Stephanie Strong, Boulder Care, on democratizing substance use disorder care via telehealth

Vivien Ho
Vivien Ho
Nov 10, 2020 · 12 min read

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In this episode of The Pulse Podcast, we interview Stephanie Strong, CEO and Founder of Boulder Care. We discuss Stephanie’s amazing entrepreneurial journey, Boulder’s evidence-based model of care, access deregulations during COVID, go-to-market and partnerships with your first pilot, and tactical advice for first time healthcare entrepreneurs.

Stephanie Strong has spent her career focused on innovation in healthcare, working to move the industry forward through venture capital investing, entrepreneurship, World Bank-funded research in India, and systems innovation at Duke University Medical Center. In 2017, Stephanie founded Boulder Care, a digital clinic offering long-term care for substance use grounded in kindness, respect and unconditional support. Boulder is backed by great investors such as First Round, Greycroft and angels such as Audrey Ostrovsky, who is the former CMO of US Medicaid.

Prior to Boulder, she worked at a $1.5B venture fund called Apple Tree Partners and held strategy, operating, and board roles with leading startups in outpatient opioid addiction treatment, mobile oncology, dermatology, and palliative care. A graduate of Highest Distinction from Duke’s School of Public Policy, Stephanie previously consulted in Washington, D.C. on emerging programs for Medicaid beneficiaries during the passage of the ACA, among other health policy reforms.

Recording of interview

Start — 06:30: Stephanie’s background

  • Early inspirations of public policy and healthcare: When Stephanie was in high school, Obama was just starting his presidential campaign. She was inspired by the notion that our generation has a key role to play in effectuating equal opportunities, social justice and human progress. She developed a real love for public policy, exhilarated by the idea of systems level change, particularly in health care. When Stephanie had her personal experience with a cancer diagnosis when she was 19, she was interacting with a system younger than most do. She found administrative challenges and seemingly small breaks in the system that had a disproportionate impact on people’s lives. She was inspired at an early age and recognized that changing our healthcare system, the way care is delivered, accessed and financed, was an impactful way to spend a career.

When Stephanie had her personal experience with a cancer diagnosis when she was 19, she was interacting with a system younger than most do. She found administrative challenges and seemingly small breaks in the system that had a disproportionate impact on people’s lives.

  • Choosing a career in policy or the startup ecosystem: She continued to study Public Policy at Duke and spent a semester in DC in 2010 during healthcare reform. She had first hand experience seeing the ACA being passed for the first time after decades of trying. On one hand, she was excited about what was on the horizon. On the other hand, she recognizes that politics is very different from policy and actually implementing these changes was very difficult. Knowing that she still had the same passion for systems level change in healthcare, she eventually found her way into entrepreneurship and venture capital.

06:30–10:00: Founding Boulder

  • Exploring addiction medicine: Through her venture experience she was inspired by entrepreneurs in all industries, but she became particularly passionate about Addiction Medicine through one of Apple Tree’s portfolio companies. In outpatient clinics, she saw patients who were coming in with opioid or alcohol use disorders who were often very sick, but after several weeks of working with their teams, the patients were coming back and looking completely transformed, healthy and happy and talking about their new jobs or reuniting with their families.

10:00–15:00: Diving deep into Boulder’s care model

  • The problem: Currently, over 20 million people in the US struggle with a substance use disorder. On top of that, COVID has been really challenging given that the social impact and context of the disorder are profoundly important in the success for addiction treatment. Due to social isolation, economic hardship, loss of work or access to substances that they physically depend on, we are seeing across at least 40 states major increases in overdose rate year over year.

“Currently, over 20 million people in the US struggle with a substance use disorder. On top of that, COVID has been really challenging…”

  • Boulder Care and its offerings: Boulder Care is a digital clinic that provides services for substance use disorder over telemedicine and is rooted in medication based treatment, with a lot of ancillary support for long term care. Today, Boulder has providers and peer recovery specialists across the country who offer support and link people to local resources to overcome stigma and privacy concerns that people have in an in-person setting.

15:00–20:00: Covid Impact on Policy and Demand

  • Removal of in-person visit requirement: During the public health emergency declaration, one important change enacted at the federal level was the elimination of the mandatory in-person visit for anyone seeking addiction medication treatment. Before this change, only after one in-person visit would the doctor be able to prescribe addiction treatment via telemedicine. This was a huge barrier to access. For example, a patient based in Alaska would have to take three flights to get to the closest program or for anyone who’s ready and feeling a moment of clarity would call different facilities only to find that there’s a six to eight week long waitlist. The original requirement was an unintended consequence of the policy that was meant to protect people from other controlled substances online, but instead has acted as a barrier to treatment for those substances. In 2019, the DEA promised new certifications for telehealth providers to ensure quality of care and patient safety and to lift these barriers. The lift was delayed, and only with the impetus of the COVID emergency, people are recognizing that there is so much you can learn from someone’s social context when you’re invited into someone’s home, or in some cases, their car.

“During the public health emergency declaration, one important change enacted at the federal level was the elimination of the mandatory in-person visit for anyone seeking addiction medication treatment.”

  • Growth in demand for Boulder’s services: Boulder has seen 5X growth in panel size since Jan 2020. A lot of this demand is driven by Boulder’s partnership with Premera Blue Cross which expanded their patient coverage to 2M+ members with no co-pay or out of pocket costs! Outside of this plan, Boulder also opened their virtual doors to all comers, providing access to all patients regardless of their insurance carrier or ability to pay. Further, Boulder’s nonprofit partners at Acumen Impact Investors has helped Boulder treat low income Americans with Medicaid coverage and the under/uninsured.

20:00–25:00: Designing a telehealth services company

  • Boulder’s employment model: Boulder employs everyone they work with including physicians and nurse practitioners, while other telehealth companies have chosen a contract model for physicians. For Boulder, Stephanie emphasizes the importance of making sure their providers are close to their mission and are trained with Boulder’s protocols. Boulder’s value proposition for practitioners is a set of technology tools and service offerings that provide the support they need in terms of compliance, regulations as well as as behavioral providers to help with the psychosocial components.

“We’re trying to really build is a model that rewards outcomes and realigns incentives across payers, providers (Boulder as the digital provider), and the people we care for. And for us, this means not putting the burden on the patient to pay out of pocket, and instead looking to stakeholders who have the greatest economic benefit to gain from treating opioid use disorder in their population.”

  • Building a value-based care model: Boulder’s goal is to create a model that rewards outcomes and realigns incentives across payers, providers (Boulder) and Boulder’s patients. For Boulder, removing the patient’s financial burden, and instead looking to stakeholders who have the greatest economic benefit to gain from treating opioid use disorder in their population — the payer. Boulder’s model includes a lot of services such as text messaging late into the night and pharmacy coordination that are not tied to billing codes but their business model allows them to create a value-based agreement to help bring down their total cost of care per member, in which untreated opioid use can be 550% more expensive

She believes there will be tremendous upside for investors who confidently fund the B2B2C strategy from the outset: prioritizing outcomes ahead of revenue, and deploying patient capital that will ultimately create a major competitive advantage

  • How do you build enough traction to establish payer partnerships? Increasingly, venture investors are recognizing that there is a valuable market for digital health solutions selling into payers, and there is willingness to pay for program efficacy. More investment dollars are going into early-stage companies to accomplish what venture capital is intended for: helping companies — pre-revenue — build the right product and bring it to market. But it’s challenging when digital health entrepreneurs feel compelled to initially sell directly to consumers, just to show what they need to show (in terms of outcomes, demand) to get that first round of funding or work with a payer. This could translate to several years and several million dollars before rolling out the “real” business model. She believes there will be tremendous upside for investors who confidently fund the B2B2C strategy from the outset: prioritizing outcomes ahead of revenue, and deploying patient capital that will ultimately create a major competitive advantage.

“It’s challenging when digital health entrepreneurs feel compelled to initially sell directly to consumers, just to show what they need to show (in terms of outcomes, demand) to get that first round of funding or work with a payer. This could translate to several years and several million dollars before rolling out the “real” business model.”

28:00–34:00: Fundraising advice and milestones and… hiring!

  • Fundraising: Stephanie emphasizes the challenges of fundraising, especially now without the ability to meet someone in person. Although it’s not easy, she is optimistic that persistence definitely pays off. One piece of advice is to find investment partners who are philosophically aligned, which is far more important than the reputation of the firm or the speed to getting that first check. She shares that developing the relationships that will help you for the years to come is a really important decision.

34:00 — End: Advice to first time healthcare entrepreneurs

  • The importance of persistence:

“It’s really important to stick to your vision and mission. Even if there are much easier ways to build a company quickly, it is important to acknowledge that this is a journey, and that managing stakeholders sometimes takes several years.”

  • Look for ways to align your ROI with stakeholders:

“Many of the major governmental, private payers, and health systems are operating under practices that may be very different from a startup or tech company, but look for ways that your company can align and help bring those strengths to those organizations as well as leverage their strengths.”

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