The “internet of things” has exploded in recent years. We now have Bluetooth toasters, smart toilets, and WiFi-enabled light bulbs that can be controlled by Alexa. The trend has also penetrated the medical device market and armies of engineers have been busily developing new ways to integrate sensors and processors into every step of the therapeutic pathway.
Something that has been a little slower (actually, downright glacial) to advance is the medical insurance coverage of these new technologies.
There are huge advantages to the new “smart device” revolution that is sweeping the medical technology world. Including but not limited to:
- The evolution of personalized and optimized treatments from the vast collections of available data.
- Efficacy research that can be conducted in real-time and in real world environments.
- The enhancement of provider and patient communication with the use of dashboards, portals, video conferencing, and messaging.
The last few months of COVID craziness has emphasized the value of telehealthcare, and highlighted new ways to leverage these connected medical device technologies to improve access to care while protecting vulnerable patient groups. Smart healthcare devices are probably here to stay. But there is a major sticking point yet to be satisfactorily solved. Who is going to pay for all this? Technology is expensive!
The Centers for Medicaid and Medicare (CMS) tend to set the tone for medical insurance payments in the United States. In 2019 and 2020, CMS has made it clear that they will pay medical providers for their time spent evaluating and treating via telehealth and remote patient monitoring. That is encouraging news. But it doesn’t solve the entire payment problem. When insurance pays the physician for remote patient monitoring, they are paying for the time it takes to provide these services, but the cost of the gadgets that enable the remote services is still not accounted for. It’s possible that the healthcare provider can find the generosity in their hearts to take a portion of their own payment to pay for the “smart” devices. But (not surprisingly) there are lots of situations where this doesn’t happen and the cost of the equipment is passed directly on to the patient, increasing the out-of-pocket cost of care.
The CMS reimbursement system uses a series of codes to represent the various medical items and services that a patient will encounter throughout the healthcare system. These codes (called Healthcare Common Procedural Codes – or HCPCs) are essentially a shorthand to standardize and abbreviate reimbursement communication. Each HCPCs code is tied to a predetermined payment amount and coverage policy. HCPCs can be quite specific. For example:
- E1130 – Standard wheelchair, fixed full-length arms, swing-away detachable footrest.
- E1140 – Standard wheelchair, detachable arms, swing-away detachable footrest
But when it comes to describing smart medical devices, that careful specificity flies out the window.
CMS has only 1 code to describe anything with a sensor in it:
- A9279 – Monitoring feature/device, stand alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified.
So, this one little code is expected to be used for everything from a sleep apnea mask to a thermometer to a pressure-sensing cane. As long as the device in question contains a sensor or a monitoring feature, it falls under the classification of A9279. You can clearly see the problem here. Not all of these smart devices are created equal, and they shouldn’t all be referred to by the same name.
That is like my very non-Italian grandfather on my father’s side driving my very Italian mother up the wall by referring to all pasta (no matter the size, shape, or ingredients) as “noodles”. It could be any dish from fettuccine alfredo to lasagna and it would all just be “noodles” to him. This limited vocabulary obscures communication and it is very frustrating! Imagine a restaurant menu that used this system. Chaos would ensue.
This imprecision and confusion is not the only problem with A9279. In CMS’ own words: “claims for A9279 are denied as statutorily non-covered”. This means that CMS has decided that no-way, no-how is it ever going to pay for devices with this code. In fact, it would take an act of congress to change their minds. That is a pretty firm “no”.
For years, enterprising medical device companies have been applying to CMS to add new HCPCs codes that will better describe their new technology, with the hope that these new codes could lead to insurance coverage. But, time and again, CMS has denied these requests and stated that an appropriate code already exists – A9279.
CMS occasionally issues corrective statements about the use of its HCPCs codes (most often when people have been using them incorrectly). A new statement about A9279 was issued this month, reiterating the broad nature of this code:
Code A9279 (MONITORING FEATURE/DEVICE, STAND-ALONE OR INTEGRATED, ANY TYPE, INCLUDES ALL ACCESSORIES, COMPONENTS AND ELECTRONICS, NOT OTHERWISE CLASSIFIED) describes any type of monitoring technology. Code A9279 is all-inclusive, and is to be used whether the monitoring technology is incorporated as part of a base item, supplied as an add-on module or is a stand-alone item.
This is really starting to get ridiculous. Back in 2007, when this code was created, it might have been adequate to describe the small number of smart medical devices that were available. After all, at the time, the internet of things was just a far-fetched concept and Steve Jobs was just announcing the first Iphone.
The future of medical tech is here, but many of the most impressive innovations are unattainable in real life because of insurance payment issues. It would be really great if CMS could help to lead adoption of new technology, instead of clinging blindly to the past. An excellent way to start would be with a system of HCPCs codes that can appropriately handle the new generation of medical equipment. And while we are at it, maybe we should see about updating the definition of what constitutes medical equipment from the confines of the Social Security Act. In technology terms, those definitions are ancient history. Innovation is accelerating. We need the US reimbursement system to reflect this reality.
References:
https://www.dmepdac.com/palmetto/PDAC.nsf/DID/MZI98M11U6
https://www.dmepdac.com/palmetto/PDAC.nsf/DID/E6IJ1IZCZW
Figure 15 image: https://www2.deloitte.com/content/dam/Deloitte/global/Documents/Life-Sciences-Health-Care/gx-lshc-medtech-iomt-brochure.pdf
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