Chris Wasden is no stranger to digital health. As chief strategy officer at Twill (previously Happify) Chris is leading the effort to bring Twill’s platform to the pharmaceutical and healthcare industries. Prior to Twill, Chris was a professor at the University of Utah and executive director of the Sorenson Center for Discovery and Innovation, a digital health game incubator. He is the named inventor of 12 issued patents, has been the founding leader in 10 startups and has held leadership positions at JP Morgan and PwC. ZS sat down with Chris to talk about the challenges of scaling digital therapeutics (DTx), innovative delivery models and the future market landscape.
Tra-My Nguyen: Digital therapeutics is a rapidly growing area, and Twill is one of leading players. Can you give a brief background on Twill and its vision?
Chris Wasden: We call Twill an intelligent healing company. We use our intelligent healing platform, therapeutic intelligence and therapeutic media to provide people with the right therapy, at the right time, in the way they want, in a hyper-personalized manner. At Twill, we work with multiple stakeholders including employers, health plans, healthcare systems and pharmaceutical companies to support patient care. We work across a wide range of conditions including mental health, pregnancy, women’s health, multiple sclerosis, diabetes, rheumatoid arthritis, psoriasis, migraine and cancer, among others. Originally, our focus was supporting patients with mental health solutions, but we have now expanded our portfolio to also support physical conditions, which have a high level of comorbidity with mental health disorders.
TN: Getting DTx into the hands of patients at scale is a challenge the whole sector is still working through. How is Twill thinking about reaching the right people?
CW: I think there’s a number of things that we, as an industry, need to think about differently. First of all, we are a digital product and so we should focus on digital distribution. As a digital product, our distribution and go-to-market strategy is different from traditional pharmaceutical products. Field-force channels commonly adopted by pharmaceutical companies are costly and are limited in their capacity to promote digital therapies. With DTx, we are operating under lower reimbursement economics than expensive biologic therapies. We need to think about different channels: How to leverage telemedicine as a channel of distribution, for example, or how to leverage digital education platforms that offer continuing medical education (CME) to reach physicians at scale.
TN: I’m curious to hear more about how you’re leveraging telemedicine as a channel of distribution.
CW: In telemedicine, physicians typically offer a consultation for a fixed fee, which commonly results in a prescription being written. To get your DTx prescribed like any other product by these telemedicine providers, you’ve got to get into their electronic prescribing systems and payer systems, which is not always straightforward. One way we’ve navigated around these issues is by managing the telemedicine channel directly. With Ensemble, our prescription digital therapeutic (PDT) for major depressive disorder (MDD) and generalized anxiety disorder (GAD)—which is currently available through enrollment in a real-world evidence trial—we have a partner with a telemedicine platform that owns the consultation, diagnosis, prescription and dispensing. With this approach, we are responsible for patient acquisition, which can get very expensive when you’re targeting a specific therapeutic area and population. If you compare it to general wellness companies, their products can apply to almost anybody, so you can activate patients at the top of the funnel at fairly low costs. With our prescription digital therapeutic, we’re only looking for people that a physician will accurately diagnose as having MDD or GAD who also meet our inclusion criteria and do not meet our exclusion criteria for our RWE study. This increases the activation economics substantially. And what that means is that the price of a PDT will need to be high enough to cover that level of activation.
TN: I’ve seen this approach taken by Twill and other players in the U.S. How are you thinking about access and distribution in Europe or other markets? What challenges do you face in scaling DTx across countries?
CW: DTx access gets very complicated in places like Europe because it’s not a single country—the European Union is made up of 27 countries with different regulations and healthcare systems. The problem becomes further complicated by differences in payer structures and levels of reimbursement. The country that is probably most advanced in thinking about DTx access is Germany. With DiGA we see the reimbursement and access barrier largely removed as long as you meet the criteria to be listed on the DiGA. But you still need to figure out the last mile in both getting physicians to prescribe your PDT, as well as for activating patients and getting them engaged throughout the 10-20 weeks of therapy in the PDT.
Access challenges can also arise due to different physician roles and prescribing rights in different countries. For example, in China, only psychiatrists can prescribe medication for psychiatric disorders. While in the U.S., half of all physicians can treat mental health disorders and half of all antidepressant medications are prescribed by primary care physicians. This can be good and bad news: The good news is you can have a very targeted sales and marketing effort in China focusing only on psychiatrists, but the bad news is this means limited access. There are not enough psychiatrists to provide access to care today with drugs, let alone with digital therapies. How you get the product into patients’ hands when you have very limited access based on regulations is a problem we’re all still trying to solve.
TN: Across the range of stakeholders, I’ve seen that gaining physician buy-in is one the toughest steps. What strategies or tactics have worked?
CW: The most difficult stakeholder to convince is the physician. The trick with any new tech is to find the market segment that is most willing to adopt these digital therapies. This could be physicians who are known for innovation or younger physicians who are more open to using new technologies. Given our need to be efficient with sales and marketing efforts, microtargeting within a specialty or across specialties for the types of physicians that are more likely to prescribe an innovative digital therapy is important. This means focusing on the 20% of early adopter physicians initially and not wasting time trying to get the other 80% to adopt at this time.
We’ve also found that having a human element as part of the solution can help with physicians’ comfort. This gets into the evolving business model, which we call “precision care.” At the base of a precision care solution, we have a digital therapy and then you can layer in an AI assistant that provides additional support. On top of this, we have a human coach, therapist, nurse or physician who can be included for additional virtual care. For example, with the currently running Ensemble real-world evidence study, we have a licensed clinical social worker who monitors every patient for high-risk issues. In the current use case, we have a safety monitor who responds in the event of one of several safety triggers to provide resources. The forthcoming commercial product is expected to have a prescriber and care team dashboard with an alert system that could allow for follow-up.
At the end of the day, you’ve got to show physicians that it’s effective, simple and safe and does not complicate their lives.
TN: That aligns with research we’ve conducted with physicians too. At a minimum, you must show that the DTx works and does not add extra physician burden. Let’s talk about pharma. Twill probably has more pharma partners than any other company in this space. What role do you see pharma playing in DTx, now and in the future?
CW: Today, we see pharma interested in offering DTx as a companion product alongside a core portfolio of pharmaceuticals, often as part of a patient support program and in partnership with a company like ours. This is the path of least resistance because it fits into the pharma company’s existing business model and outsources the DTx product development, support, services, activation, engagement and outcomes to the DTx company.
Looking forward, I think one of the wild cards would be combination products. Pharma has been doing combination Rx products for decades with devices like injectors, but no one has been willing to seriously explore an Rx-DTx combination yet. When you think about the value proposition of DTx-Rx combinations, this could give you as much as 20 years longer in the patent life of the Rx product. It would require, however, running a clinical trial to demonstrate how a DTx and Rx combination is more efficacious than the Rx alone. Very few pharma players are investing the money and time to explore this pathway today. But if that door is opened, I think this will create an explosion of opportunities for DTx and pharma companies in the future. Another thing that would create an explosion in DTx-Rx combination is if payers were to demand data from pharma companies regarding medication adherence, clinical outcomes and improvement in quality of life in order to pay for the Rx. Such payer demands would force all pharma companies to have DTx complements, companions or combinations because digital capabilities found in DTx are the only way to gather this data.
TN: What are your projections on how the DTx market will evolve in the next three to five years? What’s the business model that will enable digital therapies to be a successful business?
CW: The only way digital therapies will become successful is by creating a new business model. Trying to copy the Rx or medical device business model will not be successful for DTx. In my view, that model is going to be an at-risk business model—we will only get paid for our DTx products and services by delivering measurable results that improve patient outcomes and quality of life. When you look at companies like Transcarent, they’re an at-risk model, and when you look at Livongo, Omada and Onduo, they’re increasingly an at-risk model. I think we’re going to see digital therapies being paid for predominantly on an at-risk model, where we are only going to get paid for demonstrating outcomes with patients, whether that’s on a population or individual basis.