By Edward Black, founder and principal, Reimbursement Strategies
Government and private insurance health plans struggle to be clear and concise when writing contracts for their members’ health care coverage. In each state, these contracts have to be filed and approved by the state departments of insurance and commerce. Is it any wonder why there is a need for simplicity, clarity and consistency in the services each state and private insurer covers? Is it any wonder that general terms, such as digital health, connected health, and mHealth (mobile health) are only vaguely defined and are impossible to incorporate into a legal insurance product?
You won’t find these terms in any health plan medical coverage policy, or in a member contract filed with a state authority. These are industry terms from innovators seeking to rapidly leverage new sensor and communication technologies for the consumer and insurance markets. The challenge is that these are vastly different markets utilizing different languages.
The first step toward rectifying the clarity issue is defining terms. The government and private insurance use the overarching term “telehealth” to generally describe the industry, while “telemedicine” and “telemonitoring” have more specific meanings. Telemedicine is most commonly used to describe direct interaction between a single patient and physician, via audio or video communication, for a patient encounter. These services are broadly covered by most insurers. Telemonitoring has been with us for years and includes devices used to monitor, store, and forward (asynchronous communication) data about the heart’s electrical activity (though medtech advances are opening the door to remote monitoring of other physiological gauges of health). However, beyond the terms telehealth and telemedicine, it is very difficult to find agreement between industry and insurance language.
Federal and state guidance on the subject is confusing and only slowly evolving. The following excerpt is from the Federal Medicaid program:
Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care. As such, states have the option/flexibility to determine whether (or not) to cover telemedicine; what types of telemedicine to cover; where in the state it can be covered; how it is provided/covered; what types of telemedicine practitioners/providers may be covered/reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid statute/regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed Federal Upper Limits.
Meanwhile, the Center for Connected Health Policy (CCHP), the federally designated National Telehealth Policy Resource Center, uses the following description: “Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technology.”
Even on an international level, connected health suffers from a lack of clarity between industry and insurance. The University College Dublin, Ireland (UCD) Connected Health center acknowledges:
There is no standard, accepted definition of Connected Health. Connected health is a new model for health management. It puts the correct information in the correct hands at the correct time. Connected health is not just about technologies. It’s about connecting people and information within a system – the healthcare system. Technology is vital and exciting – but it is just one part of a picture that includes patient care pathways, business and revenue models, data analytics and more. Connected health includes terms such as eHealth, Digital Health, mHealth, Telehealth, Telecare, remote care, and assisted living.
The language of connected health is marked by both nuanced and clear-cut disparities — like the English language spoken by the English versus that spoken by Americans. Widespread efforts are underway to define terms that suit both industries. Some of this work is being done by the American Medical Association (AMA), which is responsible for the CPT® (Current Procedural Terminology) coding system. CPT® is a system to describe physician and other healthcare professional services for purposes of billing Medicare, Medicaid, and commercial insurers.
However, progress in implementing a common language has been slow, and wrought with the perils of industries that are not in full harmony. The AMA and insurers are trying to distinguish between synchronous (immediate and interactive) and asynchronous (one way with expectation of review and action, if required) communications, frequency of reporting, duration of reporting, and the value and data security. To date, there remains little coverage for telehealth services beyond the reporting of chronic cardiac care and Type I diabetes. That will change, but not as quickly as the technology advances.
This slow rate of change already has proven frustrating for several companies, particularly those who historically have developed products for the direct-to-consumer market. The gap between a consumer wearable and a medical device is huge — think FDA, CMS, and the Health Insurance Portability and Accountability Act (HIPAA). These are among the reasons medical devices take years to develop and come to market. Innovators need patience, persistence and resources — like other medical device companies.
One health plan executive revealed to me in a recent conversation six critical criteria by which their company evaluates adoption of new telehealth technologies:
Those in the medical technology industry will recognize these criteria, commonly applied to almost all new devices.
Beyond terminology, the greater question may be insurance versus patient responsibility. The development and adoption of connected health/digital health devices bring payers to a familiar crossroad: When is a patient responsible for his or her health, and when should insurance cover and pay? When are these devices developed to assist healthy, active people maintain health, and when are they needed to monitor patients in declining health?
I’m reminded of a health plan medical director who advised that health plans only want to pay for actionable data that will change patient behavior. For example, if a diabetic patient with a Hemoglobin A1c level of 12 and a BMI of 38 chooses against improved diet or exercise, what is the point of having that data? It is a careful reminder that not all data is actionable, and not all patients are motivated to change.
Connected health/mobile health companies will have to create value within this construct if they seek to be reimbursable by government or commercial insurers. A huge gap separates consumer wearables and medical grade devices. There is a great deal to sort out before the industries are in harmony, placing connected health medical technology firmly in the realm of those companies in it for the long haul.