Stacy, thank you for this question. My vision is to use digital tools to increase the efficiency of providers, increase access for patients, and allow providers to "practice at the top of their license". One example is eConsults. Studies show that these increase access to specialists and about 25% of the time the patient never has to see the specialist in person. Think of the time and resources saved for the patient, referring provider, specialist, and healthcare system. This also means that the patients who end up seeing the specialist in person actually have conditions or situations that require an office visit and are higher complexity/acuity. Similarly, I envision genetic counseling chatbots helping genetic counselors by performing less complex education/counseling and freeing up the GC's time to perform more complex/intensive counseling services.

Nathaniel, I think that a good case can be made for encouraging coverage of telehealth services delivered to in-patients, especially for Medicare patients in rural/critical access hospitals, if this enables patients to receive otherwise unavailable specialty care without being transferred to another hospital. Maybe CMS will surprise us one day.

Telemental health is widely used in the US. I do not know of specific companies which specialize in school-based telemental health, but I can put you in touch with some folks who would know, on the pediatric mental health side, and on the school-based telehealth side, if you contact me off line.

Kristin, I can say with certainty there are. We represent a few such companies. They are doing some very exciting things and helping drive up presenteeism in school. Unfortunately for kids, that means kids don't get to fake sick and stay home to play video games.

Check with Ritvik Singh at wayforward.io/ They started with College age kid focus, and may have pivoted into payer sale, but he is an expert on the space.

Many variables at play for these. It also depends on the customer, the stage of solution (are they young and proving ROI or do they have data points to show reduction in cost). The simple answer, reimbursement is more determined by expected savings as opposed to the cost to implement them. Another variable to consider is the reimbursement a la carte or an unlimited survey for all members (a PMPM)

It's called narrow networking or exclusive contracting. You can read the new Kentucky telehealth law to see how that state addressed the issue. Here is an article on it: healthcarelawtoday.com/2018/05...

Educate providers as they sign contracts with insurance providers to not be subject to the "workaround" of narrow networks and exclusivity? Seems this should be part and parcel of contract negotation.

This is a great question and I fear that I don’t have a great answer! That said, coverage of digital health services and products varies from payer to payer. Commercial plans are increasingly receptive to negotiating/partnering with digital health companies for the operation of programs that address a particular pain point of the payer and/or their covered members — but it often requires quite a bit of negotiating and, at times, finding the right person (which can feel like searching for a needle in a haystack) within the commercial payer to pitch the opportunity. The coverage and payment terms can vary widely depending on the program, payment methodology, allocation of risk, etc.

As for Medicare, there are several different bodies that play an important role in the coverage and payment of digital health solutions. The RUC is believed to be particularly influential. Notably, AMA convened the Digital Medicine Payment Advisory Group (DMPAG), which will/has helped to inform decision makers, in 2017.

In addition, we shouldn’t overlook the persuasiveness and effectiveness of well organized groups who unite in their efforts to lobby CMS on a particular coverage and payment issue. One example is discussed here: mhealthintelligence.com/news/m...

Great question for providers! I'd like to address each separately. With respect to coding, individual payer sites for "authorization lookup" can be a good resource to find out general information about which billing codes accomplished with implementation of a digital health product will be reimbursed. The 'rubber hits the road" however with the individual provider's contracted fee schedule. It is the actual contract with the payer which determines payment. The ultimate test of reimbursement is with a short term "demonstration project" in which the product is implemented in a clinic/hospital and the money hits the practices bank account, preferably electronically within 14 days.

Pricing for digital health products is separate issue. There are a variety of pricing models which depend on the features of the product, integrations, and specific outcomes attained with the product. Many of us price our products in a SAAS model. SAAS models can be per patient, or they can be per provider. Tiered SAAS pricing is common as it makes sense for a 2000 provider employed physician group using Epic to pay less per provider than say a 7 provider private practice. Ultimately digital health products should provide a specific Return on Investment. In the short run, return on investment should be realized within 180 days for a practice. Dependencies on return on investment are multiple and are as follows:

1. The Physician user target of the digital health product. ( is this a product for ALL physicians to use? or is this a specific product for a specific kind of physician)
2. Incidence of the particular patient group that the digital health product. (Is this an intervention for a specific patient group? or is this a "portal" for the use of all patients")
3. Custom Features (can add cost but worth asking for)
4. Integrations with EHR. (Integrations take 12 to 16 weeks and add some cost. Here is where scale is possible, with data access for an entire health system.

Similar to previous responses, there are a few ways to approach this. One, CMS regulates payments for various services and releases them with the Medicare payment fee schedule. Depending on the negotiated payer rate, a % of medicare is agreed upon as the reimbursement amount. The second, depending on the population in question, typically employer group or a provider in a capitated risk contract, determines the expected value from the service and is able to negotiate a price. I am more familiar with the capitated risk space. As our physician groups move from FFS to risk, they adopt various products and services based on expected ROI. Typically they will pay a PMPM (per member per month) price for the unlimited use of the service, and ROI is determined based on the service. Can be APT / EVPT (admits/thousand and ER visits/thousand) or Med Adherence etc.

We are developing a digital + hardware solution targeting the chronic respiratory disease population, planning a pilot study, how many patients in a pilot study would typically be needed to prove a good ROI?, it probably has a complex answer but some guidance would help. Thanks. Great questions and answers BTW

Are you self funded? Venture Backed? I will say that VC's would like to see pilot data for 40 patient groups in my experience. Check out Revon from Louisville and Propeller in Louisville for competition, then of course Cohero for Pediatrics, in NYC. Good luck! Natalie

Payers have different approaches to determining what services they cover and reimburse. Generally they want to see that the service has clinical utility. Utility could mean that there is a change in management of a patient's condition or the service is more cost-effective than another approach.

Demonstrating improved outcomes is challenging for many services, as there is not much data on outcomes with "usual" care and there are frequently questions regarding what the outcome measure should be. In a perfect world there would be clinical trials, but for most health care activities clinical trials would be logistically complicated and expensive.

Nate, great question, as always. One thought that crossed my mind relates to the types of physiologic data that can be monitored using this code. Given the opioid addiction epidemic and the need to help patients to monitor and respond/manage their pain in a safe way, and facilitate ongoing communication with providers, seems like it would be helpful for this code to also cover monitoring of patient-generated measures of pain — in other words, allow pain measurement to fit within the definition of physiologic data for this code. (Perhaps there’s an argument that it already does.) Just seems like a potential use that could solve an acute problem!

For some reason, perhaps you know, these codes are not reimbursed for pediatric patients. Any idea why?

Most kids are not eligible for Medicare because children are under 65 years old. But if you have a Medicare-eligible kid, and they also have the chronic diseases required for RPM reimbursement, then I would imagine the service will be reimbursed.

I just heard yesterday from a CPAP rep that people are starting to use their portal (which monitors CPAP compliance data) to bill for RPM, first time I hear this and surprised me as there are millions of people using these devices. Will look into, access the data and find out..

Laura, you bring up an important point. There is so much innovation going on in digital medicine that it is hard for regulators to keep up and also hard for payers. I will put in a little "plug" for the AMA here, which set up the Digital Medicine Payment Advisory Group of experts in telemedicine, digital medicine/health and in coding, to be pro-active in identifying what new use cases are out there and to develop proposals for CPT codes for these evolving services in a timely manner.

The DMPAG's new RPM codes are a HUGE improvement over CPT 99091. Thanks for the great work on that! Particularly including clinical staff and thereby allowing much more cost-efficient leveraging.

Traditional direct reimbursement (ie, FFS) is definitely not keeping up with the pace of innovation. But an interesting question that my colleague, Dale, has raised over the years is whether digital health needs direct reimbursement to thrive. Given the extent of innovation, perhaps not.

Value based / quality based reimbursement models and other alternative payment models are changing the payment landscape in a way that requires providers to focus on quality over quantity, etc. Patient-facing solutions, like telehealth, help providers to deliver higher quality care and increase their revenue (theoretically) at the end of the day. (While ACOs have experienced financial and performance challenges over the years for a variety of reasons, some have exemplified efficient and effective digital health adoption that has resulted in financial reward.)

I agree that digital health should have its own direct reimbursement model, parallel to this there should be much clearer path from creation to testing, pilot, implementation and payment. I guess we are still in the early stages.

One question I have regards CMS' proposed new service of a virtual check-in with a patient. It is a brief non-face-to-face encounter between the physician or QHCP using communication technology. The description seems to limit this to patient-initiated virtual check-ins, but perhaps I did not read the section thoroughly. What do other think?

For the virtual check ins, I think that CMS is going to introduce a lot of confusion if they don't do away with the suggested timeframe limitations.

Also, they should allow these check ins to happen over the phone, it works well for a majority of cases and all offices have the infrastructure for it. If not, there will be a perverse incentive to overuse live video telemedicine services. The only people who will benefit from that are telemedicine vendors.

For peer to peer consults, I think the proposed rule is really good. I'm a little biased here, but I don't think requiring patient consent is necessary for an ethically run program. That said, after any initial hurdles, it really isn't such a big burden that it's worth worrying too much about.

I agree on the check-ins. They should not be video anyhow, as they are defined as "non-face-to-face services". This means there is no "face-to-face" (i.e. no interactive audio-video). I think the payment rate on the P2P consults is far too low, however.

Likely, yes that it's patient-initiated. But the overlap with this an RPM is certainly something to consider.

My mistake, I should have read that part of the rule more closely. I agree, I was especially disappointed in 994X0 and 994X6 being set at a work RVU of 0.5. If CMS wanted parity between PCPs and specialists for doing similar amounts of work, they should have raised 994X0 to 0.7 instead of dropping 994X6 to 0.5.

That said, it may not prevent adoption of this kind of care. Many eConsult programs have had fairly low payments to PCPs and specialists (average compensation per consult in line with what CMS is suggesting) but have been very successful and strongly supported by the providers involved.