summary
Digital health technology (DHT) is emerging as a promising category of healthcare interventions that leverage technology to prevent, manage, and treat medical conditions. Over the past several years, the development, regulation, and implementation of DHT in a variety of disease areas has grown rapidly in the United States. Therefore, significant progress has been made in the payment of some types of DHT. However, reimbursement for some categories of DHT, particularly prescription digital therapeutics (PDT), defined as health software that delivers medical interventions to treat or manage a disease, disorder, condition, or injury, poses significant challenges. remains. The longstanding lack of clear CMS benefit categories for PDT has historically made establishing coverage and coding structures particularly difficult. As a result, coverage of these products by both public and private payers is limited.
The 2025 Physician Fee Schedule represents a tipping point with the first reimbursable code for PDT. However, this only applies to a limited number of products, and PFS continues to state that legal reform is needed to cover a wider range of PDTs. This issue’s overview explores opportunities to integrate PDT into Medicare reimbursement structures in a value- and outcomes-centered manner. This issue overview covers the following:
- How current different types of benefit categories facilitate or impede value-for-money payments, and the ability to differentiate between PDT products that show evidence of better patient outcomes.
- Ensuring coding and payment is important, giving you flexibility in how the PTD tool’s capabilities continue to evolve over time. and
- Methods for producing more effective evidence on the performance of these tools.
