Omada's Paul Chew, MD: From Treating Chronic Disease to Prevention

For years, Paul Chew, MD, commuted from his New Jersey home to Paris, France, where the pharmaceutical giant Sanofi Pasteur has its headquarters. A cardiologist and former faculty member at Johns Hopkins, Chew served as senior vice president and global chief medical officer at Sanofi,¹ where he helped develop therapies to treat cardiovascular disease, the number one killer in the United States,² and diabetes, which has been on the rise for decades and now affects 30.3 million Americans.³

However, in January, Chew’s career path took him in different direction—literally. He now travels back and forth to San Francisco, California, where he is the chief medical officer at digital behavioral health provider Omada Health. The company is harnessing technology to help people with prediabetes make lasting lifestyle changes to halt the chronic diseases that kill too many Americans, changes that evidence shows few can make on their own.

Chew visited Evidence-Based Diabetes Management™ (EBDM™) for an interview to discuss his transition from treating chronic disease to preventing it and how managed care companies—and employers—should weigh evidence when selecting a digital behavioral health provider.

Eighty-four million people have prediabetes, a condition of elevated blood glucose that falls short of a diabetes diagnosis.³ Chew calls prediabetes “the waiting room” for chronic disease, but he says identifying it represents an opportunity. With the right lifestyle intervention, this condition can be reversed. Evidence going back to the original study of the Diabetes Prevention Program (DPP) showed the right combination of dietary changes, exercise, education, and support can reduce the likelihood of progressing to type 2 diabetes (T2D) by 58%.⁴

Companies like Omada are built on the idea that the flood of Americans headed for T2D is too staggering to wait until people are sick to treat them. With an aging population and more proof of diabetes’ links to Alzheimer’s, failing to invest in prevention means diabetes will eventually lay claim to more than the third of the Medicare budget it already devours.^5,6

Yet 15 years after the original DPP study, and more than 7 years after the CDC launched the National DPP to make the program more accessible,⁷ uptake remains limited. There are many reasons: Physicians may be unaware, managed care plans may not be promoting DPP, but most of all, traditional face-to-face programs simply don’t fit into schedules or are located too far from rural residents where diabetes rates are high.

That is where there is hope for digital health—it has the potential to scale DPP to the millions who need it.⁸ Chew said Omada has worked with groups like the American Diabetes Association and the American Medical Association to help digital DPP reach places where face-to-face programs will never go. This is the case that Omada and other digital health providers will make in the coming weeks, as they try to convince CMS that they must be included when Medicare offers the DPP starting in April 2018. As Chew points out, Omada has published peer-reviewed research to show its programs produce both transformational weight loss and rapid return on investment, making the case to payers and employers that the investment is worth it.^9-11

Chew is optimistic. Despite the issues digital providers face, CMS’ decision to fund DPP in fee-for-service Medicare is a breakthrough.

And the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) will give physicians more incentive to refer patients to diabetes prevention, especially if they use the Merit-Based Incentive Payment System (MIPS) in the early going.

Compared with his days in the pharmaceutical sector, Chew says success in the world of preventive medicine is defined differently. When a new therapy is created, “it’s 1 patient at a time and 1 pill or 1 injection at a time. The physician and the patient can see the benefits very quickly, and that was very gratifying,” Chew said.

“When you talk about prevention,” he added, “you’re talking about a much larger group of people. Eighty-four million people have prediabetes in the United States; 90% don’t even know it. Diabetes prevention through a digital platform can approach this problem on a population level and in a very patient-centric way, through diet, exercise, lifestyle intervention, and counseling. All of these are safe, effective approaches for most people who can participate. So this is quite different, in the sense that the patient is part of the solution.”

Adoption of Diabetes Prevention Strategies in the Era of MACRA

EBDM™: The CDC just announced that 30.3 million Americans have diabetes. Prevention clearly needs to be priority, but there is a lack of provider awareness about available options. The health system has been slow to integrate prevention into routine care. How can payers work with providers to build awareness about prevention?

CHEW: What’s not known is that 12% of Americans have diabetes, and 35% have prediabetes. It’s even more amazing that 90% of those who have prediabetes don’t know it.³ The problem we have is that there’s lot of clinical literature that shows that behavioral counseling and dietary management can reduce the incidence of diabetes in those at risk by more than half. The problem we have is not the lack of literature but the fact that it has not been translated into practice for the benefit of people and to prevent them from becoming patients.

The main reason is that there is a system that has not been reimbursing or recognizing the value of prevention. The other issue is that this problem is so massive, with more than 84 million Americans having prediabetes, that it is literally impossible to address it in the old, traditional way. So we need proven digital approaches, where return on investment and publications can validate the approaches to make this a reality. Finally, one of the bright spots is that CMS will be encouraging prediabetes testing and prediabetes referrals, so that sort of alignment of the medical need, the incentives, and benefits can be brought closer into harmony.

EBDM™: Has the implementation of MACRA increased provider awareness or sped adoption of digital health? Conversely, is there any concern that the “pick your pace” approach with smaller and rural providers will slow adoption in areas where diabetes rates are highest?

CHEW: One of the most significant advances for the problem of prediabetes will be the MACRA and MIPS incentives for referral to programs—validated Diabetes Prevention Programs—as well as testing for prediabetes through the MACRA and MIPS initiatives. People at risk for diabetes live all over the country; some are closer to Diabetes Prevention Programs than others. So to reach the more than 84 million people at risk, we need a combination of both face-to-face as well as digital programs.

EBDM™: Beyond just the financial, what are the costs—for providers, patients, payers, and health systems—of the lack of adoption of diabetes prevention?

CHEW: One of the things we learned in medical school was that diabetes can affect you literally from the top of your head to the bottom of your feet. Diabetes is the leading cause of stroke—in your head—and it’s the major cause of blindness in adults. It can cause heart attacks. It can also cause kidney failure and neuropathy—from the top of your head to the bottom of your feet. And the reason for that is the effect of diabetes on your whole vascular system. So that is the biggest medical problem. It’s the leading cause of nontraumatic amputation as well. Prediabetes is the best bad news you could get because it allows you the opportunity—through lifestyle, diet, and exercise—to reduce that risk [of diabetes] by more than half. A digital Diabetes Prevention Program will allow this sort of benefit to reach people who are inaccessible to face-to-face programs, who may not want to go to face-to-face programs, and who are more comfortable with a self-paced program.

EBDM™: Beyond the clinical benefits of preventing progression to T2D and heart disease, what are the other positive effects from Omada’s intervention?

CHEW: One of the reasons I went to Omada is that it is a research-based program. We’re seeing not only the clinical benefits of diabetes prevention but also the financial benefits. Omada has published articles showing the return on investment⁹ and the reduced need for prescription drugs and hospital interventions.¹⁰ So it’s important [to ask] when you select a Diabetes Prevention Program, “Has it been validated for its clinical endpoints as well as its financial return on investment?”

The Role of Employers in Diabetes Prevention

EBDM™: Why is it important to engage employers in diabetes prevention?

CHEW: Omada is approaching a problem that is found with every workforce. We estimate that 30% to 40% of people in the American workforce may be at risk for prediabetes. What elevates the risk? If you’re 45 or older, if you have a close relative with diabetes, if you’re a member of a minority group, and if you’re overweight or obese. Those factors are found in a large number of Americans in the workforce. We feel strongly that the workforce, where you spend so much of your time, is a great opportunity for employers to reduce their costs and to improve the overall health, well-being, and enthusiasm of their employees.

EBDM™: How should an employer evaluate a digital health program?

CHEW: One of the most important things that face employers—in fact, the nation overall—is the ballooning cost of healthcare. For employers, I would suggest they look at their organizations for the major healthcare costs, and I’m sure it will be diabetes, cardiovascular diseases, and obesity at the top. They should look at potential solutions that can reach the broadest number of people when they need it, when they want it, at home, at the office, or even at restaurants, where they can access a digital program. They should look for publications that validate [their corporate approach] in terms of clinical outcomes and return on investment. They should also look at a digital solution or a face-to-face solution that can be accessed and help the employer reach as many of their employees as possible. We know there are initiatives that are not taken because the approach or engagement of employees is just not there.

The Role of Managed Care in Diabetes Prevention

EBDM™: How does an intensive behavioral counseling program like Omada’s differentiate itself from weight-loss programs or apps?

CHEW: The most important concept we must realize is that diabetes prevention is more than just weight loss. It’s a change in your lifestyle in terms of healthy eating, exercise, and a change in mind-set. It’s not a cosmetic approach but an approach that will internalize the benefits of these interventions to reduce your risk of chronic disease—not only of diabetes but the risk of cardiovascular disease as well.

EBDM™: One of the big obstacles for digital health has been integrating into the physician and care team workflows. How has Omada approached this problem?

CHEW: Integration into the medical workflow is very important. Working as we have at Omada through optimizing the patient portal, [mediating] between the patient and the physician so they can communicate more effectively is one way. We also work with the electronic health record—these are initiatives we have under way.

EBDM™: What specific roadblocks have you seen within managed care settings?

CHEW: Managed care settings have so many competing priorities nowadays that we must be very clear that the coming tsunami is one of the biggest ones they must address—and that is chronic disease. More money is spent on chronic disease than infectious disease. As the population ages, the cost of chronic disease will be even greater. Diabetes prevention can reduce the cost of cardiovascular disease, kidney disease, and neurologic disease, and it’s something that can be seen—with the publications that we have, we’ve modeled the [return on investment] to be within a couple of years.^10,11 It’s a clear and present danger. And we believe it’s a clear and present return on investment.

EBDM™: Where have managed care organizations “gotten it right” when it comes to digital health adoption?

CHEW: It’s a very early area, so it’s hard to say there’s a successful digital adoption [in managed care]. The ability to make an appointment through a patient portal or to get refills—those are rudimentary digital approaches to healthcare. We have found, for example, that wearable devices, though helpful, need to be supported by intensive behavioral change. That’s why we believe Omada—with its publications, approaches, and 120,000 participants to date—is one solution that should be considered when it comes to diabetes prevention and cardiovascular disease prevention.

Implementing the Medicare Diabetes Prevention Program

EBDM™: As you know, CMS has proposed delaying full participation of digital health providers in the Medicare DPP when it launches in April 2018. Is the CMS’ call for more evidence legitimate, or is this barrier emblematic of others that digital health has encountered?

CHEW: One of the greatest innovations in the digital approach or the diabetes prevention approach has been the CMS program that will go into effect next April. As you may know, at this stage [the CMS is] approving and reimbursing DPP programs that have been approved or certified by the CDC. They are still getting comments for digital diabetes prevention. We feel very strongly that the evidence base for seniors is already strong for diabetes prevention. We’ve published 2 articles on the effectiveness of the Omada program with results that are even better than the YMCA program’s, which is the basis for the CMS program. The second [study’s results] showed that the return on investment is even sooner than the 1-to-2-year time frame for seniors.¹¹ So overall, we feel the evidence base is there. Most important, if the CMS benefit is to [reach] its full realization for seniors, we have to access seniors who may not have the ability or the desire to go to a face-to-face program once a week. We have to be able to provide access digitally for those participants, and we also have to recognize that there’s only a very thin slice of time you spend in a face-to-face program, whereas in a digital program, it’s constantly accessible—when you need it and where you need it.

EBDM™: Where do you see digital health and the DPP heading in the next 5 years?

CHEW: The next 5 years are going to be very important as we go forward in digital health because we will get a critical mass of experience. It will become even more clear that diabetes prevention is needed. The CMS program and the MACRA and MIPS initiatives to encourage screening, I believe, will make it easier for physicians and other healthcare providers to recognize and refer patients with prediabetes.

References

1. Omada Health adds Dr. Paul Chew as chief medical officer, Tom Schoenherr as chief commercial officer [press release]. San Francisco, CA: Omada Health; January 6, 2017. http://omadahealth.com/news/omada-health-adds-dr.-paulchew-as-chief-medical-officer-tom-schoenherr-as-chief-commercial-officer. Accessed January 6, 2017.

2. Heart disease fact sheet. CDC website. http://cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm. Updated August 18, 2017. Accessed August 20, 2017.

3. National Diabetes Statistics Report, 2017. CDC website. http://cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Published July 18, 2017. Accessed July 18, 2017.

4. Knowler WC, Barrett-Connor E, Fowler SE, et al; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403. doi:10.1056/NEJMoa012512.

5. Smith A. Research emerging that links insulin resistance to cognitive decline. Am J Manag Care. 2016;22(SP7):SP264-SP266.

6. American Diabetes Association. Economic costs of diabetes in the United States. Diabetes Care. 2013;36(4):1033-1046. doi: 10.2337/dc12-2625.

7. The National Diabetes Prevention Program. National Association of Chronic Disease Directors website. www.chronicdisease.org/mpage/domain4_ndpp. Accessed August 20, 2017.

8. Payne M. History lessons in innovation: digital behavioral medicine can address the diabetes “double epidemic” facing Medicare and America’s seniors. Am J Manag Care. 2016;22(SP7):SP275-SP276.

9. Su W, Chen F, Dall TM, Iacobucci W, Perreault L. Return on investment for digital behavioral counseling in patients with prediabetes and cardiovascular disease. Prev Chronic Dis. 2016;13:E13. doi: 10.5888/pcd13.150357.

10. Chen F, Su W, Becker SH, et al. Clinical and economic impact of a digital, remotely-delivered intensive behavioral counseling program on Medicare beneficiaries at risk for cardiovascular disease [published online October 5, 2016]. PLoS ONE. 2016;11(10):e0163627. doi: 10.1371/journal.pone.0163627.

11. Castro Sweet CM, Chiguluri V, Gumpina R, et al. Outcomes of a digital health program with human coaching for diabetes risk reduction in a Medicare population [published online January 24, 2017]. J Aging Health. 2017. doi: 10.1177/0898264316688791.

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