David Brailer | January 6, 2020
Innovation in digital health outpaces – by a long shot – the adoption of those innovations into daily use in care delivery. This imbalance harms the health and well-being of ill and healthy people and costs the health care system vast amounts through appropriate and unnecessary treatments. A recent announcement by Express Scripts promises to change this and accelerate the pace of digital health innovation adoption.
American health care is an industry with an outstanding commitment to ideation, discovery and innovation. Health care gets the largest share of early stage venture capital, about half of it going to digital health. Tens of billions of additional dollars fund government- and corporate-sponsored research into the development and testing of new digital health solutions such as re-imagined primary care, ICU-at-home, telemedicine, mobile visits, consumer interventions and other ways to improve quality, efficiency and patient experience.
However, for most digital health care innovations – proven ones with real benefits – the road to adoption is filled with challenges and obstacles. Electronic health records were long ago shown to improve primary and secondary prevention and improve quality of drug selection, among other benefits when compared to paper records. Even though their ultimate use was seen as inevitable, they languished for decades, with adoption rates below 5 percent when I became the nation’s first National Coordinator for HIT in 2004. There was no pathway for them to gain traction – only endless regulatory, financial and technological barriers – until the federal government incented and ultimately mandated their use.
[See also: David Brailer’s inaugural Leadership Matters column on why CEOs should support price transparency.]
Numerous digital health solutions, tools and apps have been shown to make a real difference in cost and quality for asthma, COPD, diabetes, obesity, sepsis, atrial fibrillation and a long list of other conditions, but their adoption is slow and patchy. For example, continuous glucose monitors (CGMs), a heavily funded and clinically beneficial device for diabetes patients, remains in the early adoption phase despite years of development. Concerns have been raised in the past about the device’s cost and accuracy, but it seems just as likely that the cause of slow adoption is that CGMs change the way care is delivered just enough for them to be a nuisance. Likewise, telemedicine, which has been shown to be cost-saving and equal in quality for many kinds of treatment, has fought an uphill battle for legitimacy in care.
Like these, many digital health solutions languish despite heavy investment and proof of benefit. There are many reasons for this, but one needs to be called out. Getting providers to embrace digital health solutions has been a special form of hell for innovators. Proven solutions face a gauntlet of cultural, organizational, procedural, administrative, financial, legal and professional barriers in health systems. Providers want to do the right thing, but they are conservative and cautious organizations, and so the status quo wins too often.
Express Scripts, now owned by Cigna, introduced a real game-changer in digital health adoption when it announced a digital health formulary for proven solutions. The digital health formulary is set up just like a drug formulary. Express Scripts vets the technology for efficacy, safety and cost-effectiveness and then negotiates favorable terms for it to be used on patients – just like the latest anti-hypertensive. A health plan can access the digital health formulary and make the products available, in-network, to their patients. When it is prescribed, the digital health company bills Express Scripts, which passes on the cost to the plan with a fee.
Again, just like a drug – controlled, easy to adopt and accountable. The first digital health solution on the formulary is Livongo, the diabetes management tool developed by the serial entrepreneur Glen Tullman. There are more coming.
I applaud Express Scripts CEO Tim Wentworth and Cigna CEO David Cordani for taking this step. A digital health formulary has been discussed for years, but it hasn’t ever happened, leaving digital health outside the arsenal of legitimate health improvement tools. In establishing a digital health formulary, these CEOs have thrown down the gauntlet, and other PBMs and health plans need to pay attention because this is not a passing fad but a move that will endure.
PBMs (or should we now call them CBMs for the array of Clinical Benefits they Manage?) will either have to match this move or lose business. Likewise, health plan CEOs need to think carefully about how they incorporate proven digital health solutions into their current roster of benefits and use their channels to push faster adoption. Providers needs to pay close attention as well. With digital health beginning to scale, the locus of patient management will move from the health system to physicians and plans, taking high-revenue patients with it. This won’t happen if provider CEOs push their organizations to become more agile, more virtual, more digital and to make this change one they lead, not one done to them.
A digital formulary is one of those changes that we will look back on in a few years and see that this was a true pivot point. Think of the life-years that could be added and wasteful spending saved if that were to happen and today is truly day one of a new era.