Considerations regarding opportunities to increase payer and provider uptake of prescription digital therapeutics into clinical practice to optimize care for patients with behavior-driven conditions.
Megan Coder, PharmD, MBA: Dr Luo, looking at this from the notion of increased access and adoption, what would you think is required to increase this among patients and providers? Dr Peskin, we’ll loop you in for the payer perspective too.
John Luo, MD: Patients are ahead of us as providers already because they’re very—I don’t want to say desperate, but really looking for solutions, especially if there’s going to be a wait time to see their provider or to get access for the next appointment. I’ve seen this over the last 20 years. Initially patients were slow at adopting technologies, but now people download apps without thinking to check on issues of privacy or where or how their data are being used. It’s almost as if people believe it’s free and easy, then let’s go for it versus wanting to vet it. For patients, it’s less of an issue as along as it provides hope, which is really what they want.
They want hope that something they use will help them feel or live better. From the provider perspective, we’re getting better at adopting technology. It used to be said before that psychiatrists were notorious for being the least tech savvy, but I don’t think that’s the case anymore. However, we still exercise more of a critical judgment than patients. As Dr [Nidal] Moukaddam mentioned earlier, what is the scientific basis of this app or digital therapeutic? Has it been proven in a clinical trial?
Does the theory make sense? We’re much more hesitant, only because we really want it to be effective when we offer it to the patient. Especially using apps as an example, it’s hard to know what works well for people in addition to the security and privacy concerns. Although I’m pretty tech savvy, I cannot deconstruct an app and make sure it’s not sending data to China or Russia or elsewhere. I must depend on the store to vet and confirm that this is done in a secure and appropriate matter. The same philosophy goes for reading privacy logs and statements. No person reads 20 screens of verbiage that says your data will be stored here and done for this purpose. Most often, people scroll through these agreements, click yes, and move on.
For providers, we tend to be a little more hesitant because we like to have some help in knowing that the product that we’re recommending has been useful. Comparatively, these apps are like new medication that’s available. We want to see the studies. We want to see what the reports are in terms of benefits and adverse effects before we’re comfortable with prescribing it.
Megan Coder, PharmD, MBA: Given that these have FDA clearance for the most part, especially those that are prescribed, I imagine that’s another level of confidence you have as a provider, knowing that it has undergone a study and has clearance with HIPAA [Health Insurance Portability and Accountability Act] and other aspects of security to protect patients.
John Luo, MD: I agree. The FDA approval is a gold stamp that says, “Yes, this is actually a product that we have confidence in.” That reassurance would help providers in recommending them to patients.
Megan Coder, PharmD, MBA: Dr Peskin, I would be interested to hear what you believe the challenges are and the ways to improve access to widespread adoption of these products.
Steven Peskin, MD, MBA, FACP: It certainly is one of those Clay Christensen disruptive innovation possibilities. I agree with Dr Luo when he mentioned folks going to “Dr Google” and all the other junk out there. There’s a book a friend of mine wrote, called Tabloid Medicine, that covers anti-vaxxers and other conspiracy theories that have been debunked. Yet for digital therapeutics that are vetted, as you mentioned by the FDA, I do see it as an opportunity for very significant interventions that will not disruptively disintermediate health care professionals. I do see it as a harmonization.
Certainly, there could be some opportunities where most of the behavioral health in the United States is delivered by family physicians and general internists. Psychiatrists are significantly overwhelmed, and it would be great to give psychiatrists an opportunity to do more than prescribe drugs. Perhaps digital therapeutics can help bring back some of the cognitive behavioral therapy and the talk therapy that is so important.
Regarding depression, SSRIs [selective serotonin reuptake inhibitors] and NSRIs [serotonin–norepinephrine reuptake inhibitors] are just barely better than the placebo. I’m optimistic about the prospect of digital therapeutics improving outcomes in major depressive disorder, generalized anxiety disorder, bipolar 1 and 2, and substance use disorders.