The American Medical Association (AMA) has conducted research to understand the landscape and decision-making process behind cost and commercial payer coverage for digitally enabled care. The findings indicate a lack of coverage agreement, inconsistent coverage policies within the commercial market, and varying levels of coverage policy transparency for digital health services and tools.
Study Overview: The AMA, in collaboration with Manatt Health, released a study summarizing publicly available coverage policies of commercial health insurers for 21 unique digital medicine services. The aim was to comprehend the existing landscape of commercial payer coverage and the decision-making process behind coverage determinations.
Challenges in Digital Medicine Services: The researchers noted that achieving fair, equitable, and transparent coverage and payment for digital medicine services remains a challenge. These issues impact the widespread adoption and accessibility of digital medicine services for both patients and physicians.
Coverage Analysis: Using AMA Current Procedural Terminology (CPT) billing codes from 16 commercial payers, the study identified which digital health services are funded and explored opportunities for improving digital health access. The services included remote physiologic monitoring, remote telemetry monitoring, e-consults, and e-visits.
Coverage Discrepancies: The analysis revealed a lack of coverage alignment across commercial, Medicare, and Medicaid insurers. While Medicare and Medicaid cover all 21 digital health services, some commercial plans have additional requirements. Some commercial payers only cover codes for specific conditions, and others choose not to provide coverage for certain conditions.
Barriers to Digital Health: The researchers found that commercial payers partnering with telehealth companies often offer services disconnected from a patient’s primary care physician, creating barriers to care. Jesse M. Ehrenfeld, MD, MPH, president of the AMA, emphasized that the lack of commercial coverage can hinder access to digital medicine services for a significant portion of the US population relying on private health insurance.