Commercial payers trail Medicare in the coverage of digital medicine

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The lack of commercial coverage for digitally enabled care is a roadblock to affordable access to these medical services, according to the American Medical Association.

The model of integrating digitally enabled care with in-person care is not yet realized, according to AMA president Dr. Jesse M. Ehrenfeld.

This is based on new research from the AMA and Manatt Health. The research summarizes publicly available coverage policies created by commercial health insurers for 21 unique digital medicine services, as identified and defined by Current Procedural Terminology (CPT) codes used for reporting healthcare procedures and services. 

The 21 digital medical services fall into four categories: remote physiologic monitoring, remote therapeutic monitoring, electronic consultations and electronic visits.

WHY THIS MATTERS

The research sheds light on the coverage policies of 16 commercial health insurers, including: Aetna, Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina and Texas, Blue Shield of California, CareFirst Blue Cross Blue Shield, Cigna, Elevance Health, Florida Blue, Highmark Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, Regence, Tufts Health Plan and UnitedHealth Group.

One key theme is the lack of coverage alignment across commercial payers, Medicare and Medicaid payers, according to the report. Commercial payers trail Medicare in the coverage of digital services.

Medicare and Medicare Advantage plans cover all 21 digital medicine services, yet private health plans in the Medicare Advantage program do not offer the same coverage in the commercial market.

Coverage by Medicaid is more limited, though it has been expanding over time, the report said.

THE FINDINGS: 

• Most commercial payers cover remote physiologic monitoring, while several are still considering coverage of the newer remote therapeutic monitoring. Coverage of electronic consults and electronic visits is less consistent.
• There are inconsistent levels of transparency for coverage policies within the commercial market. While some plans have publicly available clinical coverage policies related to digital medicine services, many have no publicly available information or the information that is available is difficult to access or dated. A lack of transparency prevents patients and physicians from making informed decisions, the AMA said.
• There is a time lag for determining coverage policies within the commercial market. Commercial payers contend there is no specific time line for reviewing and making coverage decisions about the digital medicine services. It can be several years before a digital medicine service is covered by a commercial payer, which creates uncertainty and complicates planning and investment in digital health programs.
• There is limited widespread utilization of most new digital medicine services, commercial payers contend. With a limited number of healthcare professionals leveraging digital medicine, payers are eager for more information on the impact and quality of these services to inform coverage decisions.
• Commercial payers are partnering with health tech companies to provide direct access to digital services for specific disease areas. While these programs offer access to innovative digital health solutions, they are often disconnected from a patient's medical home or existing primary care physician, which can further fragment care.

THE LARGER TREND

The AMA said it is working to ensure the healthcare system can harness the full potential of digitally enabled care to meaningfully improve access, quality, outcomes, affordability and health equity. 

From bringing the physician voice into the design, implementation and evaluation of innovative technology, to ensuring digital tools smoothly integrate with medical practices, the AMA is striving to help physicians navigate and succeed in a continually evolving healthcare environment.
 
ON THE RECORD

"While the United States has entered an era when digitally enabled care is integrated with in-person care, the potential of this hybridized care model is not yet fully realized," said AMA president Jesse M. Ehrenfeld. "The lack of commercial coverage can be a roadblock or bottleneck to affordable access to digital medicine services for more than half the U.S. population who count on private health insurance. Barriers to clear and consistent coverage policies must be addressed for the pace of digital health progress in medicine to match the technology's promising potential."

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org