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Critical intervention needed for remote care, experts say

October 26, 2022
PoliticoPro
By Ruth Reader

 

Complex Medicaid payment systems are seemingly blocking access to many who would benefit.

Large health systems are investing big money to provide more health services at home — everything from post-operative care to treatments for chronic disease.

Kaiser Permanente and the Mayo Clinic spent $100 million on Medically Home, a company that coordinates hospital-level care at home. The Department of Veterans Affairs is prepared to spend $1 billion on remote patient monitoring. And doctors across the country are using at-home test kits and other digital devices to track blood pressure and blood sugar – part of a broader effort to use the latest technology to reduce emergency room visits and better manage costly chronic diseases.

But even as successive administrations have touted remote patient monitoring programs as a key to improving health and reducing unnecessary government spending, state Medicaid offices remain an impediment to scaling them nationally, refusing coverage for low-income residents who suffer from chronic diseases at higher rates than Americans with private insurance.

Many states have declined to pay for them, in part because the upfront legwork and bureaucratic headaches can be stifling to officials who deal in yearly budget cycles and rarely get credit for savings decades down the road. States are also hesitant to invest because there is disagreement over how cost-efficient and clinically effective these programs are when broadened to wider populations. And whether Medicaid insurers, known as managed care organizations, take up remote monitoring as part of the scope of care can depend on state incentives.

“People get the potential — that this could be a real game changer for management of chronic illness,” said Ateev Mehrotra, professor of health care policy at Harvard University and author of a recent study on remote patient monitoring. “But like everything in health care, what we want to do is we want to minimize the spend and get the greatest bang for the buck.”

The problems of reimbursement for remote monitoring underscore the difficulty in treating chronic conditions such as heart disease, the nation’s leading cause of death, and are part of the reason why the U.S. spends more than any other country on health care despite having a life expectancy below Lebanon, Estonia and Cuba.

State Medicaid programs contract with managed care organizations, or MCOs, to pay providers. Those payments are based either on a fee-for-service model, where the insurers pay for each service separately or through a value-based contract. That’s a broader payment structure that rewards providers if they can get patients healthy. And the different incentives embedded in the payment systems have far-reaching implications for healthcare innovation.

Because state Medicaid programs are not rushing to cover remote monitoring, health systems that are keen on experimenting with them are turning to insurers and pitching their ability to lower health expenses for patients with chronic diseases.

“We’re actively talking to the MCOs right now,” said Denise Basow, chief digital officer at Ochsner Health, a large health system in southeast Louisiana that launched a remote monitoring pilot for Medicaid patients with diabetes and hypertension a year and a half ago.

But managed care organizations aren’t usually incentivized to reimburse for remote monitoring because they use the number of services a Medicaid patient gets, on average, to negotiate how much they get paid by the state every month to manage a patient’s care, at least in part. Plus, it can take a long time to realize the financial benefits of improved patient health.

“If you have something like a patient monitoring device that reduces the number of billable encounters that occur, then their rates could go down,” said Tom Curtis, the deputy director of state affairs at the National Committee for Quality Assurance, a nonprofit that works to improve the quality of health care.

Dean Schillinger, an expert in chronic disease management at the University of California San Francisco, said improving patient health while trying to reduce costs is difficult. “We did a trial of a remote monitoring program for diabetes a number of years ago, and that was in collaboration with a Medicaid health plan,” he said. “It was found to be effective in terms of improving quality of life and was deemed to be cost-effective, but not cost-saving. And so the health plan did not continue that project.”

While monitoring health vitals at home can help patients stay on top of their conditions, the devices don’t influence other mitigating factors like diet and exercise, which are heavily impacted by how close a patient is to quality food, a gym, or simply a walkable neighborhood, according to Schillinger. With no common standard for how these devices should be used, the data on how useful remote monitoring is for patients with chronic disease is mixed.

“I think barrier number one is that the jury is definitely out on whether these things are clinically effective and cost-effective,” said Schillinger.

Still, there is evidence health systems are finding economical approaches that make patients healthier.

At the beginning of 2021, Ochsner Health started giving Medicaid patients with either hypertension or diabetes access to a blood pressure cuff or a glucometer and a mobile health app to log their data, as well as a care team. Within 90 days, nearly half of the hypertension patients brought their disease under control — 23 percent better than typical care. Meanwhile, 59 percent of diabetes patients were able to stabilize their condition. Patients in the program also visited the emergency room half as much as their counterparts receiving typical care.

The experiment, which Medicaid did not cover, cost $1 million to run for 3,600 patients. The health system received a grant from the Federal Communications Commission to cover the cost of glucometers and blood pressure cuffs.

“Most insurers have limited to no coverage for remote monitoring devices, and reimbursement codes have not kept up with the technology, making it difficult for us to get reimbursed,” Basow said. “It is like fitting a square peg into a round hole to make the reimbursement work for the care we provide, even though we have proven that our care is cheaper and of higher quality.”

Kaiser Permanente, which is both a health system and a health insurer, recently released a study showing that it was able to bring gestational diabetes under control for 90 percent of patients within 8 weeks using remote monitoring. It also uses remote monitoring for patients with hypertension.

The VA in 2018 reported that patients enrolled in its remote patient monitoring programs saw a 53 percent decrease in “bed days” and a 33 percent reduction in hospital admissions. At the end of 2021, the agency published a request for a proposal for remote patient monitoring contracts worth $1 billion.

Among a small cadre of primary care doctors, remote monitoring is gaining traction. There were 19,762 claims for remote patient monitoring across 15,682 patients in 2021 compared to 4,355 claims across 3,653 patients in 2020, according to a September study using UnitedHealthcare data. Claims for continuous glucose monitoring grew 51 percent over the same time period.

Mehrotra, who co-authored the September study on remote patient monitoring, said that growth rates were similar for private insurance and Medicare. Ultimately, for Medicaid adoption to grow, he said, health systems need to figure out how to target remote patient monitoring to the patients who would benefit the most to show that it really is cost-effective.

The Medicaid problem

But cost-effectiveness may not be enough to drive the adoption of remote patient monitoring within Medicaid. While the Centers for Medicare and Medicaid Services has some reimbursement codes for remote monitoring, states have broad discretion to set their own rules.

Some 19 states’ Medicaid programs don’t reimburse for remote patient monitoring, according to data from the Center for Connected Health Policy. Several states that pay for remote monitoring have stringent restrictions around its use.

In Minnesota, remote monitoring is only reimbursed when monitored by a physician, nurse, respiratory therapist, or a licensed professional under the supervision of a medical director. Kentucky says that while it may reimburse for remote monitoring services, its department of Medicaid Services does not need to reimburse for remote patient monitoring equipment, equipment upgrades, and the internet connection needed to transmit data back to a health system.

Louisiana does not directly reimburse for remote monitoring devices. However, the state Medicaid office has encouraged its managed care organizations to reimburse for them.

Basow is hopeful the data Ochsner collected on its program’s outcomes will entice managed care organizations to set up a contract for the service. She said even if they don’t, Oschner will continue the program, because the health system is increasingly shifting toward value-based care. That allows Ochsner to save money by reducing Medicaid patients’ emergency room visits. Still, Ochsner loses money when it provides these services to patients whose Medicaid plans use a fee-for-service payment structure, said Basow.

That jumble of payment systems is an impediment to health care innovation nationwide, Schillinger said: “The main problem is that we do still have a health care system that is a massive hybrid of different kinds of payers and different kinds of reimbursement models.”

Doctors can’t operate a health business where they get paid for every service they render and a separate health business where they’re paid a single monthly fee to manage the health of a patient on an ongoing basis, because these models require different infrastructure, he said.

When Ochsner set up its pilot program, the health system created a team responsible only for patients in the remote monitoring program, largely made up of coaches, nurses, physician assistants, and pharmacists, allowing them to keep costs lower. But creating this team was a substantial upfront cost, said Basow, and getting the program right took seven years.

Not unsurprisingly, the health systems investing the most in remote patient monitoring are the largest, according to KLAS Research. And many hospitals are under financial strain already.

It’s also why primary care organizations that have taken on remote patient monitoring will partner with companies like Omada Health and Livongo, which essentially run the program for doctors. But it’s unclear whether such services are cost efficient enough for MCO’s to want to reimburse for them.

In the meantime, Basow is preaching the gospel through remote monitoring.

“I’ve been out there talking to a lot of health systems and trying to say, ‘How can we accelerate that learning curve and help you do this faster?’”

 

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