, largely pushed by the necessity for entry to telehealth and digital behavioral VA companies. Equally, AmWell, Anthem and Samsung America have partnered to increase entry for Anthem members to the Samsung Well being app and AmWell’s on-line instruments.

Well being tech corporations have expressed enthusiasm for the flexibility and willingness of sufferers to have interaction with tech.

“A big share of sufferers are Medicaid and are surprisingly tech literate. Most sufferers do have their very own good telephone with authorities help packages,” Pear Therapeutics’ McCann stated.

Since many sufferers lack enough service or cell knowledge, Pear has constructed its choices to “perform with knowledge caching so sufferers can use WiFi at a retailer or espresso store to obtain content material to make use of offline,” he stated. “I really haven’t seen smartphone fluency and availability to be [much of a] downside, since we don’t require the identical video streaming you’d want for a telemedicine encounter.”

Grey famous that almost all of their sufferers have already got entry to the required know-how, since their workforce members get sufferers from websites like Fb. That is largely as a result of they wish to deal with these going via withdrawal, the “80% not getting handled earlier than they get to the ER, … in order that we will make the [pain] of withdrawal higher,” he stated.

When requested about collaboration throughout the well being and tech spectrum, Grey identified a possibility for digital well being and telemedicine corporations to companion all through the method with an organization like Axial Healthcare that identifies sufferers in danger via work with insurance coverage corporations.

“There are such a lot of gamers that the method requires participation from payers, suppliers, [and] employers … from a shopper perspective. It must be slender, however on the again finish a labyrinth of stakeholders is important to make the method work,” he stated.

Nonetheless, there are some necessary obstacles and dangers to think about in mild of the quite a few advantages stemming from telehealth interventions:

Not all care could also be suited to digital supply.

Whereas some corporations have seen no distinction in outcomes with 100% digital care in comparison with in-person, others word that know-how is just not a one-size-fits-all resolution.

“After rules had been relaxed, and we moved to completely digital care, I used to be pleasantly shocked to see no distinction in outcomes,” Bicycle’s Gupta stated. “We are able to present a extra handy, well timed service. It’s like a same-day pressing take care of folks experiencing opioid withdrawal and/or problematic opioid use. That is massively useful for individuals who would in any other case find yourself within the ER.”

He did word that it could possibly “carry down” the extent of care, because the workers has to “refer extra folks to increased ranges of care, and discharge folks to verify they will safely obtain care” if digital care gained’t be efficient.

Equally, Petro praised the flexibility to supply identical day entry, however stated that “… we’re agnostic to how a affected person engages with us. … We must be multimodal. We will be 100% digital, however we imagine in a versatile customized strategy to satisfy sufferers the place they are and, overwhelmingly, our sufferers need a hybrid mixture of interactions – each in-person and digital.

“Some sufferers don’t have entry to broadband {or] gadgets that can be utilized for telemedicine, or discover the in-person connections to be vital. From a scientific perspective, there are particular ranges of acuity that we’d wish to deal with in individual.”

“Gate-keeping” obstacles and coordination of care points nonetheless exist, limiting applicability of those instruments.

Even when digital instruments can allow extra steady care, this doesn’t settle the problem of sufferers failing to enter into the therapy funnel within the first place. Some 90% of people who want therapy for dependancy don’t search it out. Whereas many digitally enabled options circumvent obstacles to therapy, they usually require an entry level from a payer, supplier or employer.

The unemployed and uninsured could not have the ability to make the most of the digital platforms designed to alleviate the precise obstacles they face. Moreover, populations affected by comorbidities akin to psychological or power sickness require intensive coordination with different specialists.

This care coordination is troublesome to realize due each to the lapses in care stemming from the episodic nature of overdose-related therapy and the need for privateness and anonymity. If different suppliers are unaware of the affected person’s SUD/OUD therapy, if it is performed in “personal” through a self-serve app, then the affected person could also be lacking out on advantages from extra coordinated care.

As such, digital instruments could initially be extra helpful particularly to triage sufferers searching for further care, or for long term distant take care of these requiring much less intensive intervention. Additional, regulatory complexity and problems with reimbursement additional exacerbate logistical hurdles with OUD therapy.

“It is a house the place payers transfer slowly as a method of value avoidance, whereas sufferers face stigma,” McCann stated.

Gupta identified, “We are able to’t actually present efficient behavioral healthcare once we get shoehorned into medical. We get the identical reimbursement as a PCP go to, which doesn’t account for the complexity of [OUD].”

DynamiCare’s Gastfriend agreed that the problem referring to digital well being pertains to reimbursement.

“There are digital formularies coming into existence, but it surely’s an open query,” he stated.

He identified that it’s a problem to be adjoining to, however separate from, telemedicine, the place there’s a higher understanding of reimbursement requirements.

“Telemed entails taking scientific paradigms and doing this over the telephone or video, so at its core the payer is reimbursing companies much like what would possibly occur in individual,” Gastfriend stated. “Digital well being focuses on automating evidence-based finest practices, and there isn’t all the time a CPT code.”

Michael Zubkoff, an award-winning Tuck College of Enterprise professor and Director of the MD-MBA Program at Dartmouth, agreed that “the advantages of telehealth have been proven throughout COVID-19, however the query is the stickiness of reimbursement,” additional reinforcing the intricate regulatory setting and gatekeeping obstacles dealing with progressive OUD care.

Within the coming weeks and months, adjustments to the regulatory setting and relative ease of adoption for digital instruments, significantly for these unemployed or uninsured, will largely decide how shortly on-demand and digitally enabled OUD therapy will develop into the usual of care.

Alexandra Mullin is an MBA candidate on the Tuck College of Enterprise at Dartmouth and a Flare Capital Scholar. Previous to Tuck, Alexandra labored at Ahead, a main care startup in San Francisco. Earlier than becoming a member of the workforce at Ahead, she labored as a life sciences marketing consultant at Navigant. Following commencement, she plans to hitch the Enterprise Technique workforce at CVS Well being.

Ian Chiang is a principal at Flare Capital Companions, a healthcare know-how and services-focused VC agency. Previous to becoming a member of Flare, he was the SVP of product and innovation and a founding member of CareAllies, Cigna’s household of multi-payer supplier companies, inhabitants well being administration, value-based care enablement and home-based care companies. Beforehand, he was a digital well being entrepreneur and a former administration marketing consultant at McKinsey & Firm.

 

 

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