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Tag: Reimbursement

It’s complicated. A deep dive into the Viz/Medicare AI reimbursement model.

By LUKE OAKDEN-RAYNER

In the last post I wrote about the recent decision by CMS to reimburse a Viz.AI stroke detection model through Medicare/Medicaid. I briefly explained how this funding model will work, but it is so darn complicated that it deserves a much deeper look.

To get more info, I went to the primary source. Dr Chris Mansi, the co-founder and CEO of Viz.ai, was kind enough to talk to me about the CMS decision. He was also remarkably open and transparent about the process and the implications as they see them, which has helped me clear up a whole bunch of stuff in my mind. High fives all around!

So let’s dig in. This decision might form the basis of AI reimbursement in the future. It is a huge deal, and there are implications.


Uncharted territory

The first thing to understand is that Viz.ai charges a subscription to use their model. The cost is not what was included as “an example” in the CMS documents (25k/yr per hospital), and I have seen some discussion on Twitter that it is more than this per annum, but the actual cost is pretty irrelevant to this discussion.

For the purpose of this piece, I’ll pretend that the cost is the 25k/yr in the CMS document, just for simplicity. It is order-of-magnitude right, and that is what matters.

A subscription is not the only way that AI can be sold (I have seen other companies who charge per use as well) but it is a fairly common approach. Importantly though, it is unusual for a medical technology. Here is what CMS had to say:

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The Medical AI Floodgates Open, at a Cost of $1000 per Patient

By LUKE OAKDEN-RAYNER

In surprising news this week, CMS (the Centres for Medicare & Medicaid Services) in the USA approved the first reimbursement for AI augmented medical care. Viz.ai have a deep learning model which identifies signs of stroke on brain CT and automatically contacts the neurointerventionalist, bypassing the first read normally performed by a general radiologist.

From their press material:

Viz.ai demonstrated to CMS a significant reduction in time to treatment and improved clinical outcomes in patients suffering a stroke. Viz LVO has been granted a New Technology Add on Payment of up to $1,040 per use in patients with suspected strokes.

https://www.prnewswire.com/news-releases/vizai-granted-medicare-new-technology-add-on-payment-301123603.html

This is enormous news, and marks the start of a totally new era in medical AI.

Especially that pricetag!


Doing it tough

It is widely known in the medical AI community that it has been a troubled marketplace for AI developers. The majority of companies have developed putatively useful AI models, but have been unable to sell them to anyone. This has lead to many predictions that we are going to see a crash amongst medical AI startups, as capital runs out and revenue can’t take over. There have even been suggestions that a medical “AI winter” might be coming.

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Digital Therapeutics Category Outlook for Reimbursement | Megan Coder, Digital Therapeutics Alliance

BY JESSICA DAMASSA

What’s ahead for digital thereaputics as the category carves out its place in the broader world of digital health and health tech? Megan Coder, Executive Director of the Digital Therapeutics Alliance (the professional org founded in 2017 to guide the development of the category), swings by to level set with some definitions, talk reimbursement trends in US and Europe, and explain the intention behind the DTA’s recently published code of conduct and best practices for DTX companies.

Filmed at Frontiers Health in Berlin, Germany, November 2019.

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The Guy at the Gym Wants to be Your Healthcare Provider

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Almost three years ago, I excoriated the American College of Sports Medicine for partnering with a medical screenings company to push useless screens upon, of all things, their membership. You can read the post here. It was truly embarrassing to a supposedly credible organization. The leadership’s reply, in addition to having their communications director call me and implore me to take the post down, was to claim they had no idea this was happening.

Now, the American Council on Exercise, another fitness industry trade group, beggars itself with an open letter to the U. S. Congress, in which it essentially asks to hop aboard the national healthcare gravy train. You can read the entire plaintive wail here. The essence of it, however is this:

The American Council on Exercise, which educates, certifies, and represents more than 55,000 fitness professionals, health coaches, and other allied health professionals, and advocates for extending the clinic into the community with science-based preventative services delivered by well qualified professionals not necessarily thought of as health providers, welcomes you to Washington.

Let me translate both the highlighted paragraph, and, indeed, the entire letter: hey, Congress, everyone else is making money from healthcare reform, what about us? Where’s our handout? We’re healthcare providers, too, sort of. That ought to be enough to qualify us for reimbursement, even though we have zero evidence that the fitness industry, or any specific category of fitness professional (you could be one by 5:00 pm today), actually can change outcomes. Exercise? Important almost beyond expression. Fitness industry and its entire coterie? Not so much. Over the past three decades, the fitness industry has boomed.Continue reading…

Reimbursement, Prepare to Die!

Montoya

“Prepare to Die”, said Inigo Montoya to the six fingered man.

Reimbursement, prepare to die.

Doctors get reimbursed? Interesting….

Do Lawyers get reimbursed? Do accountants get reimbursed? When you send your check to pay for your Aetna premiums, are you reimbursing them?

The last time I checked, the act of being reimbursed implies that a person gave money and awaiting for someone to give them the money back.

Let’s take a quick look at Webster’s Dictionary.
reimburse |ˌrē-imˈbərs|
verb [ with obj. ]
repay (a person who has spent or lost money): the investors should be reimbursed for their losses.

• repay (a sum of money that has been spent or lost): they spend thousands of dollars that are not reimbursed by insurance.
#wtf
How did it come to pass that doctors don’t get paid, but reimbursed?

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Doctors vs. Zombies

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My life changed dramatically 18 months ago when I started my new practice.  The biggest change personally was a dramatic drop in my income as I built a new business using a model that is fairly new.  That’s a tough thing to do with four kids, three of whom were in college last fall.  OK, that’s a stupid thing to do, but my stupidity has already been well-established.

Yet even if the income stayed identical to what I earned before the switch, the change in my professional life would have been nearly as dramatic.

  • I am no longer focused only on patients in my office.
  • I am no longer focused on ICD and CPT codes.
  • Saving patients money has become one of my top priorities.
  • I feel like my patients trust me more, and see me as an ally.
  • Patients accept my recommendations for less care (avoiding unnecessary testing and unnecessary medications) much easier.
  • I focus far more on preventing problems or keeping them small.
  • I laugh with my patients far more.
  • I no longer feel like a Zombie at the end of the day (and I no longer eat brains)

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Who Should Pay Doctors?

flying cadeuciiHonest Pay for Honest Work.

Times have changed. And it’s time they change again.

In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications.

There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.

In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.

Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.

Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.

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Diagnosing Concussions and Assessing Balance- On Your iPhone

The fall sports season is tantalizingly near; players and fans alike are gearing up for the Friday night lights and Sunday afternoon showdowns. But the season comes at a cost; every bone-jarring hit and wince-inducing header carries the risk of sustaining a concussion.

Most media coverage focuses on the National Football League’s professional players, but 65% of traumatic brain injuries are sustained by children. The majority are thought to be undiagnosed, but the Center for Disease Control estimates that 1.6 to 3.8 million sports-related concussions occur each year. This puts athletes at risk of sustaining a second concussion before their brains are fully healed, leading to longer recoveries, permanent neurological damage, and the potentially-fatal Second Impact Syndrome.

A just-released app hopes to change that. Sway Medical, founded by Chase Curtiss in 2011, aims to help health professionals objectively rate the risk of concussion at the source: on the football field or soccer pitch. On-the-spot concussion diagnosis is just the beginning, though; in the near future, the young company plans to enter the hospital space by the end of the year.

The FDA-approved app, called Sway Balance, uses proprietary software and the iPhone’s accelerometer to assess an athlete’s balance over time. In a phone interview, founder and CEO Chase Curtiss said that the app can be used by a health professional to “set up a baseline,” then “compare an athlete over the course of a season to that established norm.” Poor performance compared to baseline is indicative of a possible concussion.

Health care professionals can purchase a yearly subscription to the app for $199 – a fraction of the cost of a typical balance platform – and the patient-facing app is free to download.

Sway Medical has partnered with ImPACT Applications, an organization which Curtiss described as conducting the “gold standard of concussion testing on the market.” ImPACT uses baseline cognitive testing – verbal and visual memory, processing speed, and reaction time – and synchronous testing immediately after a hit to assess if a concussion has occurred.

“But you don’t have an element of physical control of the body,” Curtiss said – which is where Sway Balance comes in. “[ImPACT’s] interest in us is in pairing a balance test with cognitive testing.”

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Can Medicare Reach Its 65th Birthday?

Every day, 10,000 people in the U.S. celebrate their 65th birthday, making each one of these seniors eligible for Medicare. The very program that gives America’s seniors access to affordable health care will turn a youngish 48 on July 30, but in a biting irony, it could go bankrupt before reaching its 65th birthday.

We cannot wish away or ignore the reality that Medicare’s Part A trust fund — the portion that pays hospital claims — is currently projected to run out of money by 2026. The good news, however, is that it is possible to put Medicare on a sustainable path if we can surmount current political hurdles.

It is no secret that Washington is better known for what it is not doing than what it is doing these days. Partisan gridlock has proved to be an insurmountable impasse for potentially worthy legislative efforts. This is especially true when it comes to making the changes needed to sustain Medicare’s future, where Washington is truly making things much harder than they need to be.

Much of the current debate has focused on reforms that would only slightly defer Medicare’s pending insolvency, with the potential for mere cost-shifting. With many of those recommendations, political disagreement is so strong that an extremely limited chance exists to pass a compromise version. However, even if enacted, these reforms would only address the symptoms of Medicare’s condition rather than the underlying problem. The result would only help Medicare limp to its 65th birthday at best.

There is a much more meaningful reform out there that addresses the underlying problem, and, surprisingly, bipartisan consensus exists around the need to end the fee-for-service system in Medicare.

The current fee-for-service payment system compensates physicians and other health care providers for each service they deliver, such as an office visit, test or other procedure. While it is critical that providers be fairly compensated, Medicare’s fee-for-service structure contributes to inefficient care that is often disconnected with actual patient outcomes. It has accelerated the program’s financial imbalance with inflationary spending that has little or no connection to helping beneficiaries get healthier.
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Physician Collaboration Isn’t Collusion to Increase Costs

“This GAO report sheds new light on the behavior of physicians reaping personal gain by referring patients to services at locations where they have an ownership interest. The analysis suggests that financial incentives for self-referring providers is likely a major factor driving the increase in referrals for these services. As Congress looks to reign in unnecessary spending, my colleagues and I should explore this area in greater depth,” Rep. Waxman said.

Explore you should, Representative Waxman. For if you look beyond the GAO’s conclusions, you will find that what we really need are bundled payments and a regulatory environment that supports, not inhibits, innovation to improve high-value health care.

Just because physicians have come together to manage their own futures doesn’t mean that their intent is to collude and increase costs. Could it not also indicate that health-care professionals have joined together to provide better care in a more efficient manner that reduces waste and unnecessary services to save the system money?
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