Deeply embedded obstacles hinder the full benefits of digital connected care

Digital technologies and online app-based services provide a clear pathway for innovation that enable care where consumers and providers reside. Digital health data exchange fuels technology and app-based services providing the health information on demand needed for evidence-based telehealth, remote patient monitoring (RPM), care management, patient engagement and self-care, and virtual behavior change programs. In the U.S., temporary policies, regulations, and coverage changes allowed digital care delivery during the COVID-19 public health emergency. These new (and still temporary) regulations, policies and coverage, made it abundantly clear that digital care delivery is efficacious.

Technologies that are integral parts of digital connected care can flourish with the right policies, regulations, laws, collaborative agreements and workflows.

There are many virtual tools that address the challenges integral to: chronic condition management, maternal health, diabetes prevention, heart failure, sleep apnea, weight management, blood pressure control, and diabetes self-management programs in the market. Barriers to use of these digital tools exacerbates the well-established link between socioeconomic status and chronic disease burden in the United States[i], amplified by limiting access for those who need them most.

The Diabetes Prevention Program, an intensive behavior-change for healthy lifestyle program, using the best behavior-change science is able to deliver a low-cost intervention that delays onset of Type 2 diabetes. When tested in the Medicare program (via a CMMI pilot), the community based, lay coach delivery model was found to save over $2,000 per Medicare beneficiary within 15 months.[ii] The program is now available virtually, with the same outcomes in the private sector.

The disconnects between reimbursement and coverage policy, prevention policy, and evidence and regulatory implementation of policies impedes widespread use of the digital tools and benefits of digital connected care, they include:

• Insurers cover only clinic or hospital-based screenings and do not cover digitally enabled prevention services.
• Medicaid rarely covers evidence-based digital care, even when it is clearly associated with significant improvements in maternal and child health.
• Medicare National Coverage Decisions (NCDs) do not align with the United States Preventive Task Force’s full recommendation or with professional standards of care.
• Medicare (and other insurers) requirement that digital tools must be solely dedicated to a specific health function does not meet consumer expectations, nor does it align with capabilities available today via smart device enabled apps.

The cost of the disconnect between coverage, reimbursement, innovative prevention and self-management tools is high. The obstacles and barriers to the evidence proven programs that support healthy lifestyle leads to:

• Higher costs for Medicare Medicaid and private payers which all must cover more care.
• Poorer outcomes and quality of life for consumers who continue to struggle with adopting the behavior changes associated with healthy lifestyle when there is no support for evidence-based behavior change services.
• Stifled innovation because reimbursement and coverage are limited to clinic and hospital-based services.

HIMSS Accelerate Health is working with a community of healthcare providers and system integrators to develop and deploy the underlying tools and infrastructure that supports the effective application of PGHD to a broad range of workflows that allow for successful transitions to RPM models of care. You are invited to participate in this effort by joining the HIMSS Innovation Organization, Personal Connected Health Alliance.

[i] Paula A. Braveman, Catherine Cubbin, Susan Egerter, David R. Williams, Elsie Pamuk, “Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us”, American Journal of Public Health 100, no. S1 (April 1, 2010): pp. S186-S196.

[ii] DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Certification of Medicare Diabetes Prevention Program

Originally published by HIMSS on February 25, 2022