1.

Is the DynamiCare model generalizable and applicable to a wide variety of patient populations?

Contingency Management (CM) has been demonstrated to be effective in over 100 randomized controlled trials, across a variety of substances and patient populations (dual-diagnosis, homeless, criminal justice, pregnant women, adolescents, etc.) (Petry et. al, 2013).
The DynamiCare platform is designed to automate this methodology in a highly scalable, turnkey solution across Android, iOS, and web. Provider training is minimal, overcoming a traditional barrier to CM adoption. Patient training is embedded into the app itself.


2.

What evidence is there that financing will be sustainable beyond a pilot?

Funding for incentives can be provided by patients themselves (deposit contract), families (crowdfunding), insurers, employers, and/or government agencies. Each of these has been demonstrated to be feasible and sustainable in similar programs:
         - Deposit Contracts (patients): We expect 10-15% of patients to be willing to deposit their own funds to earn back as an accountability tool for their recovery. In a study of financial incentives for smoking cessation, 14% of patients were willing to fund their own incentives (Halpern et. al, 2015). This approach has actually proven quite popular among smartphone users -- the commercially available Pact app has attracted 600,000 users who self-funded deposit contracts to incentivize themselves to work out or eat healthfully  (Olson, 2014).
         - Crowdfunding (families): Crowdfunding has already demonstrated success in helping patients raise money for many medical issues. In fact, three general-purpose crowdfunding websites (Rally.org, GoFundMe, and YouCaring) have found health care to be the most popular category for campaigns on their sites (Sharrock, 2013). Patients have been using these platforms to raise funds for their addiction recovery. We analyzed a sample of 150 patients using the Next Step debit card (a smart recovery-focused debit card) in 40 US private treatment programs, and found that families on average place $340 on each card per month– more than enough for effective CM incentivization.
         - Payers: DynamiCare has secured a contract from a major national insurance company in paying for both the DynamiCare app and drug testing, and the financial incentives. Other payers – including managed Medicaid programs – have funded financial incentives in other disease areas to reward healthy behavior. The CeltiCare Health Medicaid program pays up to $210 for healthy behaviors (CeltiCare Health, 2017).
        - Government: Researchers have estimated that for every $1 spent on CM, there are $34 in societal benefits. This is a substantial ROI for addiction treatment. DynamiCare’s approach offers a cost-effective way for states to reduce healthcare costs, solve social problems, and improve economic productivity (WSIPP, 2017).


3.

Do low-SES patients have smartphones? Do they lose smartphones, change numbers, or lose service?

A majority of low SES patients own smartphonesand the proportion is rising rapidly. A 2016 survey found that 64% of adults in the US who earn less than $30,000 per year own smartphones (Pew 2017), up from 50% in 2014 (Smith, 2015). While some loss or damage to smartphones may be inevitable, we mitigate this by: a) encouraging patients to use a smartphone they already own; b) emphasizing the ongoing financial incentives patients can earn by continuing to participate on their mobile device; and c) offering an equipment return fee for study-provided phones after study completion.


4.

Can patients cheat the saliva tests?

An expert panel convened by the American Society of Addiction Medicine (ASAM) determined that oral fluid testing is appropriate for detecting substance use in addiction treatment. In fact, oral fluid testing has some benefits over urine testing, such as being harder to tamper or cheat (ASAM, 2017). Adding credibility, the website “StuffStonersLike.com” (2015) complained that “the saliva drug test (mouth swab drug test) is not affected by the typical tricks and techniques that might work to defeat or beat a urine drug test.” They recommend “Ultra Kleen Saliva Cleansing Mouthwash” as a potential solution, but DynamiCare staff tested this product and found it to be ineffective.
Remote selfie videos add complexity to standard saliva tests, and opportunities for cheating (e.g. swapping out saliva swabs or cups). However, the methodology has been demonstrated to be feasible in research for saliva cotinine testing (Kong, 2016).  Our app shows patients their own face on the phone screen during testing and actively emphasizes that they must stay within and keep their test materials within the video frame for the duration of the each test; patients who do not properly follow the procedures must re-test. We expect patients to come up with new and clever ways of cheating the tests, but so far we have not found any, and we expect that we can adapt our processes to deal with them.


5.

Isn’t the DynamiCare model impersonal?

DynamiCare’s CM model should be used clinically to strengthen the patient-provider relationship. By incentivizing patients to attend treatment, verified by GPS, we encourage patients to spend more face time with their providers. In large randomized controlled trials, CM has been demonstrated to generate substantial improvements in treatment retention (Petry et. al, 2005). Furthermore, data collected by the DynamiCare Rewards app (such as drug test results, attendance tracking, and weekly surveys), along with our machine-learning based predictive analytics, can encourage providers to reach out to patients by notifying them when patients are at greater risk.


6.

How can I control the specificity of the CM treatment I wish to administer or study?

DynamiCare is easily configurable and highly flexible. The DynamiCare team can build a program specifically to a protocol’s needs. A particular strength of this technology is that a program can be customized across a broad range of CM parameters: target behaviors, testing and reward progressions and intermittencies – by protocol, by patient, and with per-patient outcome-based changes over time. This modular approach allows researchers to fine tune their study the way they want to, all within the automated and standardized DynamiCare system. Meanwhile, the application simultaneously maintains an extremely easy and comfortable platform both for treating patients with dignity and collecting quantitative, reliable, high resolution, behavioral data – at the lowest possible cost.