This episode is brought to you by Visiopharm
Medical tests and procedures can get reimbursed. The basis of the reimbursement are the Current Procedural Terminology (CPT) codes developed by the American Medical Association (AMA).
But how can such a code be obtained for digital pathology which is so much more complex than a group of tests or procedures that could be reimbursed on a fee-for-service basis?
According to Esther Abels, Visiopharm’s Chief Clinical and Regulatory Officer, to align the digital pathology reimbursement with its value the fee-for-service paradigm needs to shift to a value-based reimbursement strategy.
To determine the real value of digital pathology for patient care we need to
- Articulate the services provided and define their added value and uniqueness in patient care (e.g. risk assessment, improvements in responses to therapy, delay in disease progression),
- Gather data relevant to support the claimed added value (e.g. cost-effectiveness data),
- Ensure that the reimbursed fee is based on a combination of technology use and physician involvement,
- And identify the key values relevant for the decision-making stakeholders.
Limited work has been done in this area so far, but if we look into the existing care decision-making and treatment patterns and analyze the claims for existing codes in the payers’ databases, we will be able to identify key datasets where digital pathology could make a difference and use this information to start applying for new CPT codes more aligned with digital pathology value.
To analyze what steps would need to be taken to prove to the payers that a digital pathology test deserves reimbursement, let us take a tangible example of the Visiopharm’s AI-assisted metastasis detection in Lymph nodes application.
This application has a technical, artificial intelligence-based screening component and a pathologist’s reviewing component. Currently in order to assess the presence or absence of cancer metastasis in lymph nodes several (even up to 60) lymph node sections need to be visually evaluated by a pathologist. Finding a metastasis in one of those slides is sufficient to make the diagnosis, but regardless all the other slides need to be reviewed as well. One of the benefits of the AI application would be to save the pathologist’s time, but reducing cost is not the only added value of such an application. The value proposition lies in adding value to patient care. In this case, using a computer algorithm would increase consistency and precision increasing the overall quality of the slide review. AI-aided slide review for metastasis would result in faster turn around not only for the cases where it was used but also for other cases, as the time for visual review could now be used for evaluation of other cases or spending more time on more complex cases again increasing the quality of patient care. Faster diagnosis means faster access to treatment, which often means shorter treatment times.
Every time we are able to point out and overcome limitations in the current standard of care with digital pathology applications we have both a legitimate reason to get reimbursed for its use and an incentive to fight for it if we want to make the patients’ lives better.
This episode’s resources:
“Aligning reimbursement for digital pathology with its value”