A prominent trade group is calling on the federal government to cover digital health tools for people with public health insurance during the coronavirus pandemic, which has forced widespread delays in routine care.
These tools, some of which are known as digital therapeutics, use software and smartphone apps to connect patients with tips and coaching for diseases like diabetes. For the most part, they are not currently covered for Medicare or Medicaid patients, though some private Medicare Advantage plans and Medicaid managed care organizations have contracted with digital diabetes prevention and care providers. Employers and commercial insurance plans, however, are increasingly paying to make the tools available for their workers and members.
“A lot of private payers are starting to reimburse and provide access to these tools, but patients on the public side don’t have the same options,” said Megan Coder, executive director of the Digital Therapeutics Alliance, the group calling for broader coverage of such tools. The alliance includes 35 companies, some of which are startups and others of which are established pharmaceutical giants, such as Novartis and Bayer.
The Digital Therapeutics Alliance is asking the federal health department to use its special powers during a national emergency to grant publicly insured Americans access to digital therapeutics. The organization does not yet know what final form that access might take, but it could include, for example, making digital therapeutics reimbursable for members of public insurance plans.
Those tools come from companies such as Big Health, which uses cognitive behavioral therapy to help people with anxiety and sleep issues, or Omada Health, which connects diabetes patients to health coaches over their phones and laptops. (Omada, in particular, has been conducting research aimed at persuading public payers to cover its offering.)
The Digital Therapeutics Alliance wants to see the federal government give clinicians the ability to prescribe a digital tool like Omada’s offering along with a more traditional treatment, such as therapy or medications, Coder said. She added that if the Department of Health and Human Services does not take substantive action to make the treatments available to Medicare and Medicaid patients, the Digital Therapeutics Alliance will turn to Congress and ask lawmakers to intervene.
The alliance is pushing for these changes on a temporary emergency basis — but it could be difficult to put the genie back into the bottle.
“Those policy changes could be hard to reverse once more people get experience with these solutions and realize that they can be safe and effective and should be more broadly available,” said Andrew Matzkin, a partner at the consulting firm Health Advances.
“I think it would be a tremendous benefit if public payers made these tools more accessible to lower-income patients, to seniors during the pandemic, and I hope that would lead to lasting openness in coverage of and access to these solutions for those patient populations,” he added.
Because digital health tools don’t require in-person visits, they could help fill gaps in care for patients with chronic illnesses whose care has been sidelined due to the pandemic response. Those patients need regular access to care to manage their symptoms. That care is also important for managing their risk of complications if they do develop Covid-19, because people with certain chronic illnesses are at higher risk of developing more severe cases. But that care is largely unavailable right now, as hospitals and clinics are focused on dedicating all available resources to coronavirus patients.
“Right now it’s such a pivotal time where patients don’t have access to their health care providers, to the everyday opportunities they had, but still need to manage their disease,” Coder said. “It’s hit a turning point.”
In recent weeks, the government has taken several steps to address that need, including making sweeping changes to the way telehealth services are delivered to Medicare patients.
On April 1, the Centers for Medicare and Medicaid Services announced broad alterations to the range of Medicare services that can be provided remotely. Telehealth visits can now be conducted by phone only, without a visual component. Also, clinicians can now supervise staff virtually.
In some ways, then, the request from the Digital Therapeutics Alliance is akin to asking the government to do for digital therapeutics what it has already done for telehealth.
“The fact that telehealth is starting to reach its potential is amazing,” Coder said. “But digital therapeutics are different. They’re still connecting patients to providers, but in a different and sometimes more targeted way.”
Even before the pandemic, CMS had begun to signal that it may be open to paying for certain digital health tools. In 2017, Medicare officials rolled out a first-of-its-kind program to prevent diabetes in seniors — but, to the disappointment of many health-tech companies, it excluded virtual health providers from participating.
But as gaps emerged in that program, digital health startups and a bipartisan group of 19 senators pushed CMS to rethink that exclusion. In a letter to those senators in January, CMS Administrator Seema Verma wrote that the agency is “currently exploring ways” to let virtual providers get reimbursed for offering their services in the diabetes prevention program.
CMS’s new telehealth rules issued this month allow existing in-person providers in the diabetes prevention program to use digital tools to supply make-up services or cover gaps due to the pandemic. The rules do not create a new path for all virtual providers to become suppliers.
