Health equity through cms collaboration with startups and digital health innovations

There is a need for digital health innovation focused on bettering the health of marginalized populations. These communities, often insured by Medicaid and Medicare, face complex healthcare

barriers that technology can address—emphasizing the role of the Center for Medicaid and Medicare Services (CMS) in fostering innovation. Dasari et al. identify four areas of CMS

collaboration with startups: enhancing consumer awareness, leveraging telehealth, streamlining cross-state licensing and billing, and adopting technology-enabled tools. INTRODUCTION As

investment in digital health companies has slowed following unparalleled financing during the Covid-19 pandemic, the pressure on existing health technology companies to acquire customers and

prove value has grown1. Given the predominance of employer-sponsored health insurance in the U.S., many health technology companies have focused their efforts on business-to-business (B2B)

models in order to expand their services quickly rather than sticking to direct-to-consumer (D2C) models. However, many Americans are not insured by their employers—18.8% are insured by

Medicaid, and 18.7% are covered by Medicare2. With a population of 92 million Medicaid and 65 million Medicare patients, the Medicaid and Medicare market has an annual market spend of $728B

and $829B, respectively3. These patients typically have various complex healthcare barriers, such as lack of access to medications, challenges with health literacy, and difficulty with

transportation. The myriad of inequities that these patients experience are areas that are often overlooked and, as such, are desperate for innovation. As a result of the above factors,

vulnerable populations are falling behind in receiving equitable healthcare. Few companies, such as Cityblock, Unite Us, and Nuna, recognize the holistic approach necessary to provide

healthcare for populations whose health is disproportionately impacted by social factors. As the public provider of care for these individuals, the Center for Medicaid and Medicare Services

(CMS) is responsible for cultivating an innovation economy that encourages startups to create and collaborate. Compiling the insights from 15 digital health and health equity experts, Dasari

et al. suggest four pivotal areas of partnership with health technology startups to enhance the work of CMS4. THE FOUR PIVOTAL AREAS OF OPPORTUNITY ENHANCING CONSUMER AWARENESS The first

area of opportunity Dasari et al. highlight involves enhancing consumer awareness about CMS programs. There are multiple barriers that hinder access to CMS programs and benefits, such as

lack of a regular primary care provider and knowledge of programs. Startups that focus on creating a centralized repository of benefits would improve both coverage and awareness, especially

if the platform is personalized to individual patients’ health plan reimbursements, state programs, and tax credits. This could look similar to an application created by Propel, which helps

low-income Americans manage their electronic benefit transfer (EBT) balance and understand their supplemental nutrition assistance program (SNAP) benefits. A similar healthcare financing

application would help patients navigate their healthcare benefits and spending; however, innovation in this space would require thoughtful strategies regarding scale as several existing

patient navigator resources are location-specific. LEVERAGING TELEHEALTH The second area of opportunity is to mitigate access gaps through virtual care programs. During the pandemic, CMS

allowed reimbursement of telehealth services to be on par with in-person care. Since many low-income patients struggle with transportation, a continuation of these reimbursement incentives

is essential to enable patients to receive care in various settings. The digital divide persists despite efforts to address access to broadband services through initiatives such as the

Affordable Connectivity Program5. However, continuing these coverage policies is important since having the option of telehealth is transformative in increasing healthcare access. STREAMLINE

CROSS-STATE LICENSING, BILLING, CREDENTIALING Even with the reimbursement incentives for telemedicine, challenges with billing and obtaining cross-state licenses further inhibit the

distribution of healthcare providers in communities that need them most, such as rural areas. The third area of need highlighted by Dasari et al. is to streamline the complexity of

licensing, billing, and credentialling across states. Recognizing that physicians will need to practice in multiple states with the rise of telemedicine, US state medical boards created the

Interstate Medical Licensure Compact (IMLCC) to help streamline medical license application processes. An area of opportunity exists to support and conjoin efforts with CMS to balance safety

and accessibility with cross-state medical practice. ADOPTING TECHNOLOGY-ENABLED TOOLS The fourth area of opportunity is using technology-enabled services to address social risk factors

without imposing additional burdens on providers. The article by Dasari et al. recommends reimbursements for social services and provider time to address social determinants of health

(SDOH). Arguably instead of reimbursing physicians, increasing the quantity and reimbursement of care provided by social workers, peer advocates, and patient liaisons–in addition to Dasari

et al.’s suggestion to leverage networks of remote community health workers–will be critical to ensure that providers are not overburdened. Furthermore, expanding funding streams to these

care providers will also attract the creation of technology-enabled tools that are unique and specific to the tasks of social workers and patient advocates. AN UNTAPPED MARKET OPPORTUNITY

While Dasari et al. clearly highlight the need for innovation and partnership with CMS, a looming question remains. _Why should these profit-driven startups and companies enter the Medicaid

and Medicare market?_ Because community health organizations and federally qualified health centers (FQHC) are willing to pay for the right technology-enabled tools. Although these

organizations may have a tighter budget, creative business models do exist, such as obtaining additional funding from Section 115 of the Social Security Act. This gives organizations the

flexibility to create experimental, pilot projects that promote the objectives of each state’s Medicaid program6. Furthermore, on a market level, the Medicaid and Medicare market still

remains largely unpenetrated. To be successful, startups must obtain immediate increased profits or cost-savings for the hospital since FQHCs have less tolerance for longer-term financial

outcomes. Startups must also achieve scale. As seen in many other consumer industries, even though the individual consumer has financial constraints, a company can still be profitable if it

can serve a niche and aggregate customers quickly. There is no time better than now to recognize the opportunity in the Medicaid and Medicare market—creating technology-enabled solutions

that tackle the health inequities leaving communities behind during this digital health boom. REFERENCES * Gunasekeran, D. V., Tseng, R. M. W. W., Tham, Y.-C. & Wong, T. Y. Applications

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AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Harvard Medical School, Boston, MA, USA Serena C. Y. Wang, Grace Nickel & Joseph C. Kvedar * Division of Urology, Department of Surgery,

University of Toronto, Toronto, ON, Canada Jethro C. C. Kwong Authors * Serena C. Y. Wang View author publications You can also search for this author inPubMed Google Scholar * Grace Nickel

View author publications You can also search for this author inPubMed Google Scholar * Jethro C. C. Kwong View author publications You can also search for this author inPubMed Google Scholar

* Joseph C. Kvedar View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS First draft was written by S.C.Y.W. The remaining authors, including

G.N., J.C.C.K, and J.C.K provided critical revisions and approved the final draft. CORRESPONDING AUTHOR Correspondence to Serena C. Y. Wang. ETHICS DECLARATIONS COMPETING INTERESTS J.C.K. is

the Editor-in-Chief of _npj Digital medicine_. The remaining authors declare no competing interests. RIGHTS AND PERMISSIONS OPEN ACCESS This article is licensed under a Creative Commons

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http://creativecommons.org/licenses/by-nc-nd/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Wang, S.C.Y., Nickel, G., Kwong, J.C.C. _et al._ Health equity through CMS

collaboration with startups and digital health innovations. _npj Digit. Med._ 7, 221 (2024). https://doi.org/10.1038/s41746-024-01228-z Download citation * Received: 09 July 2024 * Accepted:

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