An Interview with Alejandro Foung, Co-Founder and CEO of Lantern, and Richard Gengler, CEO and Founder of Prevail Health Solutions

According to the National Alliance on Mental Illness 60% of adults with mental illness do not receive treatment. For individuals with depression, anxiety, or PTSD, seeking treatment is often inconvenient and embarrassing. We spoke with Alejandro Foung, Co-Founder and CEO of Lantern, and Richard Gengler, CEO and Founder of Prevail Health Solutions, to understand how Lantern and Prevail Health are tackling these problems by extending the reach of Cognitive Behavioral Therapy (CBT) with technology.

PULSE: Please describe your product offering and how you’re innovating in the behavioral health space.

ALEJANDRO FOUNG: Lantern is a mobile app. And what we deliver are personalized CBT programs. They focus on stress, mood, body image, anxiety, et cetera. We determine fit and then get users on a personalized program that pairs them with a one-to-one coach, who supports them via asynchronous text or in-app.

The day-to-day experience is you open your Lantern app on your phone, and each day there’s a check-in. Typically, it’s just a note of where’s your stress level, where’s your anxiety level, which gets sent to your coach. Then there will be a podcast or some informational content about the technique that you’ll be learning that day. All of this is within ten minutes. The technique might be learning about and measuring automatic thoughts and tracking them. Or it could be audio, such as a breathing exercise.

The idea generally is to be really accessible, personalized, with real professional care, positioning Lantern as another rung on the ladder within the mental health ecosystem, which has just typically been face-to-face therapy and pill-based psycopharmacology.

RICHARD GENGLER: Our story is that Prevail was built to solve a pressing need in the military since I was a Navy pilot. I also saw enormous need for disruption in the broader behavioral health marketplace, and so came up with a plan to work with some of the leading clinicians throughout the country, from Northwestern, University of Chicago, and the Beck Institute to translate a lot of the proven methods of in person therapy online into something that can be delivered over the computer in a scalable way. The key is personalization- when you see a doctor face-to-face, he or she learns about you and then tailors their treatment to fit your personal situation. Computer programs didn’t do that before- it’s not been traditionally scalable to do anything other than have a one size fits all computer based program. We set out to change that, and in partnership with the national Science Foundation through their SBIR program, we built a novel technology that delivers highly personalized treatment experiences, yet in a very scalable way.

Since there’s a challenge with the lack of doctors and clinicians in behavioral health, we have a trained peer specialist model. We want a really easy way to kind of bring them in, allow them to feel comfortable, something that they can engage in. From the beginning we realized that we had to validate our programs and build a strong evidence base. To do that, we went through multiple clinical trials. One was a Randomized Clinical Trial done supported by Brystol Myers Squibb Foundation and done in partnership with the VA and Rush University Medical Center in Chicago, which showed that our programs are as clinically effective face to face care for users with PTSD and Depression. And we delivered those results at less the 1/30th the cost of traditional face to face care. In addition to that, the Agency for Healthcare Research and Quality also independently reviewed and accessed our technology. They gave it the highest evidence rating of strong.

So thanks to our robust clinical data, and showing that it’s effective, and the huge need in the veteran population, the Veterans Health Administration has recognized the power of the model and decided to make it available to all Veterans nationwide, and have been delivering on that under contract for two years now.

PULSE: How has the clinical community including providers responded to this type of offering?

GENGLER: It’s always tough to bring a disruptive new technology into the marketplace, and probably nowhere is that more so then in health field. Many clinicians seemed hesitant or skeptical at first, but that is changing quickly. There are seemingly more and more innovative leaders that see this as the future, like Dr. Thomas Insel, who was the national director at NIMH, who has left for Google, and others along with him who see this as the future, and it’s all happening right now. With the evidence base we’ve put together and the results we’ve shown delivering the program at scale to tens of thousands of users, we are starting to see a big change in attitude and many want to do what they can to support it or be involved. It also helped us tremendously to make the case with clinicians that the results of our last RCT was accepted for publication in the Journal of Consulting and Clinical Psychology this last August, and so there are more and more clinicians who see this as the future that they want to be part of.

FOUNG: There’s been clinical support. We licensed our first product out of Stanford. We also have a clinical advisory board of researchers that work at Stanford, Wash U, and Penn State. We’re in the third year of a four-year longitudinal $4 million National Institute of Mental Health grant, of which we’ve actually deployed a Lantern program to 40 colleges and campuses across the country. So we have a clinical background, and we use the gold standard of a randomized control trials to know whether what we’re doing is effective or not.

So to answer your question, it’s been very favorable because I think we’re using very realistic measuring tools and methods to prove effectiveness. And then on top of that clinical psychology very much believes in cognitive behavioral therapy. The question isn’t, “does it work?”. The question is, will people use it?

PULSE: Do you feel online or computerized CBT will eventually be reimbursed by insurance?

GENGLER: There are definitely some different trends that lead us to believe that it could be the case. Senator Schatz from Hawaii — is heavily involved in telehealth legislation and has expressed interest in our model, as well as Congressman Murphy from Pennsylvania with the Mental Health Act. It’s all about reducing cost at this point, and the trend in health right now has to do with value based re-imbursement and controlling costs. Our model is perfect for this environment- it actually allows increased access to evidence based mental health care for a population while at the same time reducing overall cost. Because MH issues are so prevalent, and because there has not been much improvement in this area in the last 3 decades, there is tremendous opportunity for savings through our model. In fact, the USPSTF recently released new guidance that advised all adults get screened for depression in the primary care setting and be offered CBT based treatment options where applicable. That’s a great idea, but the only way it is going to happen given the already short supply of mental health professionals is through programs like ours. And so there is a lot of change going on in this field right, and all trends look like it will be reimbursed very soon.

FOUNG: Without a doubt, it will happen. Insurance companies already reimburse for face-to-face CBT. So it’s just a matter of time until they reimburse for online CBT. It’s not that there’s not enough evidence about online CBT to get reimbursement. It’s just that no one’s practically shown that they can get enough people to utilize it over time that the insurance company should pay for it.

PULSE: How are you approaching barriers to access like stigma and lack of clinicians?

FOUNG: We really think about the three primary barriers to mental health, are access challenges, cost, and there’s also stigma on top of all of that.

So I think solving the access issue is — people don’t necessarily have time to drive or sit down for 45 minutes each week. So by having it be mobile delivered is — it improves the access, obviously. The cost is improved comparative to a pill or therapy.

So how are we solving those issues? I think it’s making it more accessible. I think it’s making it be more self-guided. And then ultimately, it’s delivering a product that feels, to a degree, easy to use and has a point. People can see the payoff and see why it’s relevant to them. And so that’s a little bit the magic of the product and the content that we provided.

GENGLER: That is where the real difficulty is- getting people to follow through and engage with mental health treatment. We call them “reluctant care seekers” and nowhere is that more true than in the Veterans population. Most of us know a Veteran- they tend to be on the stoic end, and are not lining up to do online mental health programs. If you can get them to do it, you can get anyone to do it, and we’ve been forced through trial by fire to figure out how to acquire and engage users in our programs. We’ve become really good at it at this point. There are a variety of things we do to make that happen- people are different and so the strategies you need to use need to be different. One strategy is we use a peer specialist model. People who have gone through our program, once they’ve graduated some of them want to help other users behind them, and then there’s a training program for them to Become peers themselves to do just that. There’s a lot of research showing that if you go back, you help others that have had similar issues as you, that that also helps you recover and helps you become healthier. You can think of it almost the next generation of AA Online. And so because of that, and since we reward them, that as the coaches go through it helps to engage them.

On the peer front, we’ve been recently speaking with a few different colleges and schools who are very interested to have this as part of their service learning, which is also a big trend in universities and colleges now. And so as part of their academic curriculum, this could potentially down the road help them with practicum hours or service learning. It’s really exciting. It’s a way to get past this challenge of not having enough clinicians and then having it in a scalable manner that people can do it whenever and wherever they need to.

PULSE: How are you using technology to improve monitoring and measurement of patient experience and clinical effectiveness?

GENGLER: Our model is data driven completely. We use, the PHQ9, the CSD, and other clinical measures as part of our assessment at the very beginning. So that provides a baseline measure of what the person is at that time. And then as they go throughout the program, we measure them again to continue to show their clinical progress.

With the Veterans Health Administration, we provide them with a monthly report with clinical progress and usage and engagement throughout the program. The average usage time for our users is about eight to ten weeks. And over that time, they progress quite a bit clinically. We do have some users who have used it for a year and a half and continue to see value in it. That’s one side of it.

Also with AHRQ, when they reviewed us, they had 96 percent of the people who went through it would recommend the program to their friends. And so it’s something that not only are they clinically getting better, they are also enjoying it and want to share it with their friends.

Also we have a provider or an administrator dashboard. So from a population health perspective, you can look across your population, whether it’s a thousand, fifty thousand, however many people it is, and see what the clinical status is of them and then help to dedicate resources where you need them to be.

FOUNG: What Lantern is able to do because it’s modular in nature and it’s over the app is we’re actually able to collect measures. One way is that every check-in you do, it’s a self-reported 1 through 10 score of how I’m doing against an item that I’m working on, anxiety, stress, et cetera. We take measurements of where you were, how you were feeling before and after individual techniques. We have an understanding of which techniques are effective for you and for a greater population of people like you.

We’re also using evidence-based measures, whether it’s a G87 or PHQ9, measurements for mood and anxiety. We’ll do standard measures before people start their program, and then after they complete it so that we can have a benchmark against academic literature and what you’d expect for face-to-face CBT and online CBT.

So we do all of those things because ultimately you have to know. We believe you have to know if you’re being effective in a quantitative way, if ultimately you’re going to have success.

PULSE: What are the greatest challenges you see ahead for your company?

FOUNG: The state of healthcare in the United States is actually rapidly changing. Well, it is changing — I’ll say this. It’s changing faster than it has in a long time. And so ultimately the question is, from a company that offers digital tools to fit within what is not a digital ecosystem, is the pace of change fast enough such that you can meet a need when the entire system is ready for it?

How well can you fit your new idea or new product or new technology into what ultimately is a pretty slow-moving, complex system? The challenge is not necessarily getting the evidence or building a product that people like to use — the real challenge is, can you make it fit with the byzantine, crazy ecosystem that is United States healthcare? And if you cannot, you will not be a successful company. If you can, you potentially could be a very, very successful company.

GENGLER: There’s definitely a lot of reluctance to change and to do something new. And so you need a great track record of getting users to do it in the real world and driving outcomes. You also need a very strong evidence base, which we have. There is a lot of money at stake, and so all the decision makers are part of big bureaucratic organizations, who you have to convince to try something new and potentially risky. These are large systems and plans that we’re speaking with, and they have a lot going on and there is a lot of noise out there. So to have new programs implemented, it’s enormous challenge because there are so many apps starting now and so many health technology companies starting, and many of them don’t have as robust clinical base, so it’s really watered down the entire marketplace and made it tough for decision makers to sort through and determine what is valuable and useful and what is not.

PULSE: So what have been the key success factors that have supported entry into this space?

GENGLER: All these factors are coming together, yet the industry is reluctant to change, but with 18 percent of our GDP now on healthcare, and premiums going up 30, 40 percent year over year, something has to change. We are extremely confident that technology that is proven in clinical trials to provide clinically equivalent care for one thirtieth the cost — that this has enormous opportunity. It’s just a matter of patience while all these factors come together — it’s really a right place at a right time situation.

FOUNG: It’s staying true to what you’re telling people you do so that you’re not saying something but then doing another. I think that’s important. I think ultimately you can put things on a continuum as far as all the digital solutions. There’s software- only solutions, and then there’s people-only solutions. And ultimately, there’s going to be a lot of different methods that are successful because there’s lots of different types of people out there, meaning you could have an individual who gets a diagnosis of clinical anxiety, and they’re not going to perform against any digital tool, not Lantern’s, not anything. But they respond really well in person. You could have a person who would take the PHQ9 and get the same exact score. And they could perform really poorly with face-to-face therapy, but they’d respond very well to a digital or a remote coach supported tool comparative to Lantern.

So I think ultimately the companies that will have the most success will be very clear about what their product is. And it works well with the existing ecosystem.