The Biden Administration is encouraging new digital therapeutics reimbursement strategies in both the public and private sector as part of its National Drug Control Strategy report.
In the plan the White House pitches digital therapeutics, evidence-based treatments delivered through software interventions to treat or manage a condition, as a potential tool to help expand access to substance use disorder (SUD) treatments. The reimbursement plans, which was first spotted by Exits and Outcomes, was part of a larger plan to tackle substance use disorders.
“Coverage for the provision of motivational incentives could be considered within health plans,” said the report. “This will require considering billing codes and setting reimbursement parameters.”
The administration also wants to explore covering incentives for providers to administer them and enable the treatment —including FDA-cleared and evidence-based approaches.
“With the majority of individuals in need of treatment for substance use disorders not able to access care or only receiving treatment without a strong evidence base, expanding access to digital therapeutics could address a number of key barriers people struggling with addiction face,” the Digital Therapeutics Alliance (DTA), told Behavioral Health Business in an email. “As the White House Drug Control Strategy outlines, expanding access to evidence-based treatment is critical to tackle the addiction and overdose crises the nation is facing.”
The Administration also encouraged agencies to seek authority from Congress to cover the costs of motivational incentives and reimburse providers who work with patients using incentives and digital services for contingency management.
“These incentives are an integral part of protocol-driven and evidenced-based contingency management programs and can be offered through smartphone applications and smart debit card technology designed to provide comprehensive and personalized treatment for SUD,” said the report.
These programs include tools that enable, for example, automated appointment reminders and attendance verification, automated medication reminders, drug, alcohol, and tobacco/nicotine testing, self-guided cognitive behavioral therapy, and recovery coaching.”
Digital therapeutics are one component to the Biden Administration’s drug control plan which also outlines the case for harm reduction approaches, treating patients in a greater variety of healthcare settings and improving treatment quality through payment reform.
Other key areas of focus include supporting at-risk populations and creating a workforce and infrastructure to address the growing demand.
This plan comes at a time when substance use disorders are on the rise. According to a Kaiser Family Foundation report, 13% of adults reported a new or increased substance use due to the pandemic. However, there is still a major gap when it comes to accessing treatment. A Substance Abuse and Mental Health Services Administration report found that in 2019, only 12.2% of individuals who needed substance use treatment in the last year received treatment at a specialty facility.
More solutions but few reimbursement models
Digital therapeutics have been on the market for sometime. For example Pear Therapeutics’ substance use disorder digital therapeutic reSET landed an FDA de novo in 2017. Since then a slew of products addressing everything from ADHD to insominia have been cleared by the FDA.
However, digital treatments have historically faced reimbursement hurdles, as policies for the treatment is still largely under development. But new regulations could move the dial on reimbursement for the future.
“There has been a lot of progress in this area since [the Digital Therapeutics Alliance] formed 4.5 years ago. The industry has really matured and many digital therapeutics receive third-party payment through employers, Pharmacy Benefit Managers (PBM), insurers, or other third-party payors. DTx products may be covered under the medical benefit, the pharmacy benefit, or through other forms of contracting,” DTA said.
However, the alliance said there is still much work to be done in the Medicare and Medicaid space.
“The next step is establishing a benefit category for digital therapeutics for public programs, such as Medicare and Medicaid, to formally recognize and provide patients with access to DTx products,” DTA said.
In late 2021 CMS added a new Level II Healthcare Common Procedure Coding System (HCPCS) code for “Prescription digital behavioral therapy, FDA cleared, per course of treatment”, which made it easier for commerical and Medicaid payers to cover the technologies.
New legislation could also open doors for digital therapeutic reimbursement. In March a bipartisan group of US Senators introduced the Access to Prescription Digital Therapeutics Act, which calls for the Medicare program to cover FDA cleared DTxs.
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