PDT coverage: pharmacy or medical benefits?

John Fox, MD: There is a lot of concern among the developers of these tools and among payers as to where this is paid for and how it is distributed. Is it a pharmaceutical benefit or a medical benefit? Medicare is considering developing a new service, a digital therapy [DTx] benefit to. What is the main thought on this subject? Scott, do you want to take this?

Scott Whittle, MD: From the payer’s perspective, either is fine. In fact, when we drafted contracts in this space for prescription digital therapies [PDTs], what we use to make the decision is what is deployable in a strategy that is relatively easy to raise on the payer side, and then what feels most natural on the provider side for use. In terms of our internal decision-making, that’s the math we face. How do we get it back up? How do providers perceive the strategy? In this calculation, we are leaning heavily towards the prescription because the prescription has a strategy that is already deployed, so putting it into the prescription delivery works very well. It also matches the pattern that people have in their brains, so we encounter less resistance and it’s very convenient.

The main concern behind all of this is to distinguish between processing and software, since software is usually part of the administrative expenses of a paying agency. Administrative expenses are not reimbursed by other stakeholders. It comes directly from a payer’s bottom line and will be totally unattractive to a payer. The first discussion anyone would have with a payer in a discussion like this would be how do we deliver deployability. Then we ensure that it comes from either the medical benefit or the behavioral health benefit, integrated into a prescription benefit. But it can come from administration money because it doesn’t fit into the world it belongs to.

John Fox, MD: Fair enough. Tim, any reactions to that?

Timothy Aungst, Doctor of Pharmacy: The Academy of Managed Care Pharmacy has held several focus groups on this, and I have participated with other DTx companies and with other payers. Scott, according to you, prescription is a natural choice because it follows a traditional mindset. It is already established. Even saying PDT resonates with some people. If it resonates with patients, it will resonate with prescribers and such. It’s easy to follow up on that.

But we are still at the beginning of the game. We recognize that this is the Wild West. We don’t know which CMS [Centers for Medicare & Medicaid Services] and other organizations will. We are exploring around the world what is going to be undertaken. It has to evolve at some point. It’s a good palliative [measure]. I don’t think it’s sustainable. If we’re going to talk about the whole digitization of healthcare, if we’re going to talk about further integration into many other therapeutic areas with DTx or PDT, we’re probably going to have to step back and say it’s working for now , but it won’t work forever.

What should we do and evolve? Does that mean some separated? Maybe. But if we think about how health care is changing as a whole, then how we embrace and do this stuff needs to be addressed. It comes down to thinking about how we pay for it and why we should pay it, and that will be a new weapon. It’s exciting, though.

Arwen Podesta, MD: As a prescriber, as a person who is trying to help the patient get better and be satisfied, there are many obstacles with all these specialty drugs with small specialty pharmacies that I deal with in addictions. If one payer has it as a medical benefit, another as a pharmaceutical benefit, and another as this new thing that might happen, then I can’t handle it. My office won’t be able to handle it. New prescribers will not. It’s a huge hurdle when you have 1 product that is in different MCOs [managed care organizations] according to different payer strategies. For those of you on paymaster committees, I ask that we stick to 1 and do what your neighbor is doing. Let’s all go with the pharmacy until the next phase happens.

John Fox, MD: It’s fascinating. At the end of the day, what matters is that we can put this in the hands of patients. If we make it difficult for providers to perform, it decreases the likelihood that patients will benefit from this treatment if they cannot get it.

Transcript edited for clarity.

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