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Evidence-Based Diabetes Management September 2017

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

Mary Caffrey
The chief medical officer of Omada Health discusses a transition from one of the world's largest pharmaceutical companies to a digital health provider, and from treating chronic disease to preventing it.
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?

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