The American Medical Association (AMA) issued new research examining the status of digital health advancement in the commercial health insurance industry by comparing current coverage across private health insurers and exploring how coverage decisions are made for digitally enabled care services.
“While the United States has entered an era when digitally enabled care is integrated with in-person care, the potential of this hybridized care model is not yet fully realized,” said AMA President Jesse M. Ehrenfeld, M.D., M.P.H. “The lack of commercial coverage can be a roadblock or bottleneck to affordable access to digital medicine services for more than half the U.S. population who count on private health insurance. Barriers to clear and consistent coverage policies must be addressed for the pace of digital health progress in medicine to match the technology’s promising potential.”
The research, completed by the AMA and Manatt Health, summarizes publicly available coverage policies created by commercial health insurers for 21 unique digital medicine services, as identified and defined by reporting codes found in Current Procedural Terminology (CPT®), the nation’s leading medical terminology for reporting health care procedures and services. The 21 digital medical services fall into four distinct categories: remote physiologic monitoring, remote therapeutic monitoring, electronic consultations, and electronic visits.
The research sheds light on the coverage policies of 16 commercial health insurers, including: Aetna, Blue Cross Blue Shield of Illinois, Massachusetts, Michigan, North Carolina, Texas, Blue Shield of California, CareFirst Blue Cross Blue Shield, Cigna, Elevance Health, Florida Blue, Highmark Blue Shield, Horizon Blue Cross Blue Shield of New Jersey, Regence, Tufts Health Plan, and UnitedHealth Group.
The research found the following key themes regarding commercial payer coverage of digital medicine:
- Lack of coverage alignment across commercial payers, Medicare, and Medicaid
Commercial payers trail Medicare in the coverage of digital medicine services explored by the research. Medicare and Medicare Advantage plans cover all 21 digital medicine services. Yet private health plans in Medicare Advantage program do not offer the same coverage in the commercial market. Coverage by Medicaid is more limited, though it has been expanding over time.
- Inconsistent coverage policies within the commercial market
Among the digital medicine services explored by the research, most commercial payers cover remote physiologic monitoring, while several are still considering coverage of the newer remote therapeutic monitoring. Coverage of electronic consults and electronic visits is less consistent.
- Inconsistent levels of transparency for coverage policies within the commercial market
Transparency of coverage policies for digital medicine services is highly variable across commercial payers. 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 prevents patients and physicians from making informed decisions.
- Time lag for determining coverage policies within the commercial market
Commercial payers contend there is no specific timeline for reviewing and making coverage decisions about the digital medicine services explored by the research. It can be several years before a digital medicine service is covered by a commercial payer, creating uncertainty and complicating planning and investment in digital health programs.
- Limited widespread utilization of most new digital medicine services
Commercial payers contend that a limited number of health care professionals leverage the digital medicine services explored by the research. Payers are eager for more information on the impact and quality of digital medicine services to inform coverage decisions.
- Partnerships between commercial payers and health tech companies
Commercial payers are partnering with health tech companies to provide direct access to digital services for specific disease areas. While these programs offer access to innovative digital health solutions, they are often disconnected from a patient’s medical home or existing primary care physician, which can further fragment care.
Through its ongoing leadership, the AMA is working to ensure the health care system can harness the full potential of digitally enabled care to meaningfully improve access, quality, outcomes, affordability, and health equity. From bringing the physician voice into the design, implementation, and evaluation of innovative technology, to ensuring digital tools smoothly integrate with busy medical practices, the AMA is striving to help physicians navigate and succeed in a continually evolving health care environment.