Navigating the Intersection of Health and Technology: A Patient’s Perspective, Part 1

In the dynamic landscape of digital therapeutics, where technology converges with healthcare to revolutionize patient outcomes, the Digital Therapeutics Alliance (DTA) stands at the forefront as a pioneering force. At the heart of its commitment to patient-centricity and the seamless integration of digital interventions into healthcare protocols is the invaluable contribution of its Patient Advisory Council. This esteemed council, convened in partnership with SAVVY Coop, serves as a cornerstone in shaping the alliance’s strategies, with insights and experiences that guide the alliance to navigate the complex intersection of technology and healthcare while improving patient well-being.

Embarking on a journey through the complexities of chronic illness and healthcare, our patient advisor shares a unique narrative that intertwines personal resilience with the transformative power of digital therapeutics (DTx).

 

Interview

Can you walk us through your patient journey? 

Patient advisor: I was born with a genetic systemic and degenerative disorder, as well as a neurodevelopmental disorder, and in my early adolescence I developed my first autoimmune disease. My symptoms were life-altering but manageable with traditional adaptations or “quick hacks” at their mildest and totally debilitating to where extreme accommodations were necessary in other cases.

I was a vigorously devoted student, so I came out of K-12 intentionally prepared to have a storied academic and practical career, but I also had to double-duty becoming a “professional patient” and continuing my own crash course hands-on medical education with more-than-casual proficiency in:

I’ve since had to radically re-orient my perspective and my “life/career balance” to where I’m not leading so much a double life as I am a full-time career professional patient who moonlights as a gig worker in being “normal.”

How have digital therapeutics fit into that journey and how would you describe the impact of DTx on your health and wellbeing?

Patient advisor: I grew up in the 90s and early 2000s, and, as an islander, things were relatively rural. My family did have internet access, and my district was an early adopter of virtual school, but most of my medical needs had to be met in-person and required taking long trips to the mainland or working with local onsite therapists. Countless hours on the phone, endless faxes and snail mail correspondences, days (and weeks!) out of school, whole class periods and nap times were rescheduled to account for tutors, therapists, doctors, nurses, case workers, insurance adjusters, medicaid adjudicators—-all just to access and then still maintain my basic health needs!

When I moved to the mainland for college, my health regimen was completely uprooted and started from scratch. There was no transition. My health coverage stopped, my childhood resources were cut off and had no adult equivalent. Adult care and independent living resources for people with my diagnoses was (in some ways still is!) the wild west. But when starting from a completely clean slate, I was open to pretty much *everything*. 

The initial part of my adult patient experience in the early 2010s was very much me trying to retrace my parents’ steps (with the adult equivalents). Time was definitely less of an issue, as was distance, because I had so much of my health history on paper and had freedom of choice to pick my coverage and my care providers. As my care plan became more complex and the “milestones” in my health journey changed, digitalization and virtualization was also exceeding pace. I started to be referred to trial cutting-edge therapies, such as biofeedback in pelvic floor therapy. These experiences illustrated to me exactly how much control I had in my therapeutic process and directly influenced the next-steps goals of my continuing PTT curriculum. In the late 2010s, when I was evaluated for my replacement wheelchair, I was initially evaluated with the goal to transition from a manual chair to a powerchair, but my physical therapist–understanding that my everyday lifestyle still greatly benefit from the flexibility of a standard manual wheelchair–found me to be an excellent candidate for a manual chair with a separate (and lightweight!) power-assist that is controlled by a proprietary app and wristband.

However, it’s what happened in the aftermath of COVID lockdown restrictions in the 2020s that absolutely made me appreciate the dynamic nature of digital therapeutics and made me realize how very different my adult patient life is from my childhood experience. In so many ways, I was re-living some of those challenges from my childhood, most notably being back to physical isolation from my care providers—only this time due to capacity restrictions, social distancing, and risk of exposure on public transit (I don’t drive, and like many other patients, I am immunocompromised). Where in the past my parents may have been faced with the choice of forgoing treatment, taking an inconvenient (and far away) appointment, an extended pre-planned hospital admission, or scheduled in-school therapies, I now had the option to follow my own physical therapy regimen via a phone app (or a web portal!) on my own personal device. 

The monitoring for my cardiac study was similar with a phone delivered to my home with the proprietary app and software pre-installed. In both cases, the initial “hardware” was administered to me by my providers—so not 100% digital or remote, but significantly expedited. A one-time appointment for acquiring tools without having to schedule follow-ups is doable.

The nature of my health is degenerative, but the future of DTx is emerging. Things are getting “worse,” but things are also getting so, so much better. The result is… normal! I feel like I am able to, at least part of the time, feel “normal,” a sense of neutrality. I’m very hyper-conscious of my health and way more hands-on than I was as a child, but digital therapeutics and advancements in digital-assisted medical technologies has given me back so much of the time and the autonomy that my parents and I did not have when I was young.

 What do you think patients need in terms of education so that they can adopt DTx solutions into their own care plan?

Patient advisor: When I first moved out of my parents’ home and to the mainland, things got a lot harder before they got “easier”. My parents did an excellent job of caring for my needs, but not with preparing me to be my own patient advocate. All of the opportunities I’ve had as an adult have come to me by being in the “right place at the right time”. I’ve been fortunate enough to be referred to these more-than-modern solutions. 

Unfortunately, the average patient might not be a patient at all–they may be a consumer, and their only access to health “care” may be through predatory wellness trends via social media. This was also some of my earliest exposure to digital aids (or what I thought were digital aids). Had it not been for my care providers introducing me to actual assistive technologies, and for me being able to verify these tools actually existed and saw success in my patient communities (particularly the wheelchair power assist), I don’t think I would have become nearly as passionate on how powerful and meaningful they’ve been to my quality of life.

Digital therapeutics, as a whole, need a strong public service outreach and visibility campaign on mainstream platforms and in patient-oriented support spaces in the form of direct ambassadors, information campaigns, access to trials, and patient success stories.

Check back in January to hear more from our patient advisor. Part 2 of this interview will focus on what DTA can do to promote awareness among patients, clinicians, and payors. 

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RPM and RTM Reimbursement Implications in U.S. Private and Public Insurance

The Implications for Remote Physiologic Monitoring and Remote Therapeutic Monitoring Reimbursement in Private and Public Insurance in the United States

Authors: Steven Driver MD, Di Jiang, Alona May, Lani Hessen, Andy Molnar

Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) codes are playing an increasingly important role in the adoption and uptake of digital health technologies, particularly digital therapeutics (DTx). DTx products – evidence-based therapeutic interventions driven by high quality software to prevent, manage, or treat a medical disorder or disease – frequently generate physiologic and therapeutic response data. Clinicians use RPM and RTM Current Procedural Terminology (CPT®) codes to account for time spent reviewing and assessing DTx-generated data, thus making these payment codes essential to clinician adoption of these technologies.1

Ecosystem Overview

RPM refers to the use of digital technologies to capture and analyze patients’ physiological data, such as blood pressure, glucose levels, and lung function. By contrast, RTM refers to codes that capture and analyze outcomes such as therapy response and patient adherence related to treatment (musculoskeletal, cognitive behavioral therapy and respiratory). In the case of RTM, clinicians are able to bill for their review of non-physiologic medical device data that is generated by digital technologies.

RPM codes, established by CMS in 2018, establish coverage and payment for remote monitoring of patient data. In the same year, the American Medical Association developed CPT codes for remote physiologic monitoring (RPM) equipment and companion treatment management services (TMS). In 2019, CMS covered and paid for RPM and RPM-TMS codes. Over the ensuing years, CMS has continued to refine their coverage and payment policies related to these codes, along with additional non-face-to-face care management services.

As the use of remote care continues to increase, healthcare leaders need to understand coding to account for the supply of RPM and RTM equipment as well as professional time working with patients using remote methods.

Evolution of RPM and RTM

Varying forms of remote monitoring and their uses in clinical care have existed for decades. The Covid-19 pandemic only helped to underscore its importance. As service waivers from the pandemic are now transitioning, decision makers are determining how to continue their ongoing use. However, RPM and RTM along with the recent creation of a Healthcare Common Procedure Coding System (HCPCS) Level II supply code are not temporary and signal permanent direct reimbursement mechanisms.

This publication discusses the impact that the Covid-19 pandemic had on clinicians’ utilization of RPM and RTM codes, and sheds light on the increasing trajectory of clinician use of remotely delivered care solutions.

Methods and Code Definition

The analysis was primarily conducted using Komodo’s patient cohort creation platform, Prism, and supplemented with additional analysis from Komodo’s Healthcare Map. For each set of codes (RPM and RTM), queries were run to identify the healthcare professionals (HCPs) using the codes and further segment them by specialty and location. In consideration of the length of time each code set has been available to providers, uptake over the COVID pandemic was assessed for RPM and initial post-launch uptake was assessed for RTM. Each analysis (RPM and RTM) was executed looking at the entire code set – not specific to any individual code within the set.

For the RPM landscape analysis, the following codes were queried from Komodo’s Healthcare Map using the Prism software.

Code Code Type Description
99453 CPT Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
99454 CPT Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
99457 CPT Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes
99458 CPT Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes, each additional 20 minutes
99091 CPT Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days
95250 CPT Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional (office) provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording
99473 CPT Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration
99474 CPT Self-measured blood pressure using a device validated for clinical accuracy; separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

RPM Results

Covid-19 sped up the already positive uptake of RPM codes by clinicians. The majority (64%) of providers started using RPM codes for the first time during Covid. Towards the end of 2022, nearly 10,000 clinicians, referred to in Figure 1 as healthcare providers (HCPs), were utilizing the RPM codes that were examined in the analysis.

Figure 1.

Figure 1 – Created using Komodo’s Healthcare Map, this graph demonstrates how many HCPs billed using RPM codes each month during the time period of Jan 2018 – Mar 2022 (projected to Jul 2022). The query was completed by pulling the number of unique HCPs who used any of the RPM codes each month from de-duplicated medical claims. HCPs may repeat month by month (if using the codes consistently). Steady growth was evident after the start of the COVID pandemic and to account for claim lag while reviewing initial numbers for the last 4 months of activity, a positive projected slope was deduced.

Over the last four years, 50,000 unique HCPs located at over 19,000 healthcare organizations have billed for an RPM code. Of these HCPs, 64% began using the codes during the pandemic (starting March 2020). Prior to Covid, the use of RPM codes remained fairly stable, but following the start of the pandemic, there was a significant surge in RPM usage, effectively doubling the number of HCPs using these codes per month.

As demonstrated in Figure 2, the most frequent types of clinicians using RPM codes are community-based primary care clinicians, such as family practitioners, internal medicine doctors, and nurse practitioners. Additionally, as seen in Figure 3, cardiologists, nephrologists, gastroenterologists, and psychiatrists made up the majority of the new adopters of RPM codes during the Covid era (represented by yellow arrows).

Figure 2.

Figure 3.

When analyzing the data by clinician specialty, patterns begin to emerge. Of the top twenty specialties who most commonly use RPM codes, many are primary care clinicians. Of all the clinician specialty groups who use RPM codes in practice, only a select few have a larger proportion of Covid adopters vs pre-Covid users: cardiologists (including interventional cardiology), nephrologists, gastroenterologists, and psychiatry. Even though primary care specialists tower over the others in terms of the sheer volume of RPM code usage, the majority of primary care providers who used RPM codes during Covid billed at least once for an RPM code prior to the pandemic.

As more primary care specialists (particularly internal medicine) became consistent users of RPM codes during the pandemic era, there was a significant uptake in unique HCP counts.

RTM Results

For the RTM landscape analysis, the following codes were queried from Komodo’s Healthcare Map using the Prism software.

Code Code Type Description
98975 CPT Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment
98976 CPT Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days
98977 CPT Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days
98980 CPT Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes
98981 CPT Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)

Figure 4 shows the RTM HCP and patient use per month starting in January 2022. The use of RTM codes has continued to steadily increase over the first 5 months.

Figure 4.

Overall, physicians make up the largest group of RTM code users, according to Figure 5. Community-Based Assistive Therapy Specialists, such as physical and occupational therapists, have been the most common clinician group to adopt RTM codes.

Figure 5.

Although long-term data is limited given the recent release of these codes (i.e., RTM and RTM-TMS coverage became effective January 1, 2022), a conservative uptake is being noted. It is important to continue tracking usage as time goes on.

While primary care clinicians are still frequent RTM code users, assistive therapy specialists are by far the most common RTM code users. In comparing HCP institution types, a majority of RPM users were found in community-based organizations versus academic organizations, This is similar to the institution split for RPM codes. Also like RPM code utilization trends, primary care clinicians serve as the top specialists for this code cohort.

Discussion

Translating new evidence into widespread clinical implementation typically requires approximately 17 years1. However, the Covid-19 pandemic rapidly accelerated the adoption of digital health technologies, in particular those that enabled remote physiologic monitoring and remote therapeutic monitoring. While certain digital health tools such as telehealth visits initially spiked early in the pandemic they subsequently declined.2 The utilization of RPM and RTM codes observed a more durable and steady increase in adoption over time. This suggests that clinicians and patients perceive the high worth of RPM/RTM codes, in addition to CMS rightly compensating for the associated value.

Similarly, Congress is considering creation of Medicare and Medicaid benefit categories for another class of digital health tools via the Access to Prescription Digital Therapeutics Act3. Digital therapeutics are currently regulated by the FDA as medical devices, but not reimbursed by CMS in a defined benefit category. This presents a challenge for health systems which might otherwise be eager to get such evidence-based tools into the hands of their patients. While consumers and clinicians wait for an act of Congress to promote widespread adoption of these tools, RPM and RTM codes could help.

Many digital therapeutic interventions generate significant physiologic and therapeutic data including weight, blood pressure, and data related to treatment adherence. If captured, such data could be used by clinicians for RPM and RTM billing as a means of offsetting what can otherwise be cost prohibitive implementation, especially among fee-for-service populations. Digital therapeutic companies wishing to transition from the employee space dominated by insurers and large self-insured employers would do well to understand coding, coverage, and payment available to prescribers who could otherwise be ready partners in a broadening digital health ecosystem.

Education around the use of these codes enables clinicians to feel more confident in prescribing a DTx because the codes support that prescription. We observe a cohort of early adopters in the data, but clearly as uptake is generally slow for new codes, we are also dealing with a still nascent industry. Major updates are expected to the RPM-TMS codes as CMS has proposed through 2023 rulemaking to dramatically affect RTM-TMS codes. Should these proposals be finalized, it will affect the current makeup and utilization of these codes.

Conclusion

All new CPT codes, including RPM and RTM codes, take time to see broad adoption, or any adoption at all. Their creation seeks to address gaps in services and reimbursement for clinicians’ time that specifically allows them to provide better care for their patients. These gaps exist with government and commercial payors.

Considering technological advances in healthcare, adoption can be difficult for a variety of reasons including technological resistance, education, etc., but also from a coding perspective.

Looking at the impact of Covid to the use of technology in healthcare, it is very encouraging to finally see that technology can be adopted at a faster rate. Clinicians are seemingly willing to adopt new technologies.

Looking at recent utilization, we’re starting to see a new industry take hold.

Keywords: Digital therapeutics, Remote Physiologic Monitoring (RPM), Remote Therapeutic Monitoring (RTM), Medicare, Medicaid, Current Procedural Terminology (CPT®) code, Healthcare Common Procedure Coding System (HCPCS) code, Centers for Medicare & Medicaid Services (CMS)

References:

1CPT© Copyright 2022 American Medical Association. All rights reserved. AMA and CPT are registered trademarks of the American Medical Association.

“Building A Regulatory And Payment Framework Flexible Enough To Withstand Technological Progress” by David Flannery and Robert Jarrin; 10.1377/hlthaff.2018.05151

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