Hey Payers!!! Are you listening? Developers of Digital Therapeutics want to know…
By: Nick Harsh
For developers of prescription Digital Therapies (DTx) it can “FEEL” like NOBODY is listening….especially commercial payers.
We are often asked, how do we gain the attention of the payer for our prescription DTx product?
Digital therapies as a stand-alone prescribable medical modality has yet to create that “feeling” of medicine for payers.
Payers want to SEE the difference in their patients as a result of the use of a digital therapeutic.
A robust RCT resulting in an FDA designation is one path and clearly a key to the locked door of the payer but it’s important to knock loudly as you approach the payer’s door. Payers will need to feel the power of your knock. You must have something that gains their attention.
Does it makes sense to be knocking on the payers doors alone? We recommend that patients, physicians and the employers all need to knock on the payer’s door along with the DTx developer.
Since the precedent of the utilization of a prescription DTx is still not prevalent in the market, the question continues to be; how do prescription DTx developers demonstrate that “feeling” of results to payers? We know from our research that few Prescription DTx’s are currently under review as stand-alone therapies by payers. Even fewer payers have a clear process in place to review and decide on the utilization of a DTx. Where to enter that process is different with all commercial payers and PBM’s. That journey into the payer space for digital prescription therapy is in its infancy.
Entering the commercial payer world through the pharmacy door by trying to have a positive review by a plans pharmacy P&T committee has proven to be difficult if not impossible. Even if a champion within a plan were able to move the approval decision forward, it may not make it to formulary given there isn’t a precedent of a digital therapeutic on the covered benefit status which may send you to experimental status on the benefit list even with clinical clearance.
If you think it’s an easier path through the medical side or through the innovation teams….LOOK OUT! The budgets for pharmacy and medical services are well defined overtime and new expenses without the corresponding cost savings make the current health plan reimbursement model difficult for a DTx to enter. But not impossible.
Most payers will look at a prescribed DTx as an experimental modality even with a sound and successful RCT. Therefore, RCTs along with well-constructed pilots or demonstration projects are necessary. Understand the the data generated through robust utilization by a prescribed DTx is critical but will take time.
So what happens when the payer door actually opens? Are you ready? More importantly, are you ready to go?
- Do you have the clinical muscle?
- Can you describe and clearly answer the “how do we implement” question that will come immediately?
- What are the roadblocks for that payer or the risk reward for working with that payer?
- Can you clearly articulate and justify the price of your DTx?
Above all, you must be prepared to answer the four essentials necessary to drive DTx adoption:
- Does it decrease cost?
- Must be real dollars
- Does it improve healthcare quality?
- Measureable results within the identified population
- Does it fit into healthcare providers’ current workflow?
- Is it easy to use?
- Does it increase the practices capacity?
- Does it improve patient satisfaction? (A MUST)
Nick Harsh: 610-283-7760