Indian pharma has watched from the sidelines as e-pharmacies like 1mg and Medlife have swooped in, tossed distribution channels out, and increasingly become the direct link between pharma companies and patients. They hold patient data and monetise for behaviour; which, in pharma terms, is a bit of a superpower.
It’s now or never because if Indian pharma can’t fix this, it loses its connection with the one thing that matters—the patient.
The only way out of this tricky situation for pharma companies is to beat e-pharmacies at their own game. Enter digital therapy.
Digital therapy is a kind of software, typically a mobile app, used by the patient to complement the treatment of the disease. For instance, the application nudges patients of chronic diseases like hypertension and diabetes to exercise and eat right. It is technology that aids pharma companies in improving clinical outcomes, their compliance with the drug regime, and their understanding of patients’ behaviour, as in the case of Welldoc and Omada Health, internationally.
Now, in a first for India, drug manufacturer Cipla has bought a stake in a digital therapy company, Wellthy Therapeutics. And in a first for the world, one can finally draw a comparison between a pharma company and a fast-food chain—for McDonald’s, too, has invested in machine learning to feed their customers’ needs better. Both mark a shift towards the focused use of a new generation of digital tools, with big companies across sectors realising their significance.
This partnership between India’s largest (in terms of sales) drug manufacturer and a three-year-old startup attempts to combine drug therapies for diabetes and cardiovascular disease with digital therapies that manage these diseases via a mobile application.
Nifty? Yes. But also a sign of things to come.
Cipla, which earned a revenue of Rs 15,219 crore ($2.2 billion) in the year ended March 2018, the highest among all Indian pharma companies, isn’t the only pharma company adopting digital therapy in the near future. Because why else would it bet on a startup that earned a meagre revenue of Rs 12 lakh ($17,000) after burning Rs 3.8 crore ($546,000) in the same year its own revenues soared over the $2 billion mark? And bet Rs 10.5 crore ($1.5 million) on an 11.71% stake at that.
Cipla’s investment is built on the hope for a digital treatment for Indian pharma. One through which digital therapies manage diseases by pushing patients to stay healthy—exercise, eat right and do whatever the physician says, specifically, never missing a dose of the prescribed medicine.
In fact, this sort of therapy could be key to arresting the widespread growth of certain diseases. Lifestyle diseases, for one, cannot be cured with pills alone. Diabetes already affects 72.9 million adults in India and is poised to cross 150 million patients by 2045.
The association with Cipla works well for Wellthy, too.
Wellthy has a tie-up with Swiss multinational pharma company Roche’s diagnostics arm in India to complement its second-best selling product globally—Accu-Chek (used to check blood sugar levels). This is its chance to see large-scale adoption of its therapy. The tie-up will help Wellthy prove that it is universally efficacious for two out of its three products—digital therapy products for diabetes and cardiovascular diseases.
The startup is already working with health insurers and hospitals to make treatment affordable and to convince doctors to prescribe, respectively. Wellthy’s imperative to stay independent meant that Cipla’s investment had to be small.
Still, this tie-up is a sign that Indian pharma is considering digital therapies more seriously, which, up until now, were mostly limited to certain diseases and using tools created in-house. In May 2016, Sun Pharma had rolled out an asthma monitoring mobile App, RespiTrack, and in November 2018, Lupin launched an AI-powered chatbot to address queries related to diabetes to manage the disease better.
Now, the sector needs its products to stand out as patients and physicians ask for unbiased real-world evidence—clinical outcomes that illustrate the combination of drugs working with digital therapy over a specified period of time—proving that the combination of drugs and digital therapy leads to better health. But would investing in digital therapies eventually lead to more sales for pharma? There is some hope in the fact that a tough regulator like the US FDA has approved digital therapies; pharma majors, globally, have started investing in them. Although Indian pharma have focused all their marketing campaigns on convincing physicians to prescribe in their favour, they are now following the MNCs’ footsteps. Since Indian patients and physicians have now caught on to the fact a drug’s brand name alone does not promise better healing than its competitors, combining drugs with digital therapy is a chance for them to stand out.
Can I eat this?
Consider this. The Indian pharmaceutical market grew at 9.4% to Rs 1,29,015 crore ($18.5 billion) in 2018, but the sale of cardiac and anti-diabetes medicines grew faster, at 11.7% and 12.9%, respectively. And this is likely to grow further because one reason for it was the uptake of drugs to treat chronic diseases, according to market research firm AIOCD-AWACS.
Cipla, The Ken has learnt, is among the top 10 companies selling cardiology drugs in India. And yet, it needs to meet that standard with diabetes. The tie-up with Wellthy is also a step towards that. The diabetes medicines market is currently largely dominated by MNCs—nine anti-diabetic drugs in the top 20 selling drugs come from MNCs, even though they have about 40% overall market share.
“The imperative behind this partnership was to offer a combination of pharmacotherapy and digital therapeutics for improved patient outcomes in the chronic therapies of diabetology and cardiology,” wrote Nikhil Chopra, Head-India Business, Cipla, in an emailed reply to The Ken. But why Wellthy? It is multilingual, clinically-validated, manages diseases digitally, uses behavioural science and artificial intelligence. All of these to monitor, coach and advise patients, Chopra explains.
Wellthy can bridge the gap between Cipla and patients. The tech answers many and more questions that patients ask once the diagnosis is done and the doctor has prescribed the medication. It meets a need as most physicians do not have the time to follow up. Cipla’s agreement with Wellthy includes offering digital therapy to patients suffering from diabetes and cardiovascular disease via doctors’ clinics or co-packaging on select Cipla brands.
Can Wellthy really keep patients healthy though?
Wellthy’s co-founder and CEO Abhishek Shah explains that in an ideal world, the drug regime along with diagnostics and a good lifestyle will lead to great health outcomes for chronic diseases. But this isn’t an ideal world; patients don’t follow all instructions. Wellthy guides them in a manner that the doctor can’t over 5-10 minutes of consultation, says Shah.
It can take a whole range of questions. Would dieting lead to lower blood sugar? How much of my colleague’s birthday cake can I eat? Why do I need to eat salad in the evenings? Wellthy’s first product was a 16-week lifestyle modification programme for patients with Type 2 diabetes. It included reminders and disease-management education using AI-powered real-time feedback and coaching from a personal health coach. Clinical studies done by Wellthy show that the average level of blood sugar in patients reduced over those 16 weeks.
However, patients are not yet convinced about digital therapy enough to pay for them. Wellthy’s revenue of about Rs 1 crore in 2018-19 includes roughly 5% contribution by patients, one-third by the insurer and the rest by pharma and device companies.
Going forward, Shah expects insurers to be one of the drivers of digital therapeutics in India as they benefit the most from people managing their diseases. He expects the trend in India to be akin to the west, where 1) pharma has designed the therapies, 2) has made them available to patients following approvals, and 3) insurers have started to reimburse these therapies after checking for measurable improvement in outcomes.
Eventually, it will become easier for insurers to ask patients to follow these therapies as they can link them to the premiums they pay. But right now, pharma needs the physician prescribing meds to come through, and that’s not easy.
An app(le) a day keeps…
Bengaluru-based Biocon, the market leader in India for insulin, that is often used in the treatment of diabetes, plans to launch a mobile application for diabetics and cancer patients over the next three months. Except Biocon’s app will be administered by the treating physicians to their patients. Instead of Biocon connecting with the patients directly. This has proved tricky once before.
In 2004, the company had launched ‘Winning with Diabetes’, a patient support program involving a team of ‘Field Scientific Officers’ who go to clinics and hospitals and counsel patients on managing their life with diabetes. The Ken learned that Biocon faced trouble with doctors’ insecurity when educators got directly in touch with the patient. The programme was augmented in 2017 with a mobile app launched in a tie-up with Bengaluru-based Jana Care, a digital chronic disease diagnosis and management company, to make the information available directly to the patient. Until doctors took objection to some of the information. This time Biocon plans to work with the healthcare provider.
“With increasing bandwidth and its increasing access, patient management apps will play a key role in sustaining and enhancing point-of-care interventions. Integrating it with the healthcare provider only empowers the patient and improves the outcomes,” says Suresh Subramanian, Head South Asia, Biocon Branded Formulations.
It is reliably learnt that Biocon bypassed Wellthy, which it found to be a rather inferior copy of Welldoc, a US FDA-approved digital therapy company. Moreover, Wellthy is into lifestyle management. Whereas the digital tool that Biocon plans to launch will take into consideration geographic diversity in India and focus on lifestyle management. For instance, Gujaratis have heavy dinner and South Indians have three meals of rice. In India, people in each region have varying calorie and sugar intake and the app will factor this diversity into the diet plan.
Subramanian wouldn’t comment on Wellthy, but he wants to be very careful with lifestyle management information as there is diverse information, and if doctors—the only point of trust for patients—rubbish the app, Biocon will fail in its efforts. Too many sources of health information can also be a problem; doctors are wary of information overload.
But Dr V Mohan, founder of the diabetes specialist hospital and clinic chain Dr Mohan’s, thinks it’s a good idea. Mohan, who operates 48 clinics in 10 Indian states, is underwhelmed by the older digital health tools.
“Diabetes is a lifelong disorder and we need face-to-face interaction to sustainably manage it,” he says. Digital reminders support that aim as the reminders sent through mobile applications have resulted in repeat appointments, he adds. The doctor has observed that if diabetic patients visit the clinic three-four times a year, it reduces kidney complications to a large extent. “It is repeat visits for diagnosis, clinical examination like eye, foot and abdominal examination requiring see and touch that helped patients,” he claims.
The doctor sees value in using a mobile application to share information with patients, acting as a health coach, motivating them and reminding them to eat well and exercise. Dr Mohan’s employs diabetes educators to play this role—they make calls and counsel at the clinics—and it plans to shift some of this to digital, without underplaying consultation with the doctor.
Meanwhile, digital therapy platforms are beefing up.
Shah of Wellthy plans to build a research base that showcases what digital therapy can assure and to what extent. Wellthy’s first set of published clinical studies were based on a pilot with 102 diabetic patients who recorded lower blood sugar levels over 16 weeks. It has conducted another such study with 800 patients that would be published over the next few months. Once Cipla goes live with Wellthy over the next quarter, says Shah, together they will be able to validate their research with tens of thousands of patients across two therapeutic areas—cardiology and diabetes. Quality research should also mean better business. But will Indian pharma be convinced of its ability to improve sales?
It is difficult to establish a direct correlation between digital marketing tools and sales, says KG Ananthakrishnan, former vice-president and managing director, MSD India, a subsidiary of US-based pharma major Merck. Ananthakrishnan, who has spent four decades in the Pharma sector and worked with Pharma companies Pfizer and Novartis in the past, now advises consulting companies and health startups.
When Ananthakrishnan was with MSD, it had launched a diabetes patient engagement programme in 2008 called Sparsh in India. It was aimed at counselling patients to monitor blood sugar levels, improve compliance with the drug regimen and encourage them to see their physicians regularly and guide them on diet and exercise. It became a telecom-plus-digital programme when MSD later collaborated with HCL, wherein patients on MSD’s drug therapy would receive calls as well as messages on their phones. The programme is ongoing and relies more on digital tools now.
Ananthakrishnan recognises that such programmes using digital tools like mobile applications can help increase awareness of the disease, improve compliance and manage chronic diseases better.
“Digital marketing must be part of the strategic marketing mix of a product,” he says. He feels that the patients are becoming aware of the tactical approach by pharmaceuticals, and thus, sales tools will have a short life. If the problem is solved in a holistic manner via a third party, it is seen as strategic.
Instead of becoming a pusher of pills, if pharma takes a supportive approach, it will earn goodwill in a country that is grappling with lifestyle diseases.
This approach may also increase sales, feels Ritesh Dogra, Managing Partner at Hyderabad-based Medium Healthcare Consulting. Dogra, through a lifetime value analysis of a diabetes patient’s expenditure, established that 20-30% of that spending, which includes consultation, diagnosis and pharmacy, is on care packages that digital therapies or compliance programmes can provide. The total cost of managing diabetes per patient per year, according to Dogra, could vary from Rs 18,500 ($266) to Rs 33,650 ($484) depending on their blood sugar levels. A digital tool that provides these services complementary to the pill will stand out.
Pharma companies in every geography today are under immense pricing pressure from governments, insurers and patient groups. And one effective way to fight that out is value-based pricing, especially for expensive, innovator drugs. Speaking about his company’s efforts to set up value-based pricing for the heart drug Entresto, Novartis CEO Joe Jimenez commented in September 2015, “Previously, the only thing that you had to do was prove that your drug was safe and effective. Now, there is much more onus on us to prove that the drug delivers more than that and has a positive patient outcome.” The drug is priced at around $540 for a supply of 60 tablets in the US.
Indian companies sell me-too generics drugs where dozens of brands exist in one therapeutic area. Digital therapy is a potential tool for Indian pharma to bring that value. It would be a calculated risk.