AN FRANCISCO — At the headquarters of Omada Health, the exposed ceiling, stocked kitchen, and MacBook-toting millennials evoke the industrial-chic feel of a tech startup. One conference room here is named Kale, another Broccoli.
Many employees have waistlines as thinly cut as their Levi’s.
But the digital health company is at work on an experiment involving a very different kind of demographic, one that faces a greater risk of certain chronic health problems than the people who work here. And if it proves successful, it could open the door to a new approach to prevent diabetes, one of the country’s most pressing health problems.
Omada, which offers an online program geared to helping people who are prediabetic or obese lose weight and avoid developing type 2 diabetes, is rolling out a version of its program specifically tailored to people who rely on safety-net services like Medicaid. It is also sponsoring a clinical trial to try to demonstrate that such a program can work in low-income communities.
In all of Omada’s programs, participants are given a scale that tracks their weight every day and are matched into groups based on geography and weight loss goals. The groups are paired with health coaches who provide guidance and lessons, customizing them so that a group of Louisianans, for example, can discuss how to keep up healthy habits during Mardi Gras.
“Someone in Louisiana is not going to relate to a health coach in San Francisco,” said Eliza Gibson, Omada’s director of Medicaid and safety net commercial development. “You gotta know where people shop, you gotta know what the weather is like, you gotta know what the culture is like regionally.”
The hope for digital health is that it can offer effective interventions on a mass scale, reaching people on devices they already use around the clock. And advocates say the poor — who are less likely to have a regular doctor and rely more on emergency services — stand to benefit the most from a consistent monitor of their health.
But no one really knows if online programs can help such a population, which has elevated rates of diabetes, shed significant pounds; the issue hasn’t been rigorously studied. Some experts wonder if the programs will be able to deliver real change.
Omada’s program is designed to alter behavior around food and exercise, but in low-income communities, even basic components of a healthy lifestyle that weight loss programs promote — access to nutritious food, for instance, or a safe place to go for a walk — might not be available.
“I don’t want to prejudge this and say that it won’t work, [but] I know that there’s a lot of challenges,” said Michael Cousineau, a public health expert at the University of Southern California and lead investigator in the clinical trial. “These are very poor people, so there are a lot of things on their plate, if you will. So if they can move things off the top of their agenda to make this successful, that’s the question.”
The trial is enrolling 300 participants who are uninsured or on Medicaid and are patients at three health clinics, two in southern California and one in rural Washington.
For Omada — which has raised more than $75 million since its 2011 founding, largely through venture funding — a successful trial could also help its business. Data that show the program is cost-effective and improves health could convince Medicaid plans to cover it.
“I think the trial will continue to help inform preventive services … and also indeed show that digital health works in low-income populations,” Gibson said.
(Omada is only trying to market the version of its program for underserved populations in states that expanded Medicaid under the Affordable Care Act.)
Typically, Omada’s program is offered as a benefit by some health plans and by self-insured employers to employees at risk for diabetes or heart disease; customers include university systems, Lowe’s, and Costco. According to published studies that were cowritten by an Omada researcher, people who completed the program lost an average of 4.9 percent of body weight in the first year and maintained a weight loss of 4.3 percent after two years. Participants also saw a drop in their blood sugar levels.
About 65,000 people have enrolled in its programs so far, with the average user approaching 50 years old and having a ninth-grade reading level.
Company executives say they try to remain cognizant of what their participant population is like and wants out of the product, but that there’s been some trial and error as they have honed the design. When the company experimented with using “zanier” and “wittier” language in a group of participants, for example, completion took a dive, said Sean Duffy, Omada’s CEO and cofounder.
“It is slightly easier to design something where you’re the target user, and you can make mistakes,” Duffy said. “It’s almost like you have to second-guess to make sure: Is this me? Would I like this? Or would Michelle in the middle of Wisconsin, who’s a different sort of person, been fighting obesity her whole life, really appreciate this?”
In March, federal health officials proposed allowing Medicare to start covering diabetes prevention programs shown to improve health and save money, whether they were in-person like those offered at YMCAs or online like Omada’s. The officials said a decrease of even 5 percent of body weight could substantially reduce the risk of diabetes for the 86 million adults with prediabetes.
But for now, most Medicaid plans do not cover such programs. Montana’s is the only state Medicaid plan that pays for them, according to a recent report from the Institute for Clinical and Economic Review.
For its program for low-income communities being tested in the clinical trial, Omada changed the language from a ninth-grade reading level to a fourth- or fifth-grade reading level, provided additional training to its health coaches, and adapted the lessons to consider issues of food access and neighborhood environment.
Instead of recommending signing up for a gym membership, for instance, the program for underserved populations encourages users to look at community center classes. And instead of discussing ways to make healthy choices at a post-work happy hour, health coaches might instead frame the conversation around a church potluck. Omada is also working on a Spanish-language program for lower-income populations.
Company executives say they expect the trial to show their program works for people on Medicaid. Gibson noted that many of the original version’s users might otherwise qualify for Medicaid if they did not happen to work for a company that offers Omada’s program.
So far, low-income participants have had similar weight loss results as higher-income participants, according to Omada data that have not been published in a peer-reviewed journal.
More broadly, low-income populations represent a largely untapped market for the burgeoning digital health industry, especially with the Medicaid expansion in some states extending coverage to more than 10 million people. Using an online health program could save them from having to take time off work or pay for transportation to go to a clinic. And while low-income populations have lower rates of internet access than high-income people, more than 3 out of 4 adults with a household income of less than $30,000 use the internet, according to a 2014 Pew Research Center survey.
“We think of low-income populations as not being particularly wired, but I think that more of them than we suspect actually do have technology,” said Rachel Davis, who leads a digital health initiative at the nonprofit Center for Health Care Strategies. “And I think that number is growing as the technology is getting cheaper.”
With grant funding, a few clinics around the country have already started to offer Omada’s program for underserved participants.
Francesca Fasano, 59, heard about the program through her primary care clinic and said that it, combined with Weight Watchers, has helped her drop about 30 pounds in six months.
Fasano, who is on California’s version of Medicaid but is not a part of the clinical trial, said the program had given her an idea of what a few hundred calories of food actually looks like and encouraged her to exercise more. She said she liked being able to track the weight she had lost online and read comments from other participants in her group.
“I love viewing my progress,” she said.
Susy Navarro, 29, who lives in the San Diego area and is also not part of the trial, said the fact that she could access the lessons and hear from the health coach all on her phone made it easier than other weight-loss programs she has tried.
“I liked that it was at your fingertips and you could go on it every day,” she said. “We’re always on our cellphones as it is.”