Empowered consumers, increasingly interoperable data, and scientific and technological advances are transforming the health care system we know today. Virtual health has the capacity to inform, personalize, accelerate, and augment prevention and care—it is a key component of the future of care delivery. The COVID-19 pandemic has accelerated these advances. Stakeholders must stay informed of the growing virtual health options and how they are being reimbursed so as to assess their value in care delivery and their optimal use.
Care delivery options and strategies have changed as a result of COVID-19, with delivery quickly transitioning to virtual and home-based services. The term “virtual” means not physically existing but made by software to appear to physically exist, which is carried out, accessed, or stored by means of a computer, especially over a network. In health care, virtual means the physician and patient are separated through the use of a phone or video connection instead of meeting face-to-face. Although virtual care is typically thought of as synchronous care, where a physician interacts with a patient in realtime, there are also many successful examples of asynchronous virtual care, such as in dermatology and even dentistry. Further, providers of virtual care now include a range of health care providers beyond physicians, including nurses, therapists, and health coaches. In the not too-distant future, a further advancement of this relationship could be the replacement of the health care provider with artificial intelligence (AI).
Advances in technology, coverage, and use are all very much evolving at a tremendous pace. Clinical pathways are tools that have also been continually evolving to more comprehensively reflect the care journey, as patients navigate through various sites of care and services rather than just guiding drug or treatment choices.1 Clinical pathways are often built into technology platforms for providers to use at the point of care, and the latest software evolutions are learning how to pull information from electronic health record (EHR) systems or are fully integrated with the EHR.2-4
A clear appreciation of how technology is advancing to better support patients throughout care delivery is essential for improving both clinical and financial outcomes. Greater understanding of available technology and their capabilities can aid in determining where they can fit into and streamline the patient journey as well as reduce operational and administrative burden for practices. By building these considerations into tools like clinical pathways and other decision-support platforms, we can achieve more efficient and effective care.
Health Technology Advances
One of the ways AI is currently being utilized is in the form of chatbots. Chatbots are “software programs that talk with people through voice or text in their natural language,” such as Amazon’s Alexa or Apple’s Siri.5 Use of chatbots has been growing considerably in recent years, even prior to the pandemic.6 According to a study published in the Journal of the American Medical Informatics Association, chatbots can deliver the same quality as human agents, with proper design.7 These chatbot applications mirror interactions not only with physicians but also with professionals and family caregivers.8 Virtual family caregivers that look and sound like actual family members have been developed to provide on-demand support and interaction for the elderly and those with dementia.9 Chatbots are also used widely to help pharmaceutical companies help patients manage their medication administration, and as virtual coaches that provide automated clinical decision support guidance to help patients self-manage their disease. Products that provide automated advice that is based on practice guidelines and well-known evidence-based findings are generally exempt from Food and Drug Administration (FDA) regulatory oversight. However, many new products are under development that utilize AI and new insights from fields such as precision medicine and functional medicine to automatically recommend dietary and behavioral interventions or changes to medication regimens. Many of these companies are currently engaging with FDA and seeking Centers for Medicare & Medicaid Services (CMS) reimbursement.
Virtual chatbots represent just a fraction of the innovation that has come to virtual care. The Centers for Disease Control and Prevention launched an in-person National Diabetes Prevention Program (DPP) in 2000, and in 2017 began to certify several digital health companies into the program that provide a virtual version of DPP. Legislation has recently been introduced to reimburse the virtual DPP,10 and similar online programs have been implemented for arthritis and other conditions. Virtual coaching has become ubiquitous in the digital health industry, with disease management apps now providing coaching via real-time chat, phone, or video for cardiometabolic
conditions, behavioral health, autoimmune disease, and many other conditions. Remote patient monitoring is also now widely used to transfer physiological data from the patient to the health care provider, and in some cases to allow the patient and provider to communicate virtually through the platform.
Health Insurance Coverage
Telemedicine has enjoyed expanded health insurance coverage under COVID-19 revisions, making it much more accessible to patients. There are examples of other virtual health care services with coverage, such as counseling for smoking cessation: Medicare Part B covers up to eight visits of smoking and tobacco-use cessation counseling visits in a 12-month period.11 This coverage comes with no out-of-pocket expenses for Medicare beneficiaries if the doctor or other qualified health care provider accepts assignment.
Indeed, one of the few positive consequences of the COVID-19 pandemic is CMS allowing providers to bill for services they have been providing through online communication tools. Based on the feedback CMS has received regarding the use of technology to care for patients without being face-to-face, Medicare has created a new category of telehealth codes that providers will be able to utilize after the public health emergency ends.12 This category includes traditional encounters as well as those that occur outside of a clinic or hospital, such as a patient’s home or nursing facility. CMS also has included codes for emergency department encounters, physical and occupational therapy, and neonatal intensive care unit services, all of which can be accomplished by using available technologies to diagnose and treat patients who do not require hands-on care.13 Through the rule-making process, CMS has recognized that services like psychological testing, cognitive assessments, and psychotherapy can be accomplished through electronic portals rather than the previously mandated face-to-face encounters, and has permanently added these and other services to the telehealth code lists.14
The extension of telemedicine to AI by providers should represent a natural progression. In its publication of the Medicare hospital outpatient payment rule for calendar year 2021, CMS acknowledged that, while AI continues to advance, payers like Medicare continue to work on adapting to this technological innovation. Medicare now interprets existing statutory authority to pay for AI in diagnosing and treating patients. For a cardiac technology, CMS extended the “new technology” payment assigned to the technology in 2020.15 For an automated detection system for diabetic retinopathy, CMS adopted a new procedure code and assigned it to a payment band that would encourage use of the technology in the hospital outpatient department.16 There is also movement to provide coverage for digital health care.17
Medicare also covers remote patient monitoring (RPM) codes that record and transmit several days’ worth of data pertaining to a patient’s physiological parameters, such as weight or blood pressure, to the treating physician so the doctor can manage the patient without having multiple in-person encounters. Procedure codes extend to a monthly management session (again without the patient being physically present) in which the physician can make treatment changes based on the data collected and analyzed. The American Medical Association has also hinted at expanding these codes so physicians can list procedures for monitoring therapeutic interventions, including those from digital therapeutics to track a treatment’s effectiveness directly. These and other initiatives from payers and coding authorities are consistent with a report issued by AdvaMed, a trade association representing medical device manufacturers, in September 2020 that called on payers to reexamine the way digital therapeutics are paid because as more of these technologies come to market, patients will surely benefit, and the innovators of these interventions should be part of the coverage and payment discussion.18
Availability and coverage are only the beginning in increasing the use of virtual health care. Utilization depends on the perceived value of virtual health services. This value is based on outcomes against cost, including administrative burden. Patient costs, for example, can be reduced through either 100% or 80% of Medicare coverage, which is standard for most Part B services. Providers also bear a cost or administrative burden. Many virtual health tools have not seen wide acceptance because providers have felt their burden was too great compared to the benefit.
More opportunities for utilization occur through “payviders” (integrated health care companies) given their need to reduce total cost of care.19 Both payviders stemming from provider groups taking on risk and also those payers acquiring providers have started to embrace virtual health services to improve their clinical and financial outcomes. In addition, pharmaceutical companies can offer virtual health as a “beyond the pill” service to improve outcomes and increase utilization.20 These virtual health services may include earlier diagnosis and treatment or adherence to therapy.
Virtual health’s acceptance will improve clinical and financial outcomes for all stakeholders. Frequently, the perception is out of touch with true outcomes and costs, with most stakeholders perceiving clinical outcomes as less important than they really are while financial and administrative costs are seen as higher than reality. This unbalanced perception of costs and benefits results in limited acceptance of many new technologies.
It will ultimately be up to providers and clinical pathway developers to determine the value of virtual health care services and their appropriate placement within pathways. Inclusion in pathways will provide a clear direction for pathway users, providers, payers, and patients as to the best use of this technology to achieve optimum clinical and financial outcomes.
1. Wong W. The state of clinical pathways: results from the Journal of Clinical Pathways benchmarking survey. J Clin Pathways. 2020;6(10):47-53.
2. McKinney M. EMR integration of Moffitt Cancer Center clinical pathways. J Clin Pathways. 2020;6(9):31-34. doi:10.25270/jcp.2020.11.00004
3. McAneny B, Schwartzberg L, Koh W, et al. Supporting optimal, value-based, and sustainable cancer care delivery. J Clin Pathways. 2020;6(8):58-61. doi:10.25270/jcp.2020.10.00002
4. Ginsburg A, Neubauer M, Wilfong L. Updated on the evolution of The US Oncology Network’s clinical pathways program. J Clin Pathways. 2020;6(9):38-41. doi:10.25270/jcp.2020.11.00001
5. Miner AS, Laranjo L, Kocaballi AB. Chatbots in the fight against COVID-19 pandemic. NPJ Digit Med. 2020; 3:65. doi:10.1038/s41746-020-0280-0
6. Laranjo L, Dunn AG, Tong HL, et al. Conversational agents in healthcare: a systematic review. J Am Med Inform Assoc. 2018;25(9):1248-1258. doi:10.1093/jamia/ocy072
7. Dennia AR, Kim A, Rahimi M, Ayabakan S. User reactions to COVID-19 screening chatbots from reputable providers. J Am Med Inform Assoc. 2020;27(11):1727-1731. doi:10.1093/jamia/ocaa167
8. The top 12 health chatbots. The Medical Futurist. January 16, 2020. Accessed March 8, 2021. https://medicalfuturist.com/top-12-health-chatbots/
9. elovee. Accessed March 8, 2021. https://www.elovee.com/
10. Wicklund E. New bill would add telehealth to Medicare diabetes prevention program. mHealth Intelligence. September 25, 2020. Accessed March 30, 2021. https://mhealthintelligence.com/news/new-bill-would-add-telehealth-to-medicare-diabetes-prevention-program
11. Centers for Medicare & Medicaid Services. Counseling to precent tobacco use & tobacco-caused disease. Accessed March 8, 2021. https://www.medicare.gov/coverage/counseling-to-prevent-tobacco-use-tobacco-caused-disease
12. Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Fed Reg. 2020;85(248):84507. Accessed March 30, 2021. https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf
13. Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Fed Reg. 2020;85(248):84511-84516. Accessed March 30, 2021. https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf
14. Centers for Medicare & Medicaid Services. Medicare Program; CY 2021 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment Policies. Fed Reg. 2020;85(248):84529. Accessed March 30, 2021. https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf
15. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Fed Reg. 2020;85(249):85943 Accessed March 30, 2021. https://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf
16. Centers for Medicare & Medicaid Services. Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Fed Reg. 2020;85(249):85960-85962. Accessed March 30, 2021. https://www.govinfo.gov/content/pkg/FR-2020-12-29/pdf/2020-26819.pdf
17. Stefanacci RG, Abraham BC, Culjat M. Digital health placement in clinical pathways. J Clin Pathways. 2020;6(10):37-40. doi:10.25270/jcp.2020.12.00004
18. Modernizing Medicare coverage of digital health technologies. AdvaMed Center for Digital Health. September 2020. Accessed March 30, 2021. https://www.advamed.org/sites/default/files/resource/advamed-modernizing-medicare-coverage-of-digital-health-technologies-september-2020.pdf
19. Hu L. The rise of the payvider. Becker’s Hospital Review. August 12, 2019. Accessed March 8, 2021. https://www.beckershospitalreview.com/payer-issues/the-rise-of-the-payvider.html
20. Rudoy J, Yu Z. Beyond the pills: when value meets pharma. Marsh & McLennan Companies. Accessed March 8, 2021. https://www.mmc.com/insights/publications/2018/jul/beyond-the-pills-when-value-meets-pharma.html