VR Modalities Could Take Off if Reimbursement Can Catch Up

This is an exclusive BHB+ story

AI may be dominating the zeitgeist around changes in mental health care. Yet, novel virtual reality (VR) techniques are emerging with strong evidence-based outcomes, and the combination of AI and VR could advance treatments if reimbursement catches up.

VR’s use cases range from exposure therapy treatments for mild phobias to complex PTSD cases. New research from George Mason University has also demonstrated success with VR treatments in preventing substance use disorder (SUD) relapses.

While VR solutions are accelerating, especially with the possible integration of AI for further refinement, reimbursement for these modalities in behavioral health care is where adoption lags.

Earlier this year, for the first time, the Centers for Medicare and Medicaid Services (CMS) classified VR devices that deliver cognitive-behavioral therapy as “durable medical equipment” under CMS code E1905, offering the first concrete path for provider reimbursement. The new classification also allows eligible patients to receive a headset that is loaded with clinical therapy programs for at-home use.

Eran Orr, the CEO of XRHealth, a telehealth clinic that offers VR therapy for mental health conditions and pain management, said the new code is one of the “biggest shifts” the industry has seen.

Since VR headset devices can also be used for remote patient monitoring, telehealth and other parts of care, Orr expects reimbursement pathways to grow as use cases do, he told Behavioral Health Business.

“We got to a point in the industry where reimbursement was the missing piece in order to actually have people adopt the technology,” Orr said. “Now, with the new reimbursement from Medicare, even though it still takes time to educate the market, clinicians, and patients, to show them VR is not a gaming tool, I do think the new reimbursement pathway is a game changer for the industry.” 

Denver-based Vivid Psychology Group, owned by Dr. Alex Littleton, has been using VR tools to assist clinicians for specific patient cases for years. Still, billing for reimbursement has never been easy. Among its staff of 10, Littleton said the on-site VR headset is used between four and six patient cases per month – usually to treat phobias, anxiety disorders, or obsessive-compulsive disorder (OCD). 

The practice primarily accepts private pay, but recently began accepting Colorado Access Medicaid plans and conducting VR-assisted exposure therapy sessions through that. When coding for reimbursement, they stick to billing it as a single therapy session regardless of whether clinicians use VR during the session or not, he said. It’s simpler to eat the cost of the tools instead of bill for reimbursement most of the time. 

“I’m not optimistic that there’s a great way to code for that,” Littleton said. “It’s on insurance in that way, to be very rigid and hard to work with, and that is just a part of our reluctance to take on more insurance.” 

The other issue with more widespread use and even increased use of VR modalities at Vivid Psychology is that not only can the investment be costly, but the technology behind it also hasn’t been quite ready or easy for clinicians to navigate, according to Littleton.

“I know that they’re working on that, but it would help to make more lightweight, easier to use, user-friendly and inexpensive headsets that are still very immersive,” Littleton said. “The phone version is not great. I think that folks in the industry are really intimidated by just learning how to use the headset and the controllers, and it’s such a new thing. I really have had to do a lot of training and walkthroughs to get folks to be more open to trying it. Hopefully, that comes with more wide-scale adoption and people seeing it and using it in more spaces.”

Additional research and the design of VR software experiences for therapy have simultaneously expanded in recent years, but there’s still more to do before the advancements intertwine in a way that removes barriers to adoption. Progress in that vein may also make more of a case for clearer reimbursement pathways, Nik Vassev, co-founder and chief operating officer at Novobeing told BHB.

Novobeing is a therapeutic VR platform that creates experiences to reduce anxiety, stress and pain.

“Initially, the barriers were just that the hardware was expensive, it was uncomfortable, heavy and had irregular controllers. That combination in a health care setting was a lot,” Vassev said. “The health care system as a whole is just overburdened, and there are just so many challenges that they’re dealing with that this is kind of like a nice-to-have. Right now, it’s not really a must-have. I think that there’s a lot more education that the VR industry needs to do on the benefits of this, a lot more clinical research that needs to happen for it to really take off at scale.”

Doing that at scale, in combination with powerful technologies like AI, could also increase the personalization of VR modalities, he said.

“I think as the technology gets better and these headsets have much bigger processing power, you’ll be able to directly connect to the cloud to stream an AI avatar of a mental health professional who then has access to all your health data and metrics data, who really understands you, and then now you have this personalized therapist that you can talk to,” Vassev said. 

AI can also work in tandem with VR to generate realistic experiences and environments that may be more impactful for specific patient cases.

When researchers at George Mason University recently tested VR experiences in therapy of substance use disorder (SUD) patients, they found that exposing them to different environments they may feel triggered in – like a bar or nightclub for instance – can help them practice forming new pathways to respond in the moment and continue on their recovery journey without relapsing.

“It’s normal in the advancement of technology that we keep incorporating the newest tools,” Nathalia Peixoto, associate professor of bioengineering at George Mason University who worked on the study, said. “I don’t think AI is going to overshadow VR, but instead it is one of the bricks in the house.” 

Advancements in mental health VR cannot be done without AI, Dr. Padmanabhan Seshaiyer, professor of mathematical sciences at George Mason University who also worked on the project, added.

“I would say VR is actually going to become even more intelligent, personalized and scalable because of AI,” Seshaiyer said. “It’s a very low barrier to entry. It’s scalable, fast and cost-effective. But in this particular scenario, you need that embodied experience, which AI cannot do alone. So in this scenario, where you are in a trigger environment or recovery space, AI cannot do that, right? So you need that VR space, the multisensory information as well, for best execution.” 

Patient demand is also going up for more technology-enabled modalities. The Department of Veterans Affairs has used VR as a component of treatment for more than a decade. The modality is included with VA care plans and the VA continues to ramp up its use of the technology.

“More Veterans and their clinicians are seeing VR as a treatment option than ever before, and VA has seen substantial growth and interest in the use of VR over the last three years,” a spokesperson for the VA told BHB. “Today, more than 4,500 VR headsets are in use across more than 170 VA medical centers and outpatient clinics in all 50 United States, Puerto Rico, Guam and American Samoa.”

In a poll, 91% of veterans responded that they wanted “more VR incorporated into their health care plans.”

But for the future to take off in a meaningful capacity clinically across the behavioral health industry, the real barriers continue to be education and reimbursement.

“I think maybe, like in the next three years, I think it’s going to really take off. Right now, AI is being used in VR a lot,” Vassev told BHB. “I think that coverage is definitely going to come. When it comes to mental health, there’s so much trust that is needed for that to come through. And I think that’s when a lot of the regulatory apparatus that we have and regulation from the FDA is going to be really important.”