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

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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.
• A stint in healthcare investing: Stephanie absolutely loved working in healthcare venture investing. Stephanie tried to be helpful to portfolio companies however she could, and worked closely with management teams. She notes that there are many different ways VCs can support founders that she couldn’t fully appreciate until becoming a founder herself. While making connections and driving relationships is sometimes very useful, time is a startup’s most precious resource: even small things such as building a slide deck and just offering an extra set of hands in a resource constrained company is tremendous. Ultimately, the founder of the portfolio company that she worked in the addiction medicine space also became an early investor in Boulder.

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.
• Founding Boulder: She realized that even though there are really effective ways of treating substance use disorder, these treatments were not easily accessible in the country. Even though she never planned to go into the operating side or found a company, the idea was so compelling and the mission was important.
• Finding instrumental first hires and co-founders: In the early founding days in Brooklyn, New York, Stephanie spent several months talking to as many people as possible, and got a lot of advice from early mentors. In retrospect, these conversations helped her refine her thesis, create a compelling argument about the problems she aimed to solve, and ideas began to crystalize into a business plan. She shared that Josh Kopelman at First Round was instrumental in their early days and was one of their leading investors in Boulder’s seed round. He even introduced Stephanie to her now CTO, David Lerman. She shares that one of the most rewarding things about Boulder’s early culture was bringing together diverse perspectives and sharing best practices across clinicians, researchers, and more traditional Silicon Valley product/engineering startup teams.

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.
• Telehealth program: The current system promotes 30 or 90 day inpatient stays with scarce follow-up post-discharge, or office-based outpatient programs that require multiple trips to clinics, counselors, the pharmacy, and labs: all in different places and between providers that aren’t necessarily talking to each other. The overall patient journey is incredibly complex, adding to the typical complexities of the US healthcare system such as insurance/financial frustrations and access gaps for specialty services. Telehealth is a great way to very quickly expand access.
• Medication-based program: Boulder Care’s addiction program includes prescription to drugs like Buprenorphine or Suboxone, which are the gold standard for treating opioid use disorder. Beyond its high effectiveness, these drugs are also really affordable compared to inpatient residential stays, or many other options that have traditionally been the first line of care. There are multiple stages of a disease and getting treated early, also known as harm reduction, and helping people be safe and meet their own individual goals contributes to incredible improvement in health outcomes and savings for the system.
• Data-driven care: Foundational to everything that she and her team does at Boulder is clinical quality and evidence-based medicine. She shares that there are many case studies internationally and in pockets of the US that show that when access is expanded to medication based treatments, we see lower overdose rates. For example, when the French government chose to take down some of their regulations that were constraining access to buprenorphine, they saw their national overdose rate decrease 80% in just three years.
• Personalized and personal care: Boulder Care’s model also emphasizes and tracks the goals of the individual and what matters to them. For example, goals such as making sure custody is not being taken away or spending more time with family on weekends.

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.
• Importance of evidence-based outcomes: Stephanie emphasizes the importance of measuring and delivering outcomes in digital health, especially in addiction medicine, an industry mired by misinformation. Boulder is also leading a number of research studies, including one funded by NIDA (the NIH) in partnership with OHSU in Oregon.
• Picking outcome KPIs: Boulder’s most important outcomes are retention in care, patient satisfaction and functional outcomes beyond just the medical, but also thinking about the whole person. Now Boulder also has a much larger panel to see replicable outcomes from previous pilots. In terms of measured outcomes, Boulder has achieved 90% retention in care at six months and at twelve months (which is above an industry average of 30–40%) and an NPS score of 91.
• Picking go-to-market: Stephanie shares the pain with every healthcare services entrepreneur that go-to-market is not an easy path. Healthcare is a very traditional industry and companies like Boulder are trying to bring new solutions in government and private institutions that have their own way of doing things. There is tremendous work that goes into developing a partnership that aligns the ROI between both the provider and the payer. While there are very successful companies that market direct-to-consumers with self-pay, they generally work around the current system to provide a better consumer experience and allow access to services or products more conveniently. Stephanie believes the healthcare services startups that are working within the system and seek to realign incentives across stakeholders are some of the most exciting solutions.

“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.
• Milestones for Series B: Boulder made the strategic decision to go deep in their first geographic region, rather than go for national expansion. By focusing on the Pacific Northwest, Boulder will be able to capitalize on organic growth by building relationships with major referral sources. Their goal is to prove out their model in the Pacific Northwest, and then show that they can scale with payer partners across the country. Beyond showing volume and growth, they hope to continue to see marketing and cost of acquisitions go down and continue to show great outcomes at scale. Series B will be about national expansion and continuing to scale their technology to take more of the burden off care teams.
• Boulder is hiring! Stephanie shares that they are hiring in many functions including operations and marketing. See their hiring link here. Stephanie talks about the importance of building a cohesive and diverse culture and that they are always seeking people who are excited and passionate about bringing together services and technology to ultimately serve patients.

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.”