Reimbursement for Digital Health Solutions for COPD Patients

Jenny Barnett
July 12, 2021

The digital health solutions continue to expand at an astounding rate. By 2017, the number of health-related mobile applications ballooned to more than300,000, a number that was increasing by 200 apps per day. Of those, some 40% were focused on health condition management associated with patient care.

Monitoring patients’ health conditions remotely and decision-support technologies have become important in caring for those with chronic conditions, including COPD.Digital health solutions increase patients’ engagement with their own healthcare, reduce the number of hospitalizations, and make the delivery of healthcare more efficient for providers. Quality increases and costs go down.

As a result, reimbursement by Medicare and private insurance carriers for digital therapeutics (evidence-based software intervention) and digital care (a broader term that includes a variety of devices and interaction with clinical providers) is gradually improving. In addition, the COVID-19 pandemic has provided an opportunity to consider changes in digital health policy more experientially.

Improving Quality of Health Care

For several chronic disorders—diabetes, cardiovascular disease, COPD, etc.—digital health care has improved the quality of care directly for patients. Remote monitoring devices can provide real-time data to providers or can transmit recorded data for evaluation. With that information, providers can make informed decisions about whether a patient needs hands-on intervention or even hospitalization.

Further, properly licensed and trained clinical personnel can respond knowledgeably to patient questions or concerns. For COPD patients, immediate adjustments can be made to medication dosage or frequency of use.Such immediate attention can prevent exacerbations from becoming serious enough to require hospitalization.

Devices that can monitor oxidation levels and use of medication can also help patients remain aware of their condition and take appropriate action as necessary. Digital health solutions can increase patient engagement and adherence to prescribed protocols.

For COPD patients, these measures have resulted in 78% reduction in rescue inhaler use and up to 35% of in-person, COPD-related health care utilization.

Reducing the Cost of Health Care

Less frequent hospitalizations or in-person clinical visits means reductions in the cost of health care due to digital solutions. Some savings can be attributed to increased use of telemedicine—a practice that became more widespread and necessary during the COVID-19 pandemic. But tele medicine is not the whole story.

While many private insurance carriers have recognized the cost-saving benefits of digital health technologies, Medicare and Medicaid have lagged behind in reviewing policies and procedures. Many are now urging CMS (Centers for Medicare and Medicaid Services) to review all regulations, policy guidance, and program manual instructions to accommodate digital health technologies.

Specifically, Advamed(Advanced Medical Technology Association) urges CMS to consider revising

·      Originating site requirement that patients must be present in physician offices or skilled facilities for services to be reimbursed,

·      Geographic location requirements that restrict payment for services only to patients located in Rural HealthProfessional Shortage Areas or counties outside Metropolitan Statistical Areas,

·      Type of provider requirements specifying that only physicians, nurse practitioners, physician assistants, nurse midwives, clinical nurse specialists, certified registered nurse anesthetists ,clinical psychologists and clinical social workers, and registered dietitians or nutrition professionals may bill for treatment, and

·      Type of telecommunications systems requirements that permit payment only for real-time audio and video and exclude store-and-forward technologies.

Of course, some regulatory changes might require changes in the applicable law. In light of the COVID-19 experience, Congress might be amenable to approving needed revisions.

If CMS were to enact greater accommodation of digital care solutions, private insurers would be more likely to include such coverage inMedicare Advantage plans and in private insurance plans for the general public.Some remote monitoring and treatment management services are already included in CPT coding for billing purposes.

Increasing the Efficiency of Care for Clinical Providers

Quite unintentionally, the COVID-19 pandemic required more widespread use of telemedicine and digital care solutions.

Because of declining numbers of patient visits due to pandemic-related prophylactic restrictions, many clinical providers and medical organizations suffered steep reductions in revenue. Thousands of solo practitioners closed their doors or sold to larger organizations with greater financial resources.

Nevertheless, and despite increased equipment (including software) and training costs, digital health solutions (along with telemedicine) offer hope of increasing efficiency in the management of care and, therefore, increased revenue.

For example, unlike reimbursement procedures for in-person patient visits and specific treatment protocols, reimbursement for digital care includes billing codes for actual time spent in virtual interaction with patients who have submitted data remotely. Providers will, under these procedures, be reimbursed for their time in managing digital care.

In addition, management of digital care will likely result in greater efficiency in time. Some routine tasks can be assigned to other trained staff, leaving the important treatment decisions to the principal provider. When elimination of travel time and inconvenience are added to shorter wait times, patient satisfaction is also likely to improve.

Finally, as technological advances continue to emerge, especially in the use of artificial intelligence, physicians and other providers will be able to take advantage of more robust diagnostic and treatment management tools. As a result, revised reimbursement policies will promote peace of mind for patients and providers alike.

Resources

AARP Public Policy Institute: Telehealth and Medicare: What is Covered. 08/27/2018.

AdvaMed: Modernizing Medicare Coverage of Digital Health Technologies. 09/30/2020.

American College of Physicians(ACP): A Digital Health Tool Aimed at COPD in High-Risk Individuals Reduces All-CauseHospitalization via Effect on Other Co-Morbidities: A Randomized, Controlled Trial. 07/2018

HealthAffairs: Accelerating Science-Driven Reimbursement for Digital Therapeutics in State Medicaid Programs. 10/20/2020.

IQVIA: Impact of Digital Health Grows as Innovation, Evidence and Adoption of Mobile Health Apps Accelerate. 11/07/2017.

Rural Health Information Hub(RHIhub): IncreasingCOPD Care with Telehealth. 2019.

STAT: Digital Therapeutics vs. Digital Care: Defining the Landscape. 02/20/2020.

Telehealth and Medicine Today: Telehealth for Limiting Readmission Rates of COPD Patients: An Assessment Based on Medicare Data. 02/21/2021.

Vivify health: YRMC is Improving Patient Outcomes with Remote Patient Monitoring. 02/06/2018.