Reimbursement Strategy Through Policy Advocacy: Interning with Omada Health
Digital therapeutics (“DTx”) will meaningfully shift what healthcare looks like over the next few decades. It is not a matter of “if”, but “how.”
After five years of advising traditional healthcare companies through Deloitte Consulting, I found that patients wanted to use their smartphones to improve and manage their health in the same way that they were using their smartphones in all aspects of their life, such as building relationships (e.g., social media and dating apps), managing their finances (e.g., banking and investing apps), and travel (e.g., hotel, flight, and map apps).
As Liz Rockett from KP Ventures explains, DTx solutions can enhance the nature of a proven intervention via the use of technology or be a new medium for therapeutic discovery. In the first category, these solutions leverage existing evidence-based therapies, making them more available to patients and supercharging them with the capabilities that come with being digital. More concisely: using digital as a means to improve access and quality of care.
However, many of these DTx companies do not have a repeatable and scalable business model — aka “viability” — if they do not find customers — aka “payers.” I see the payer landscape according to CMS’s 2017 national health expenditure categories. The three largest segments are (1) private health insurers (including self-insured employers) at 34% of expenditures, (2) Medicare (including Medicare Fee-For-Service and Medicare Advantage) at 20%, and (3) Medicaid at 17%. Thus, advanced DTx companies looking to access this medical spend are forced to sell to these customer segments with infamously long sales cycles and will not focus sales efforts direct to consumers. This can manifest as selling to the 850 private health insurers that represent 3.5 million employers and 15.2 individual marketplace enrollees (2017 figures), selling to the 275 Medicaid managed care organizations (same time period), and selling to the big kahuna — Medicare and the nearly 300 Medicare Advantage plans it “outsources” to.
Many successful DTx companies have initiated commercialization with early-adopters, picking off individual self-insured employers, Medicare Advantage plans, and state Medicaid MCOs. However, a successful “sale” into the Medicare mandatory benefit can accelerate broad reimbursement across both the public and private payer space. I am not suggesting to start here; in fact, industry research suggests that securing Medicare mandatory reimbursement is extremely hard and that the government has been historically conservative (lowercase “c”) to move first on reimbursing for innovative technology. Instead, I see this as the goal that each DTx company must strive towards.
With my passion for DTx and an aspiration to play a part in helping companies bridge this reimbursement gap, I looked for the best DTx companies that seemed to be closest to cracking this Medicare reimbursement nut. I had been tracking Omada Health for years, and through my UC Berkeley MBA/MPH Program Director, Kim MacPherson, I was connected with their public policy team. Omada Health is a digital health company (not called a startup as their Founder and CEO Sean Duffy recently explained) that helps people at risk for, and with, chronic disease — primarily those with prediabetes by digitizing the diabetes prevention program (“DPP”) and more recently those with depression and anxiety through Lantern’s CBT-based digital therapies.
I was able to work directly with Omada’s Senior Director of Strategic Communication and Public Policy, Adam Brickman, to update their public policy strategic plan as the business sought to achieve nationwide Medicare reimbursement. This included legislative, regulatory, and commercial research that informed enterprise-wide growth initiatives.
I was particularly interested given Omada’s continued advocacy for the inclusion of virtual providers in an ongoing DPP model in Medicare. The model was originally tested through the Center for Medicare and Medicaid Innovation’s (“CMMI’s”) Health Care Innovation Awards. Typically benefit design change requires an act of Congress; however, CMMI has unique authority — through the ACA — to create an “expanded model” that is reimbursable nationwide so long as it improves quality and reduces cost, which the DPP model successfully did. Upon expansion of the model in 2018, CMS made the inexplicable decision to exclude virtual providers from reimbursement. Omada has been working to change this.
During these few months, I planned to batch my research into both historical context and trending events. Then, I was to design an action plan with initial focus areas and underlying workthreads along with key messaging for various stakeholders.
Here’s how I did it…
The DPP has been in the works since 1996, and there are many patient advocacy groups and government organizations that built websites to educate and influence, such as the CDC’s National Diabetes Prevention Program Coverage Toolkit. This and many other sources gave me a grounding in the 23 years of history of the program.
Since this research was centered on physician reimbursement through Medicare, I could review many years of actual CMS’s physician fee schedules (“PFS”) updates along with associated CMS publications and expert commentary.
I then used GovTrack and Congress.gov to find relevant bills and to track legislators who voted. This was useful to compare time-series iterations of bills as well as to build profiles for specific legislators. I was able to pick apart trends and see the sentiment from various people.
I also leveraged the education materials and policy briefs from a slew of trade organizations and advocacy groups, including the Diabetes Advocacy Alliance, American Diabetes Association, American Medical Association, Connect Health Initiative, and Health IT Now and the Alliance for Connected Care. Not only did I use this to craft suggested advocacy messaging for Omada, but also I more clearly saw how various players were attacking the issue. This informed our planning around coalition building.
To keep up to date on digital health policy, I turned to the POLITICO eHealth daily newsletter, where my friend, Mo Ravindranath, writes. I also used InsideHealthPolicy as well as set Google Alerts to track keywords. Having a daily stream of insights was invaluable during the midterm elections. I was able to learn what various candidates thought on the subject and could better predict who would take on relevant leadership roles. Oftentimes, these headlines triggered new Google searches and phone calls.
With this historical lens and current happenings, I spent time synthesizing what really mattered and finding patterns across various public and private sector initiatives. This then helped me to design an action plan that would move the reimbursement effort forward. But first, I outlined the key dates in 2019 across legislative, regulatory, and political milestones, allowing me to be mindful of the various events where Omada needed to be in sync. Considering these milestones, I organized initial focus areas and underlying workthreads, including general marketing and advocacy content development, responses to existing preliminary rules and RFIs, direct advocacy, and coalition building.
Lastly, I created an executive summary that included key messaging for private and public stakeholders. Underneath an overarching positioning statement, supporting arguments were included along with relevant quotes from legislators and industry players.
I am proud and excited about my 32-page deliverable and learned much about the mechanics of seeking Medicare reimbursement from a policy angle.
Key learnings include…
- Policy research all about acquiring disparate data and synthesizing it. While the subject matter may be niche, the process of doing market access research in many ways is similar to other desk research. There is much public and private information out there and close attention and hustle will allow you to find relevant patterns that can be used to as a persuasive evidence base.
- Congress is made of an ever-changing group of people. The Congress has many roles for many individuals (e.g., chairpersonship). Many of these roles experience churn, allowing for new ideas and goals to rise and fall. Tracking and predicting the changes in each role can open opportunities to move legislation and gain allies in advocacy.
- Advocacy, enacting political change, is a team sport. Convening an eclectic coalition of similar-minded people and organizations is a much more compelling position when trying to influence policy. The Diabetes Advocacy Alliance includes 21 organizations, such as patient advocacy groups, industry lobbyists, industry incumbents, and digital health companies.
- Medicare’s reimbursement of the DPP (even if not including virtual-only) was a major shift in the program’s benefit design. The DPP is the first therapy in which Medicare is reimbursing a community organization and not a physician / advanced clinician. This was a significant step, made actionable in April 2018, for CMS to think more broadly about who and what can provide care.
- Government entities can disagree, somewhat oddly. While the has CDC ‘fully-recognized’ many virtual-only DPP providers, CMS does not reimburse for them despite much pressure from the CDC. Furthermore, various powerful politicians and voting blocs have acknowledged evidence and called for Medicare to reimburse virtual-only DPP. Yet, the CMS office would not budge. Political influence and what appears to be clear evidence can be persuasive in government only to a degree.
Note: This has been reviewed and approved for publishing by Omada Health