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The Push to Cover More Health Management Tools: A Shift From Acute Medicine to Health Management

By Madeline Verbeke

Today’s healthcare world is seeing a shift from acute medicine to health management. A contributing factor to this has been the COVID-19 pandemic. A recent report shows that 66% of respondents with chronic conditions were more interested in taking a proactive approach to health than prior to the pandemic. People are taking a more vested interest in their health and are starting to focus more on preventative medicine instead of symptom management. Rather than waiting for a heart attack to happen, an individual can use health management—like healthy eating and exercise—to prevent that heart attack from happening in the first place.

A key part of health management is early diagnosis and consistent disease monitoring to prevent acute issues and disease progression.

The Benefits of a Health Management Approach 

An early diagnosis can help improve both health and cost outcomes across many different disease states. Examples of this include:

  • Cancer patients who have a better chance of remission if cancer is caught in early stages
  • Pre-diabetic patients who can reverse their status and prevent progression by focusing on lifestyle modifications
  • Multiple sclerosis patients who can delay disease progression and irreversible neurologic damage if treatment is initiated sooner rather than later

Early detection and diagnosis can greatly improve a patient’s quality of life and their prognosis in addition to reducing overall costs by preventing additional treatment and hospitalizations. There has been a move toward better diagnostics in both the physician’s office/hospital and home setting as people have realized the true importance and impact of an early diagnosis.

However, while this shift has brought more and more home diagnostic tools to the market, a lack of payer coverage means they’re largely inaccessible for the patients who need them.

Health Management Tools on the Market

Prescription digital therapeutics (PDTs)—a growing sector on the market—treat, manage and prevent a broad spectrum of diseases and disorders but are rarely covered by insurance. For example, Canvas Dx, a PDT, can reliably diagnose autism as early as 18 months. Early diagnosis of autism can lead to numerous benefits, including early intervention, improvements in skills and abilities, and overall better prognosis for the person living with autism. While the individual could pay for this out of pocket, that does not mean insurance would cover subsequent treatment following a diagnosis from Canvas Dx.

PDTs aren’t the only tools used for preventative measures. Others include testing levels of the biomarker Lp(a). An association between Lp(a) and cardiovascular disease has been shown, with elevated Lp(a) levels possibly directly contributing to heart attacks. There’s even a drug being developed for patients who are at significant risk of cardiovascular disease because of their elevated Lp(a). Unfortunately, payers aren’t covering the cost of the lab test for this biomarker.

The health benefits are clear, so why aren’t insurance companies providing better coverage for many of these early diagnostic and health management tools?

Payer Coverage of Health Management Tools 

When it comes to PDTs, many payers make decisions on a case-by-case basis, usually resulting in a denial of coverage. Generally, coverage is lacking due to misinformation surrounding the approval process and clinical value of PDTs. Payers do not believe there are clinical outcomes associated with these devices and have a general unfamiliarity with these new types of therapies.

For Lp(a) testing, payers are reluctant to provide approval because there’s no data available suggesting that more aggressive risk factor modification improves patient health outcomes regardless of the association between Lp(a) and cardiovascular disease, according to my research of different coverage policies. Increasing payer awareness and knowledge could help sway them in the right direction.

Manufacturers can improve payer coverage of these different tools and tests by increasing both payer and provider knowledge and confidence around these lesser-known areas. As more people learn about the importance of health management and health management tools, payer uptake may increase.

Given all the benefits of shifting from acute treatment to health management, including better outcomes and cost reductions, payers should start covering the tools to help better support this lifestyle. As more data surfaces that shows the clinical benefits and efficacy of products that are used for early diagnosis and disease monitoring, there’s hope that more payers will start covering them.

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© 2024 MMIT
Madeline Verbeke

Madeline Verbeke

Madeline Verbeke is a Clinical Advisor on MMIT’s data operations team.

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