With the regulations around telehealth changing rapidly during the COVID-19 pandemic, an opioid treatment platform with a digital component is finally finding a strong market foothold after facing a mountain of regulatory hurdles.
Boulder Care was founded by Stephanie Papes, a former associate at Apple Tree Partners. She first became interested in opioid treatment after facilitating the firm's financing round with an organization called CleanSlate Addiction Centers, which focused on in-person treatment for opioid and alcohol addiction.
There are several options when it comes to opioid addiction treatment. A common one is replacement therapy via methadone, an opioid, which relieves the symptoms of withdrawal while blocking the high that comes from use of heroine and other narcotic pain relievers. There's also in-patient treatment, which usually comes with strict rules around the use of drugs and sometimes even legal addictive substances like nicotine, with a very low-tolerance policy for relapses.
In-patient treatment is usually expensive and not often covered by insurance, and asks patients to go cold turkey. Methadone, on the other hand, requires patients to come to a clinic at least once every day. Not only does that make it difficult to live a normal life, but these clinics are often targeted by drug dealers to poach clients.
Boulder Care looks at a different approach that uses a combination of telehealth services and a prescription drug called Buprenorphine (brand name: Suboxone).
Alongside a greater risk of contracting COVID-19, and having a more severe experience of the disease than those without addiction, addicts are also at a greater risk of overdose or continued use of opioids due to social distancing and increased anxiety and stress, two huge contributing factors to addiction, according to an article published by Harvard.
Boulder Care uses telehealth to offer patients a comprehensive recovery plan, including clinician support (for medical and medication needs), a peer coach (who has lived experience with addiction and can help talk through challenges and issues) and a care advocate (who helps with administrative needs around care and insurance coverage).
"It's not 100% abstinence-only right away," said Papes. "It's a journey, and every incremental step and savings for the health system is good for the individual. The work that we do, just by building that trust with our participants, telling them 'we value you, whether or not you're using substances, and we're not going to kick you out of the program for having an unexpected test result on your on your drug test or telling us that you use methamphetamine.' There are a lot of policies in some of these programs that just continue to put people in harm's way. So residential facilities will say you can't be here for your heroin addiction if you're smoking cigarettes, and they'll truly discharge you from the program if you smoke. It's not beneficial for anyone. So, we have this clinical philosophy, it's really important, and it's all about unconditional support."
One of the big challenges for Boulder Care and opioid treatment organizations across the country is the regulatory limits on prescribing Buprenorphine. Buprenorphine is an opioid partial agonist, which means it produces euphoric effects and respiratory depression at low to moderate doses. However, these effects are much weaker than a full opioid agonist like heroine or methadone.
Buprenorphine also greatly weakens the effects of withdrawal, allowing patients to try to stabilize their life and achieve a healthier lifestyle.
Unlike methadone, Buprenorphine can be prescribed by a doctor for use at home, rather than making a trip to a clinic, where patients must be examined and drug tested before they can take their dose. However, there are regulatory limits on doctors around the number of people they can prescribe Buprenorphine to in a given time period, and doctors must also pay to get training and a license to prescribe the drug.
According to Papes, this means 80% of the country who could benefit from a Buprenorphine prescription can't get it. In fact, a HuffPost analysis showed that even if all the doctors who are licensed to prescribe Buprenorphine did so at the maximum rate in 2012, more than half of Americans suffering from opioid addiction still couldn't get access to the drug.
Part of the reason that prescribing Buprenorphine has such strict limitations comes down to stigma, with many believing in the long-held misconception that replacing one drug for another isn't the answer, and that abstinence is simply a challenge of mental willpower, negating the fact that addiction is a disease.
There's no doubt about the potential efficacy of Buprenorphine. In 1995, France allowed any doctor to prescribe Buprenorphine without special licensing or training. About 10x the number of addicted patients began receiving medication-assisted treatments, cutting overdoses by nearly 80% in four years, according to the Atlantic.
Another requirement around the prescription of Buprenorphine is that the patient had to have at least one in-person visit with the doctor before they could get access to the medication.
That visit could be someone coming into a clinic or facility seeking to change their own life proactively. It could also be at the emergency room when someone is brought in for an overdose.
"It's very challenging when someone has a tiny window in which they're feeling like they're ready for change, and you have to coordinate with another facility in order to get them into your care," explained Papes.
During this national health emergency, that requirement has been waived, allowing for doctors to prescribe this medication without an in-person meeting with the patient. This is a huge boost for Boulder Care, which runs its business entirely via telehealth.
Since the start of March 2020, the company has seen 130% week-over-week increase in weekly inquiries from potential patients, and new patient enrollments is up 32%. During COVID-19, any patient who is uninsured or under-insured can get services from Boulder for free.
Boulder recently partnered with Premera Blue Cross, an insurance plan in the Pacific Northwest, to provide zero cost share options for virtual substance use disorder treatment, which will give 2.3 million customers access to Boulder Care through at least June 30. Cost shares will be waived for all patients seeking medically necessary telehealth treatment.
Alongside revamping the way patients receive treatment for substance use disorders, Boulder is also looking to change the payment model. Traditionally, the healthcare system remunerates providers based on admissions (and often, readmissions) without focusing on outcomes. Meanwhile, outpatient fee-for-service reimburses for clinical visits and drug-testing, rather than peer recovery coaching, 24/7 text messaging and same-day access, a few of the things that contribute to successful outcomes outside of clinical treatment.
Boulder partners with paying entities for "bundled" services, charging a flat rate per patient without focusing on the volume of procedures. The hope, according to Papes, is to "realign incentives and tie payment to accountability for meaningful outcomes."
Boulder Care has raised more than $10 million with investment from Tusk Venture Partners, who led the Series A, among others.