Modernizing Medicare: CMS Proposes Reforms Promoting Digital Health

The potential for telehealth and other digital health services to improve patient engagement and relieve some of the major challenges facing health care is abundant. Yet, despite the data proving how digital health effectively supports patients, the health care industry as a whole has been slow to catch up and put these technologies into practice. A variety of reasons factor in, such as reimbursement challenges, liability concerns, and health care organizations not yet being able to offer the technologies as an option

However, proposed updates to the Medicare Physician Fee Schedule and Quality Payment Program for 2019 announced by the Centers for Medicare & Medicaid Services (CMS) on July 12 (2018), signal that change could be coming. With the goal of moving us closer to a modernized health care system, CMS’s proposal drives heavily in support of using technology as a tool to empower both patients and providers. CMS’s recommendations include, reimbursement for telehealth services and promoting interoperability, all to strengthen the provider and patient relationship and improve how care is accessed and delivered.

Advancing digital health

CMS outlines plans to start paying clinicians for virtual check-ins, regardless of whether or not the clinician has seen the patient in-office or plans to, and for the evaluation of patient-submitted photos. “Innovative technology that enables remote services can expand access to care and create more opportunities for patients to access personalized care management as well as connect with their physicians quickly,” states CMS. Additionally, Medicare-covered telehealth services will be expanded to include prolonged preventative services.

If implemented, these measures would widen access to care, critically important for patients in rural areas (and some urban communities) where providers are sparse and resources to support patients are lacking. For people facing social determinants and other barriers to care (such as lack of child care, limited transportation, a mental illness or physical disability that make in-office provider visits difficult) access to telehealth and other virtual services can be game-changing, helping patients access care in a way that is most convenient for them. It also ensures health concerns don’t go unaddressed because care is out of reach, which leads to bigger, costlier, health problems.

Modernizing Medicare payment policies to promote access to virtual care would save “Medicare beneficiaries time and money while improving their access to high-quality services no matter where they live.”

In an effort to improve the doctor-patient relationship—something many feel has fallen by the wayside as clinicians continue to be buried in paperwork—CMS is pushing for interoperability, “empowering clinicians to use their EHRs to document clinically meaningful information.” Interoperability will allow clinicians to focus more on the pertinent patient information that will inform care and lead to improved health outcomes, as well as enable collaboration across providers. Patients will have a new level of transparency and a greater role in managing their health.

CMS’s step toward incentivizing technology that would improve health care for patients and providers is indeed positive, and a sign that we’re potentially entering a new era in medicine intent on providing care that’s meaningful and has patient needs at the center.

Yet, CMS’s recent refusal to reimburse diabetes prevention coaching programs can’t help but dampen the mood—seeming anything but empowering. Are we really getting closer to modernizing health care if we embrace using telehealth for longitudinal preventative care with one hand, while dismissing virtual coaching for preventative patient support with the other?

Two steps forward, one step back

Politico reported that “Senior officials at CMS are dragging their feet over expanding services for diabetes prevention programs that evidence shows can reduce insurance costs and improve the health of millions of Americans.”

The program in question focuses on group coaching for people at risk of Type 2 diabetes, in-person and virtually. According to the article, CMS has refused to fund the virtual programs and slowed the in-person ones, despite clinical trial results showing “improved health while cutting costs by $2,650 per participant.”

Diabetes is one of the costliest and most common chronic diseases—the American Diabetes Association estimates the total cost of diagnosed diabetes has risen from $245B in 2012 to $327B in 2017 yearly. And that’s not factoring in the nearly 85M Americans who have prediabetes—a condition that is prevalent among Medicare-eligible seniors and often leads to type 2 diabetes within five years if left untreated.

Coaching programs, specifically those with digital components, have proven their value as an effective tool for helping patients with prediabetes. Patients are engaged and supported by coaches via smartphone and other devices, and can easily access peer support, disease education, track and monitor eating habits, and obtain and share important data with coaches and providers. Coaching programs offer patients access to high-quality, personalized care in a way that works best for them, increasing the odds that they stay engaged, make and sustain lifestyle changes, and improve their health.

NPR reported on a pilot study with Omada Health and Intermountain Healthcare in Utah that included 200 patients, all at high risk for Type 2 diabetes. 75 percent of the participants who completed the Omada digital program (which included e-coaching, peer support, education, diet and exercise tracking, and electronic prompts and reminders, delivered via smartphone or other device), lost at least 5 percent of their body weight, and about 1 in 4 lost 7 percent or more. In a separate Omada program, Quest Diagnostics was able to reduce diabetes risk in one-third of an 107-employee cohort by combining Omada’s intervention with lab and biometric screenings, according to MobiHealthNews.

CMS’s refusal to reimburse diabetes prevention coaching programs is problematic, simply because they actually work. They work well. Politico reported that “Many startups have funded or participated in clinical trials to prove their merit” but CMS has not changed their stance or sought data from the trials.

Given the scope of diabetes in the U.S. and its impact on our physical and financial health, prevention is key, and possible. We won’t be able to truly benefit from a brave new world of modern health care if we fail to provide patients and providers with the tools that are actually working to prevent disease in the first place.