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Billing Codes for DTx Would Open the…

Billing Codes for DTx Would Open the…

Approval of Medicare and Medicaid coverage for digital therapeutics represents next step in advancing care for mental health patients.

I’ve spent the last 25 years leading and scaling IT projects for major health plans. In that time, I’ve seen our healthcare system’s inadvertent inability to treat mental and behavioral health disorders as chronic conditions firsthand. Even with the most advanced technologies and treatment capabilities based upon proven and validated science at the ready, we are still unable to get mental and behavioral health care to the people who need it most.

Far too many people struggling with mental and behavioral health conditions are doing so outside of the healthcare system; nearly 1 in 3 are going without treatment, even in states with the greatest access to providers. We are developing the tools to address this problem.

Just ten years ago, only a handful of digital therapeutics (DTx) were able to demonstrate clinical efficacy as evidence-based, digitally-delivered treatments. The market has since grown, and today, DTx are advanced enough to be complementary to—and in some cases, viable substitutes for—many traditional clinical therapies. DTx solutions have emerged as powerful tools for managing chronic diseases, as alternatives to pharmacological therapies—which can have their own drawbacks and limitations—and as vehicles for delivering full-scale treatments for mental and behavioral health conditions.

Studies have shown DTx can be just as effective as many traditional therapies, specifically for mental and behavioral health disorders, and many can be used outside of a clinical setting—providing much-needed treatment to those sidelined by the worsening provider shortage.

This means a person struggling with major depressive disorder may soon access cognitive behavioral therapy through a VR headset—that is, if they have the financial means to afford a VR headset. And therein lies the rub. As is the question with any healthcare innovation, how can we ensure DTx is accessible to those who need it most?

The answer may lie in codifying reimbursement policies for Medicare and Medicaid beneficiaries.

Support for DTx reimbursement

The COVID-19 pandemic increased demand for virtual care and telemedicine, as outpatient visit restrictions kept people from receiving traditional means of care. Likewise, it also accelerated DTx funding, development, and adoption, due in part to relaxed FDA guidelines, which have allowed temporary approval of certain solutions offering psychiatric treatment for the duration of the public health emergency.

Unlike virtual care and telehealth solutions, however, federal agencies have not yet developed guidance for DTx reimbursement. This, however, may soon change, as the Centers for Medicare and Medicaid Services (CMS) established a new medical code for digital therapeutics earlier this year. This sets the stage for developing guidance on reimbursement.

In its recent National Drug Control Strategy report, the White House encouraged new DTx reimbursement strategies for substance use disorders. The move comes on the heels of recent legislation proposed to create billing codes for DTx under Medicare and Medicaid.

If passed, this legislation—dubbed the Access to Prescription Digital Therapeutics Act of 2022—would open the floodgates for building mental and behavioral health equity by making easy for clinicians to prescribe or refer DTx to some of the most vulnerable patients in America, many of whom have trouble accessing or affording traditional means of treatment.

Today, Medicaid is the single largest payer for mental health services in the country, and Medicare is not far behind—nearly 25% of Medicare beneficiaries are receiving treatment for a mental health condition. These figures have been exacerbated by the COVID-19 pandemic, but there simply are not enough licensed clinicians to provide care to those seeking treatment.

The access gap for psychotherapists and other skilled mental health professionals has become an unfillable chasm, but we can bridge it with DTx solutions for mental and behavioral health. If the Access to Prescription Digital Therapeutics Act of 2022 is passed, vulnerable communities across the country will sooner gain access to some of the most promising technologies and treatments for behavioral and mental health conditions. Digital therapeutics companies will have a clearer path to building solutions to address opioid use disorder, depression, and anxiety.

Digital therapeutics, including those with a VR virtual experience, will provide treatment tailored to the individual condition and on a schedule appropriate to the person receiving the treatment, regardless of social and non-clinical factors. Additionally, these dynamic therapies will be integrated into the overall healthcare experience and report back progress and usage to clinicians in real-time—an innate engagement feature for digital therapeutics, and one that is sorely lacking among traditional treatments.

The transformation our healthcare system has undergone over the past three decades has been inspiring. I’ve had a front row seat for most of it—from the shift to e-prescribing to the digitization of medical records to the adoption of interoperability. It was all good IT groundwork, but there is so much more to be done. We can and must get the best treatments into the hands of the people who need them most. The adoption of DTx reimbursement codes for Medicare and Medicaid is an absolutely essential step toward achieving mental and behavioral health equity.

Patrick Murta, Chief Platform Architect, BehaVR

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