Issue 001 of E&O Wednesdays

E&O’s fortnightly newsletter on enrollment-focused digital health.

 E&O Wednesdays.

Welcome to E&O Wednesdays, the enrollment-focused digital health newsletter from Exits & Outcomes that’s for paying subscribers only. This fortnightly issue will dig into digital health companies that sell to self-insured employers as well as others that rely on enrollment-based distribution for their digital health programs.

This is Issue 001 and if you like what you see, help me out by forwarding this to that one coworker whom you hold in especially high esteem. Encourage them to join as a paying subscriber too.

Here’s what’s happening this week:

• Hinge Health, which offers tech-enabled musculoskeletal pain care services (AKA, a digital MSK clinic), inked a deal with Healthcomp. The agreement gives Hinge access to 400,000 new members covered by the TPA’s self-funded employers.
• Diabetes virtual clinic, Onduo, which was once a 50-50 joint venture between Sanofi and Google’s Verily, has tweaked its branding to stress its new majority owner. Exactly a year from the Sanofi split, the company now positions itself as “Onduo, a Verily company” in most of its marketing. It also has a refreshed website that clearly de-emphasizes its formerly exclusive diabetes-focus.
• Judging by its Facebook ad activity, Lark Health just kicked off its campaign to enroll members of Medical Mutual of Ohio into four of its programs: diabetes prevention, diabetes management, blood pressure management, and a wellness program that covers smoking cessation, stress management, and weight loss.
• Stress from the election is quantifiable: Ginger’s CEO Russell Glass tweeted that his team has noticed a 25 percent week-over-week increase in daily sessions.
• One more thing… On Monday, Livongo Health submitted its final SEC filing to terminate its existence as a standalone company. The Teladongo amalgamation is now complete.

Was this forwarded to you? Why not become a paying subscriber to Exits & Outcomes today? That 2020 budget isn’t going to spend itself. Head to the pricing page of E&O right here.

Virta Health’s $2.9M VA deal

Virta Health has partnered with the Department of Veterans Affairs (VA) since March 2019. In May of that year, the two first announced a 400-person pilot that was a freebie for the VA.

“This diabetes care will be provided for up to one year at no cost to VA or Veteran participants,” the VA stated in its release.

What hasn’t been reported yet is that the pilot went well enough to lead to a paid contract a year later.

In April 2020, the VA signed a $1.3 million one-year deal with Virta that could extend into 2022 and ultimately be worth as much as $2.9 million. The VA still considers this a pilot, however, as it described it as such: “Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Telehealth Diabetes Reversal Pilot.”

A paid pilot though, so, progress.

Interestingly, Virta Health has only ever spent $60,000 on lobbying at the federal level. It spent all of that during the first half of 2019. Yes, that’s when it announced its freebie pilot with the VA.

It also only lobbied on one issue. You guessed it: “Efforts to promote access to diabetes treatment services for veterans.” It sent lobbyists to the House, Senate, and the VA. Read one of its lobbying disclosure forms here if you’re curious.

Omada Health’s RCT is for CMS

OK, that’s a bit strong. It’s for a few other payers as well, but really this the big swing to convince CMS to finally include digital programs in its reimbursement of DPP. Before we get into the study and its potential to sway CMS, let’s recap a little recent Omada history.

A few salient points from E&O’s Omada Health Report:

• Until this study, which it started in 2017, Omada hadn’t done a randomized control trial: “Omada has found that cohort studies have worked well in its case because no payers are worried that people are going to automatically lose weight without some kind of intervention. There are countless randomized studies for in-person weight-loss interventions with control arms that show this never happens.”
• CMS almost included digital diabetes prevention programs (d-DPP) like Omada’s in its plans to reimburse DPP — and it even announced that it would — but then it punted on finalizing the decision until the new administration took over: “When the Trump administration took office in 2017, the new leadership at HHS and CMS reviewed the plans to reimburse for DPP. By July 2017, CMS proposed that the reimbursement program should not include digital or virtual programs. Since the original DPP study did not include digital programs, CMS argued they did not have the statutory authority to include them in the reimbursement policy.”
• It wasn’t just the (supposed) lack of evidence. The Trump administration’s CMS also raised concerns about “providing potentially valuable devices, like cellular-enabled weight scales, to Medicare beneficiaries as incentives to sign up… [and] fraudulently billing for weight loss not verified by an in-person coach.”

Omada really thought the CMS decision would break their way, by mid-2016 they even started recruiting a person to run Medicare development at the company.

Anyway, there’s a bit more to the story, which you can read in the full report.

Omada Health’s RCT was officially called, Preventing Diabetes With Digital Health and Coaching for Translation and Scalability, which, if you squint really hard and skip a few important words, happens to work out to a catchy acronym: PREDICTS.

PREDICTS included 599 participants who were randomly assigned, and the study was double-blinded for both the investigator and the outcomes assessor. The topline results found:

• Omada participants on average reduced A1c by 0.23 percent at 12 months, a bit more than the 0.15 percent seen in the comparison group.
• 58 percent of Omada participants reduced their A1c to the normal range 12 months vs 48 percent of the comparison group.
• Omada participants saw an average weight loss of 5.4 percent at 12 months vs 2 percent weight loss in the comparison group.
• 44 percent of Omada participants saw weight-loss of 5 percent or greater vs 21 percent of the comparison group.

Coincidentally, Omada also shared some results for participants in the study who were 65 and up. Results for this group were even better than the general results, and that’s clearly a message intended for CMS and Medicare Advantage plans.

• The 65+ cohort in the Omada group on average reduced A1c by 0.28 percent at 12 months, a bit more than the 0.12 percent seen in the 65+ cohort in the comparison group.
• The 65+ cohort in the Omada group also saw an average weight loss of 6.1 percent at 12 months vs 2.1 percent weight loss for the 65+ age group in the comparison group.

It also strikes me as significant — even if it is just a coincidence — that the results of this RCT dropped Tuesday, November 3, 2020. That’s the day the US voted to elect a new administration.

I think it’s safe to predict that we will see a more accepting attitude toward d-DPP from the Biden administration’s CMS.

Fortune 500 Digital Health Stack: Walmart

Digital health companies love to boast how many customers they have in the Fortune 500. This recurring feature of E&O Wednesdays will dig into a different Fortune 500’s digital health stack each week.

For Issue 001, I took a look at Walmart, which is sometimes called the largest private employer in the world thanks to its 2.2 million employees worldwide. That size obviously comes with a lot of power.

Famously, Walmart tanked Castlight Health’s stock in 2018 after the retail giant informed the digital health company that it was ending its six-year partnership. Fair warning to the nine digital health companies listed below.

Here’s how Walmart’s digital health benefits stack looks as it moves into 2021:

Grand Rounds helps Walmart employees find a doctor. The digital health company promises to help users find “top-ranked doctors” and figure out whether their prices are fair. It also promises to help users make sense of their health benefits and make sure they know what is and isn’t covered. Grand Rounds also offers Walmart employees phone-based second opinions from doctors. Finally, Walmart employees in North and South Carolina have access to a more concierge-like version of the service that includes phone support. They can even help find childcare for people during their physician’s appointments. Walmart is working with Grand Rounds to expand this more advanced offering to other states. Site

Doctor On Demand offers Walmart employees (enrolled in most medical plans) online video visits with a $0 co-pay for medical, psychology/therapy, and psychiatry-related visits during the pandemic.

Thrive Global, which was founded by Arianna Huffington in 2016, powers a wellness challenge for Walmart employees. Thrive ZP offers monetary rewards to participants who commit to making small changes in their daily lives. Site

Agile Health has partnered with Walmart on a number of digital health programs. The company’s myAgileLife interactive text messaging service is free to Walmart employees. It helps participants build mental and physical skills to better manage stress. It also offers monetary rewards. Site Agile Health is also behind one of the two smoking cessation programs that Walmart offers employees: Kick Buts. Like myAgileLife, Kick Buts is text messaging-based but a bit more of a coaching program. Site

Sharecare/MindSciences: Sharecare snapped up Dr. Jud Brewer’s MindSciences over the summer. Have to imagine that MindSciences biggest customer, Walmart, helped drive that deal. MindSciences powers the other smoking cessation app for Walmart employees: Craving to Quit, a 21-day mindfulness-based smoking cessation program. Site

Fresh Tri might technically be more of a homegrown program, but it operates as a digital health startup trying to sell to other self-insured employers too. Fresh Tri is a diet-focused, weight-loss program built by neuroscientists and incubated inside Walmart. Instead of tracking and calorie-counting, Fresh Tri app aims to build healthy habits slowly, naturally, and with a focus on changing the participant’s mindset toward food and weight-loss. Site

Supportiv is an anonymous group chat offering that helps Walmart employees deal with various behavior health issues, including stress, sadness, work problems, relationships, anxiety, depression and more. In addition to the moderated, anonymous support groups, Supportiv has a library of resources with tactics to cope. Site

Talkspace is sort of available to Walmart employees via Resources for Living (more on that below), a program developed by Aetna. Talkspace provides online chat therapy with therapists. This offer seems like a bit of a promo — Walmart employees have access to a complimentary 10-minute live video session with a therapist with this benefit. After that, they have to pay for it like the rest of us. Site

98point6: Technically, this is not a benefit offered by Walmart to employees. However, the company does point its associates to 98point6 because of a deal the digital health company inked with Walmart subsidiary Sam’s Club. 98point6 offers text-based access to doctors 24/7. This offering requires a $20 upfront payment and another $1 for every visit. This is a resource Walmart also sends employees to if they are not enrolled in one of its medical plans, which I imagine is mostly part-time workers? Site

Resources for Living/Aetna: This program from Aetna is another support program that connects Walmart employees with a variety of care programs. Think of it as an offering in the social determinants of health space. Site

Walmart has other partnerships in digital health, of course, that could end up as benefits to its 2.2 million employees. I’ll add them here if they do. Which Fortune 500 Digital Health Stack would you like to learn about next?

Vida Health’s big Ambetter-Centene push

Speaking of Fortune 500 companies, did Vida Health poach Boeing from Livongo Health this summer? It seems like Vida’s deal with Boeing quietly showed signs of its existence in August, while there’s some indication that Boeing’s deal with Livongo is over as we move into 2021. Vida has a much broader suite of offerings than Livongo, but it looks to be offering Boeing employees programs with the same focus areas as Livongo’s. (I’ll try to get an update on this for the next issue.)

Wonder if that was a casualty of the Teladongo merger? And don’t forget: Teladoc is actually one of Vida Health’s investors — it contributed to Vida’s $30 million round in mid-2019.

In any case, Vida Health has a bigger customer base than it lets on, including a big deal with Centene that brings Vida’s programs to the payer’s expansive list of Health Insurance Marketplace plans, which are all co-branded with the payer’s Ambetter brand.

I’m not sure either company has ever announced that they are working together.

Right now, Vida Health is marketing to members of Centene Health Insurance Marketplace plans (AKA Obamacare) in at least 11 states: Nevada, Kansas, Florida, Texas, Arizona, Ohio, Missouri, Georgia, Arkansas, Washington, and New Hampshire. The ads offer what looks to be the full list of Vida programs. Here’s the key text:

“Whether you’re focused on nutrition, weight loss, mental health or overall wellbeing, your coach or therapist will personalize a plan for you — then guide you every step of the way. All at no cost to you.”

13 fees at-risk in Virgin Pulse’s contracts

Like most of you, I spent my Sunday reading through a 58-page contract that Virgin Pulse and Arizona’s Maricopa County entered into a few years back but have amended a few times over the years. Yes, that’s one of the voting districts that came under fire — and is still under fire, really — during the 2020 presidential election.

Rest assured: Virgin Pulse provides a suite of health programs to the civil servants of Maricopa, including some stress management ones.

What struck me about the contract, however, was the long list of money-back-guarantees — performance-based fees — that are included in the Virgin Pulse contract. The company puts a small percentage of most of its fees at-risk using various measures of accountability. Is this common to have this many at-risk fees?

Here’s a sampling of the money-back-guarantees that Virgin Pulse made to Maricopa:

• 50 percent of Virgin Pulse’s implementation fee is at-risk. 25 percent can be lost if the county’s stakeholders don’t award the company an 8/10 on average in a survey that asks about satisfaction with the rollout of the program. The other 25 percent is at-risk if the program doesn’t roll-out on time as promised.
• 3 percent of fees related to running the Virgin Pulse portal are at-risk if the company doesn’t hit certain customer service metrics. It needs to answer 95 percent of emails within 24 hours and 80 percent of all calls need to be answered within 40 seconds.
• Another 3 percent of the Virgin Portal fees are at-risk based on the website’s uptime. The guarantee is for 99.5 percent of up-time each quarter. There is another 3 percent for a similar metric related to the site’s speed.
• Another 3 percent of the portal fee can be lost if 80 percent of participants in Virgin Pulse don’t give it an 8/10 in a satisfaction survey where at least 20 percent of the participants respond. A similar survey result is needed from the program’s administrators to hold on to still yet another 3 percent of those fees.
• Virgin Pulse also has participation rate guarantees: 60 percent for the first year, 65 percent for year two, and 70 percent for year three. This comes with a lot of caveats to ensure the county upholds its end of the program — incentives, marketing, etc. This annual guarantee also puts 3 percent of the fee at-risk.
• Coaching fees are also put at-risk. Member satisfaction has to hit 8/10 again with a minimum of 100 survey responses or Virgin Pulse loses 2 percent of the coaching fees.
• Another 3 percent of the coaching fee is at-risk for nutrition, physical activity, and smoking cessation outcomes. For example, 25 percent of participants need to achieve a meaningful improvement in their nutrition, where the number of fruits and vegetables consumed per day is a key part of the calculation.

Again, I’m curious — is it unusual to have so many of these in the contract?

And so ends Issue 001 of E&O Wednesdays. Did you learn anything? Let me know what you think of this first attempt by hitting reply. All feedback is most welcome.