MedCity Influencers, Artificial Intelligence

Covid-19 has presented the possibility of reinventing healthcare delivery and reimbursement must support this

While there are encouraging signs of reimbursement falling in step with the move towards a more value-based healthcare system, what is needed now to further encourage healthcare innovators is to properly rationalize approval processes imposed by the FDA and CMS.

Change is often driven by necessity, and in the short time since the outbreak of Covid-19, we have witnessed the potential of technology to transform healthcare delivery and save lives.  From patient appointments using online chat services, to AI-powered robots protecting healthcare workers by delivering medicine in Covid-19 surge clinics; and rapid remote analysis of cardiac images helping with the triage of high-risk patients*.  

The task ahead is to make sure that we don’t forget the value and impact of what we have seen technology, and particularly AI can do — and the resulting benefits of easing the ongoing pressure on healthcare providers, while giving patients the best possible chance of living a healthy life. 

So, what must change to turn this phenomenon into a reality – and to avoid turning our back on the opportunity? It means creating a new paradigm where healthcare providers are encouraged to use the latest technologies to treat and better care for patients, not least through an evolved framework of reimbursement 

The move by the Centers for Medicare & Medicaid Services (CMS) and many private insurers to improve reimbursement for telehealth services has been a positive start. During the pandemic it has allowed more providers to increase utilization of telehealth by expanding services covered for telehealth and easing previous limitations on how telehealth could be delivered. Some changes were made on a temporary basis to see healthcare providers through the current crisis, but many, including the Federal Trade Commission (FTC) would like to see them implemented on a permanent basis; enabling older and less mobile adults to take advantage of the increased access to care, in both rural and urban settings, including areas where underserved populations have limited access.   

Beyond improving telehealth provision and adoption, the reimbursement framework could evolve in a way that reflects a shifting emphasis towards value-based care, by encouraging the greater adoption of automated secure cloud transmission and remote analysis of images to deliver healthcare in smarter ways, ultimately improving patient care and outcomes. 

The challenge lies in how to evolve to more value-based models effectively and rapidly, away from purely volume-based codes built around the Resource-Based Relative Value Scale that don’t necessarily fit with the value new technologies can offer. The concept of value-based reimbursement should focus on paying for quality/collaborative healthcarenot for quantity or billable timeThe old way of ‘the more you do, the more you get paid’, no longer applies to how we should be incentivizing healthcare to be delivered 

Whilst we are seeing increased clinical validation in AI helping save lives, the reimbursement models have not kept pace to incentivize clinical staff to rapidly adopt these toolsThis must be encouraged, and the greater the move towards value-based programs and reimbursement, the greater the clinical appeal of AI and automated techimproving patient care and clinician workflow and safety. The alternative to this is the ultimate catch 22 situation, meaning that if value-based programs are not implemented, clinicians won’t have as compelling a reason to use new technology; pioneering tech companies will be more hesitant to innovate cuttingedge diagnostic tools, with patients ultimately deprived of their benefit.? 

In a post Covid-19 world, there will a growing expectation that telehealth and AI will be an integral part of the healthcare value chain, to support social distancing and rapidly optimize the delivery of healthcare to improve patient outcomes and the overall health of society. 

Towards making innovation more achievable
While there are encouraging signs of reimbursement falling in step with the move towards a more value-based healthcare system, what is needed now to further encourage healthcare innovators is to properly rationalise approval processes imposed by the FDA and CMS, or at very least to make them run more closely in parallel.?But ultimately, the new ‘normal’ for the U.S healthcare system requires a continued recognition and evolution of reimbursement based around benefits to the patient. 

To borrow from Kevin Costner’s famous Field of Dreams scene in which he heard “If you build it he will come”; we know that in the global healthcare arena, telehealth and AI tools have truly arrived and are waiting at the gates. We now need to build the infrastructure to allow them to deliver on their promise of better healthcare. 

Photo: LeoWolfert, Getty Images


Dr Ross Upton is Chief Executive Officer and co-founder of Ultromics, a health-technology company, which leverages AI to automate echocardiogram analysis, including the first world’s first heart disease prediction tool. Ultromics supports physicians with the detection and diagnosis of cardiovascular disease - the leading cause of death globally.

Ross’ vision for Ultromics took shape during his DPhil, at the University of Oxford, whilst also training as a cardiac sonographer in the UK’s NHS. He holds a DPhil in Cardiovascular Medicine at the University of Oxford, an MSc in Clinical Cardiovascular Science (Newcastle), and an MSc in Clinical Biochemistry (University of Surrey).

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