How are insurance companies / Payers interacting with digital health start ups? 

Insurance companies and payers are increasingly partnering with digital health startups to improve member engagement and health outcomes. Startups like FarmboxRx, Bold, and Summer Health offer solutions that align with health plan goals such as reducing costs and improving care.

FarmboxRx provides healthy food boxes with educational content, helping health plans address food insecurity and promote preventive behaviors like screenings and vaccinations. Bold focuses on fall prevention for older adults with virtual exercise programs, reducing Medicare Advantage plan costs. Summer Health offers pediatric telehealth services, helping to reduce ER visits and ensure well-child visits.

These startups are creating engaging platforms that help health plans meet key metrics, improve outcomes, and reduce costs by fostering member participation in preventive care.

What is the standards for digital health startups to join payer plans?

• Early Engagement with Payers: Startups should engage with public and private insurers early, ideally during the product design stage. This helps ensure their tools align with payer goals and integrate into existing healthcare ecosystems.

• Interoperability and Data Standards: Digital health tools must meet standards for interoperability and data use, as payers are increasingly looking for solutions that can easily integrate with other services and platforms within the healthcare system.

• Aligning with Payer Priorities: Developers must understand the specific needs and motivations of different payers. For private insurers, the focus is often on creating customer engagement and reducing costs, while public payers prioritize access to care and cost reduction. Tools must be designed with these priorities in mind.

• Participation in Programs or Frameworks: Public payers may offer programs (e.g., India’s Market Access Program) to help digital health tools meet specific criteria. Successful startups can gain access to simplified procurement processes, investment capital, and support from healthcare and technology experts.

• Adaptable Business and Payment Models: Startups should be ready to adopt business models that cater to the specific needs of payers, such as licensing agreements, fee-for-service models, or participating in accelerator models that support scalability and cost reduction.

Do payers provide enough reimbursement for digital health services? 

Payer reimbursement for digital health services, including Digital Therapeutics (DTx) and In Vitro Diagnostics (IVDs), is not uniform across countries and remains a complex issue. Some countries, such as Germany, are advancing reimbursement for DTx through fast-access pathways like the Digital Health Applications (DiGA) system. France is working on a similar system for faster DTx reimbursement. In the US, coverage is available through private insurance and federal programs like Medicaid and Veterans Affairs. However, the overall reimbursement landscape is fragmented, with varying definitions, evidence requirements, and payment approaches across different regions.

As a result, while some countries are making progress in reimbursing digital health services, the level of reimbursement is not always sufficient or consistent across markets, and it can be a barrier to wider adoption and commercialization of these technologies.

What data is meaningful to payers, especially value based payers? 

• Quality Data: Measures of care effectiveness, such as whether treatments are evidence-based and achieve desired outcomes. It also includes data on patient safety, timeliness of treatment, and patient-centeredness, ensuring care aligns with patients' preferences and needs.

• Cost Data: Information on the cost of care, specifically focusing on reducing unnecessary high-cost care, such as hospital admissions or emergency department visits. Payers value data showing how care providers manage costs while maintaining or improving quality.

• Equity Data: Data that demonstrates whether care is delivered equitably across different populations, especially marginalized groups. This includes tracking health disparities based on factors like race, gender, and income, and measuring how well providers address these disparities.

• Outcome Metrics: Specific performance outcomes tied to financial incentives, such as reduced hospitalizations or improved health outcomes for certain conditions.

How do Medicaid coverage programs work with digital health companies? 

Medicaid presents a unique and promising opportunity for digital health companies, given its large reach and high unmet needs. Companies are addressing key challenges like limited provider capacity, low enrollee engagement, and data utilization. Digital solutions, including telemedicine, remote monitoring, and workflow tools, are helping expand provider capacity and improve care, especially for underserved populations. To boost enrollee engagement, digital health tools are combining technology with community outreach, helping individuals navigate complex systems. Data analytics also support Medicaid programs by identifying social risks and optimizing care. With the shift toward value-based care, digital health companies are well-positioned to help Medicaid improve outcomes and manage costs through preventative care and specialized services.

Which types of digital health companies have had successful growth with payers?

Several digital health companies have had notable success with payers by focusing on solutions that enhance efficiency and patient outcomes. Cohere Health uses AI to streamline prior authorization, ensuring quicker access to care for patients while benefiting health plans. Garner Health helps patients find top-performing doctors using data-driven tools, while Strive Health applies predictive data to identify kidney disease early, resulting in better outcomes at lower costs. These companies are gaining traction with payers by offering value-based solutions that drive improved care delivery and reduced costs.