Commercial health plans show unwanted variation in digital coverage

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There's a lack of alignment across commercial, Medicare and Medicaid plans regarding coverage of digital medicine, and this is throwing a wrench into the progression of digitally enabled care, according to an issue brief posted by the American Medical Association.

As defined by the AMA, digitally enabled care entails fully integrated in-person and virtual care models that hybridize care delivery based on clinical appropriateness and other factors, such as convenience and cost. The idea has been gaining traction for about a decade now.

However, there's a chasm between the potential of digital health and the reality of its impact, something the AMA describes as a "digital health disconnect." Bridging that disconnect will take time, resources and a policy redesign, the organization said.

WHAT'S THE IMPACT

One of the foundational pillars for optimizing digitally enabled care, according to the AMA, is to improve and develop new payment models that incentivize high-value care. To that end, the organization has supported the development of appropriate Current Procedural Terminology (CPT) codes by the CPT Editorial Panel, which can provide a payment pathway for digitally enabled care services.

Coverage of digital medicine CPT codes varies widely, which makes it difficult for physicians to reliably provide digital services and for the consumer to know what services are accessible to them, according to the brief. And within the commercial market, there is inconsistent adoption of new digital medicine CPT codes.

Commercial is lagging behind Medicare in terms of those CPT codes, the report found. And some plans are adding restrictions beyond what CPT and Medicare require. For example, some payers cover codes only for specific indications – heart failure, chronic obstructive pulmonary disease, COVID-19, etc. – or may decide not to reimburse for a specific category, such as asynchronous communications.

The adoption of digital medicine CPT codes in the commercial market has been inconsistent. Some plans have explicit clinical coverage policies; others may not have explicit coverage policies but may still pay claims for the codes if they are billed by physicians and other healthcare professionals. Health plans that don't have explicit coverage policies will often default to state rules, where there may be specific coverage requirements in state-regulated commercial plans.

Based on the AMA's research, there's also a high level of variability in commercial payer transparency of coverage for digital medicine services. 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 makes it challenging for physicians to know whether services are covered – which for most physicians would require tracking coverage across dozens of insurance plans – and for consumers to know which services they are entitled to access.

Payers, meanwhile, said there isn't a specific timeline for reviewing and making decisions about their coverage of new CPT codes. After new codes are created through the CPT process, it can be several years before the codes are covered by commercial plans. This makes it difficult for physicians and other healthcare professionals to invest in and incorporate digital programs into their clinical models, as coverage is inconsistent among payers.

Payers also said they're seeing a limited number of physicians and other healthcare professionals leveraging digital medicine services. While there's data highlighting the rapid adoption of remote physiologic monitoring (RMP) – a set of codes describing non-face-to-face monitoring – the overall level of utilization remains low and concentrated among a small number of physicians and other professionals. Anecdotally, the utilization of other digital medicine services is lower than for RPM.

THE LARGER TREND

The AMA said what's needed is more consistent and broad adoption of CPT codes that support digitally enabled care. 

To that end, the organization said stakeholders should continue to expand coverage of digital medicine codes and increase transparency around coverage and payment for stakeholders, including physicians and patients. They should also continue to create new and update existing digital medicine codes as new technologies, care models and evidence emerge; promote state policies that require health plans to cover digitally enabled care services when clinically appropriate; and encourage more industry engagement around digitally enabled care coverage and payment, which may include provider, patient and payer education around the value of digital care services and availability of payment.
 

Twitter: @JELagasse
Email the writer: Jeff.Lagasse@himssmedia.com