Powell Adam C, Bowman Matthias B, Harbin Henry T
Payer+Provider Syndicate, Boston, MA, United States.
The Bowman Family Foundation, Hockessin, DE, United States.
JMIR Ment Health. 2019 Aug 6;6(8):e14724. doi: 10.2196/14724.
Although apps and other digital and mobile health tools are helping improve the mental health of Americans, they are currently being reimbursed through a varied range of means, and most are not being reimbursed by payers at all.
The aim of this study was to shed light on the state of app reimbursement. We documented ways in which apps can be reimbursed and surveyed stakeholders to understand current reimbursement practices.
Individuals from over a dozen stakeholder organizations in the domains of digital behavioral and mental health, care delivery, and managed care were interviewed. A review of Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCSPCS) codes was conducted to determine potential means for reimbursement.
Interviews and the review of codes revealed that potential channels for app reimbursement include direct payments by employers, providers, patients, and insurers. Insurers are additionally paying for apps using channels originally designed for devices, drugs, and laboratory tests, as well as via value-based payments and CPT and HCSPCS codes. In many cases, it is only possible to meet the requirements of a CPT or HCSPCS code if an app is used in conjunction with human time and services.
Currently, many apps face significant barriers to reimbursement. CPT codes are not a viable means of providing compensation for the use of all apps, particularly those involving little physician work. In some cases, apps have sought clearance from the US Food and Drug Administration for prescription use as digital therapeutics, a reimbursement mechanism with as yet unproven sustainability. There is a need for simpler, more robust reimbursement mechanisms to cover stand-alone app-based treatments.
尽管应用程序及其他数字和移动健康工具正在帮助改善美国人的心理健康，但目前它们的报销方式多种多样，而且大多数根本没有得到支付方的报销。
本研究旨在阐明应用程序报销的现状。我们记录了应用程序的报销方式，并对利益相关者进行了调查，以了解当前的报销做法。
对来自数字行为与心理健康、医疗服务提供和管理式医疗领域的十几个利益相关者组织的人员进行了访谈。对现行程序术语（CPT）和医疗保健通用程序编码系统（HCSPCS）代码进行了审查，以确定潜在的报销方式。
访谈和代码审查表明，应用程序报销的潜在渠道包括雇主、医疗服务提供者、患者和保险公司的直接支付。保险公司还通过最初为设备、药物和实验室检测设计的渠道，以及通过基于价值的支付和CPT及HCSPCS代码来支付应用程序的费用。在许多情况下，只有当应用程序与人工时间和服务结合使用时，才有可能满足CPT或HCSPCS代码的要求。
目前，许多应用程序在报销方面面临重大障碍。CPT代码并非为所有应用程序的使用提供补偿的可行方式，尤其是那些涉及很少医生工作的应用程序。在某些情况下，应用程序已寻求美国食品药品监督管理局的批准，作为数字疗法用于处方，这是一种可持续性尚未得到证实的报销机制。需要更简单、更强大的报销机制来涵盖基于应用程序的独立治疗。
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