Virtual cancer care companies are seeing the benefits from President Biden’s cancer moonshot.
The cancer moonshot initiative began under President Barack Obama in 2016, and in 2022 Biden set a goal of reducing cancer deaths by 50% over the next 25 years. The program also aims to expand payment pathways for cancer navigation services, an area of increasing focus among digital health startups.
Read more: How employers are adding virtual cancer care to their benefits plans
While the first goal is long-term, achieving the second one is within sight. In November, the American Medical Association said it worked with the moonshot team to introduce four procedural terminology codes to reimburse clinicians and community health workers for providing cancer navigation. The services, which help patients navigate appointments, medications and other complexities associated with having cancer, have existed without specific reimbursement codes for decades.
In a year of uncertainty surrounding digital health reimbursement, cancer care navigation companies say the codes will help increase adoption of their services and offer them potential financial stability. The introduction of the codes also could incentivize more competitors to enter the field.
“When I was working at Providence back in the day, we had social workers act as [cancer care] navigators and the hospital just paid for them out of its own expenses to help patients,” said Adam Pellegrini, CEO of Jasper Health, a virtual cancer navigation company. “There’s been a need for this in the health system for decades.”
The Current Procedural Terminology codes reimburse for both clinical coordination services, which can only be done by a licensed practitioner, and patient navigation services, which are handled by professionals such as a community health worker. Patient navigation services tend to focus on improving social determinants of health.
The Centers for Medicare and Medicaid Services also rolled out two healthcare common procedure codes on Jan. 1 to reimburse providers for offering principal illness navigation services. The services can include care coordination, health education, patient self-advocacy skills and facilitating access to community-based social services. Both codes work together to reimburse providers for care navigation services from Medicare.
The codes are a sign the government sees value in the services, and will make it easier for care navigation companies to sell their services to employers because of the reimbursement, Pelligrini said.
“We're no longer telling payers and employers, ‘Oh, you’re going to have to pay for this out of your expense budget,’” Pelligrini said. “Now we can sell our cancer care navigation platform and services and how we get patients to stay engaged with it…leading to better outcomes. It shifts our [business] model in the long term.”
Gary Manning, president of cancer-focused remote patient monitoring startup Veris Health, said the codes will be an added boon for the company, which works with cancer provider organizations. Veris will help clinicians track their navigation activity so they can use it for invoicing and getting paid by Medicare, he said.
But not everyone is bullish on the effect of the navigation codes. Sach Jain, CEO of cancer-focused digital health company Carrum Health, said the codes are a step in the right direction but more change is needed to increase patient and clinician adoption of care navigation services.
The codes reimburse services with fee-for-service payments rather than reimbursing a single episode of care through value-based care payments. The latter is the best way to incentivize long-term adoption of cancer care navigation services, Jain said.
“Changing the behavior of providers and patients is difficult,” Jain said. “We can acknowledge [to] CMS that this is a good first step but there are 10 steps that need to happen.”
