Payers are starting to sort out how to reimburse for digital therapies and tools while they get up to speed on the new class of products. The answer is more of an “it depends” than a straight “no,” as they wait for answers on how trial results translate to measurable benefits.
The big questions are what level of evidence payers will need to see and what the ROI is to the system.
In many cases, the decisions will tie into how stakeholders carve the rules for what is and isn’t regulated, and how they recast the first principles that will inform clinical development, since these issues will shape the evidence on which reimbursement decisions are made. This, together with the need for transparency and patient privacy, form the topic of the 2019 Back to School essay: Rules of the Road for Digital Health.
The first order of business for payers might be to sharpen their definitions, though. “Payers aren’t all sure what constitutes a digital therapeutic,” said Michael Sherman, SVP and CMO of Harvard Pilgrim Health Care Inc.
Sherman said in his conversations with companies seeking reimbursement, the products range from telemonitoring solutions for diabetes to digital therapies that could substitute for a pharmacotherapy.
“If you show that something like this changes things for the better, improves outcomes, I think it’s inevitable that there will be uptake.”
A big step will come next year when U.S. pharmacy benefit managers CVS Health