Medicare Coverage of Prescription Digital Therapeutics Is Top Priority for Industry Trade Group

Third of three parts

So much in U.S. healthcare hinges on Medicare coverage and digital therapeutics are no exception.

The Access to Prescription Digital Therapeutics Act would create a new Medicare benefit category for prescription digital therapeutics. The bill was introduced in the Senate and the House last year and the industry’s trade organization, the Digital Therapeutics Alliance, is gearing up to push for passage this year.

The bill would extend Medicare coverage just to prescription digital therapeutics, not to digital therapeutics generally, explains Sara Elalamy, M.A., the director of U.S. government affairs for the Digital Therapeutics Alliance. The decision to limit to coverage to prescription products was made to hold down the size of the projected increases in Medicare spending and therefore the Congressional Budget Office’s (CBO) “scoring” of the bill and its effect on federal spending.

“The stakeholders decided to make this bill only focus on prescription digital therapeutics,” says Elalamy. “Hopefully, if we get this bill through, we can come back to Congress a few years later and talk about reimbursement for nonprescription digital therapeutic products.”

The change from Democratic majority in the House to a slim Republican one may also factor into the fate of the Medicare access legislation this year. “We understand that in the current legislative climate and with Republicans controlling the House that a lot of Medicare and Medicaid cuts are on the table. We’re really hoping that none of cuts are going to be made,”

Elalamy and the Andy Molnar, the CEO of the Digital Therapeutics Alliance, were interviewed recently by Managed Healthcare Executive.

Sen. Shelley Moore Capito, a West Virginia Republican, has sponsored the legislation that would extend Mediare coverage to prescription digital therapeutics.

The industry’s trade association is also pushing for Medicaid coverage of digital therapeutics. The sponsor of the Medicare access legislation, Sen. Shelley Moore Capito, a West Virginia Republican, also introduced the Medicaid and CHIP Access to Prescription Digital Therapeutics Act last year. Medicaid coverage is decided state by state. Caputo’s Medicaid and CHIP access bill would have been a “no zero cost” bill, Elalamy says, and would have only required CMS to provide some guidance and technical assistance on digital therapeutics.

Molnar says the alliance’s membership is deciding whether to prioritize the Medicaid legislation. “We did see a lot of positive come out of that bill,” Elalamy says. “A lot of states are considering reimbursing for digital therapeutics,” adding that Florida is now reimbursing for digital therapeutics. She says a “next step” might be developing model legislation that members would seek to have passed at the state level.

Elalamy notes that last year’s Medicare access legislation had three co-sponsors in addition to Caputo: Sens. Jeanne Shaheen, a New Hampshire Democrat; Cory Booker, a New Jersey Democrat; and Marsha Blackburn, a Tennessee Republican. The main sponsor of the House bill was Rep. Mike Thompson, a California Democrat. Thompson had 27 co-sponsors.

Elalamy says one of the priorities this year is to get a CBO scoring for the bill. Some of the alliance’s members contracted with a third-party organization that came up with a figure of $600 million over a 10-year period, she says, but members of Congress want to know what the CBO has to say about cost and budget impacts.

“Once we find out (the CBO score ) we can definitely work with members of Congress on mitigating (the cost) if it is too much,” says Elalamy. Then we can talk about why we need this (Medicare coverage) because (digital therapeutics) really helps save lives and the technology is something we need in our lives right now.”