Recently, the Aetna Foundation announced that it had awarded $1.2 million in grants to 23 organizations to support the implementation of digital health tools intended for low-income and minority populations. Among the supported projects are a pilot project at Washington University using an app called Zuum to deliver risk assessment tools to underserved populations in a 12-month pilot project. Another example is a project by the American Association of Diabetes Educators Education & Research Foundation to use an evidence-based app for diabetes self-management and effective lifestyle modification.
There are many reasons for enthusiasm about the potential impact digital health tools like these can have. They can be low cost in comparison to medical therapy, developed and deployed relatively quickly, and have extraordinary reach thanks to the permeation of computers and mobile technology in our society.
At the same time, the explosion of commercially available digital health tools as well as those being tested in innumerable small scale trials or pilot studies leaves us with a big question – how do we decide which of these warrant further support and scaling?
We recently had the opportunity to speak to Aetna Foundation president Dr. Garth Graham MD, MPH to learn more about how his organization approached the challenge of evaluating mHealth interventions.
According to their press release, in awarding these grants, the Aetna Foundation considered criteria including:
sustainable projects that can demonstrate scalability; projects that have the potential for positive societal impact; digital health programs that leverage available evidence such as population health data or health care data; and digital health support built on a strong foundation of behavioral or applicable theory and grounded in research.
Projects were selected through a national competitive RFP process. Identifying under-served communities as a population that generally has poor access to digital health tools yet potentially the greatest need, the Aetna Foundation’s Digital Health Initiative focuses on supporting programs that are directed at minority and other vulnerable communities.
However, many digital health programs and interventions are not necessarily evidence based. As Dr. Graham described, “We tried to pick projects that looked like they had an evidence base…[principal investigators] that had a track record of working in under-served communities…and were doing something others had not before.”
An interesting part of their approach was to look not only at the evidence base for the project but also its likelihood of contributing to the overall knowledge base down the road including different strategies for working in different communities. By supporting many small projects within different communities, their aim is to capture experience working in a broad representative population in aggregate. According to Dr. Graham, “We are hoping our grantees will be part of the evidence base for how you deploy…in under-served communities.”
In addition to financial support, a major part of this initiative is mentor ship and networking. As Dr. Graham told us, “Part of what we are trying to do with this group of grantees is connect them with each other…to be able to work with diverse communities that represent a broader part of our society than just the worried well.”
Along those lines, Dr. Graham tells us that the Aetna Foundation is very interested in hearing about digital health projects being undertaken that target the health of underserved communities. In fact, he encouraged folks involved in these programs to reach out to the Foundation at aetnafoundation [at] aetna.com and share their stories.
One particular challenge of facing many such projects is how they can be ultimately scaled up to have meaningful impacts on a population level. Unlike many direct-to-consumer digital health devices, they can rely less on the ability of the end-user to pay for these services. And government research support or grants from charitable organizations are not nearly reliable enough to support real-world deployment of digital health tools.
That’s where payors – private and government insurers – come in. Reimbursement for use of digital health tools like SMS-based programs for healthy behavior change is going to be particularly important for scaling and deploying in the real world, particularly for under-served communities. So what will it take for that to happen? As Dr. Graham put it, “Strong evidence – it will take a strong compelling evidence base that the deployment of these technologies will have a positive impact especially in terms of utilization.”
Over the coming years, the Aetna Foundation has committed at least $4 million to its Digital Health Initiative which will include further support for promising projects as well as support for new innovative programs.
In digital health, there is often a tendency to put the cart before the horse – to jump to deploy systems and tools that lack an evidence base supporting efficacy. In some situations, that can work particularly when you’re talking about direct-to-consumer devices or hospitals terrified of readmissions. However, for under-served communities, the reality is that many of these tools will require support from, for example, insurer-based payments or funding from health systems working in emerging models like ACOs. Both of those will require a strong evidence base before stakeholders will commit to them. Efforts like this will help get us there.