Combatting chronic disease among Medicaid patients with RPM

Though virtual healthcare has the potential to expand healthcare access well beyond the bounds of hospital walls, social determinants of health, or SDOH, and other factors can prevent certain people from adopting and using virtual care tools. The COVID-19 pandemic laid bare this thorny issue. On the one hand, virtual care played a critical role in enabling people to access healthcare, but on the other, vulnerable populations were often unable to reap the benefits of virtual care.

To close these virtual care gaps, healthcare providers and payers are increasingly joining forces. A recent example is the partnership between New Orleans-based Ochsner Health and Louisiana-based Medicaid managed care plan AmeriHealth Caritas Louisiana. Together, the organizations plan to expand access to digital care services for chronic disease management to Medicaid beneficiaries across the state.

During the pandemic, all 50 states and Washington, D.C., updated their Medicaid programs to provide reimbursement for some form of live video-based telehealth. As of October 2023, 33 states offered some Medicaid reimbursement for store-and-forward telehealth, 37 for remote patient monitoring (RPM) and 43 for audio-only telehealth.

This resulted in a significant jump in the utilization of virtual care modalities, including RPM, among Medicaid patients. While RPM can significantly improve chronic disease outcomes among Medicaid populations -- a population that experiences high rates of chronic disease -- partnerships between healthcare stakeholders are necessary to solidify ongoing access to RPM services and tools.

Forging the RPM partnership

Though the partnership with AmeriHealth Caritas Louisiana began earlier this year, Ochsner Health's efforts to improve chronic disease management within the Medicaid population are longstanding, primarily due to the urgent support this population needs.

You're dealing with a world where the average primary care provider just doesn't have the time with their patient that they'd ultimately like to have, and he or she has to deal with an awful lot ... So, what we realized as a health system, just looking at our patient population, was that there might be a better way to leverage technology to treat these conditions.

"[The Medicaid population is] a very underserved population," said Dan Shields, CEO of Ochsner Digital Medicine, in an interview. "It's a population that does suffer from negative outcomes in chronic conditions, especially around these cardiometabolic conditions, which is kind of an umbrella term, but hypertension, high cholesterol, diabetes, things like that. And we felt that as the biggest healthcare provider [in the state] ... it was the right thing to do."

The health system has spent the last few years piloting an RPM program focused on multiple chronic diseases for Louisiana Medicaid beneficiaries. Following successful results, Ochsner sought a partner to expand the program within the state's Medicaid population.

Enter AmeriHealth Caritas Louisiana.

The healthcare payer offers Medicaid and Louisiana Children's Health Insurance Program plans. As of June 2020, its Medicaid enrollment totaled 208,885 Louisiana residents.

The partnership with Ochsner was an easy decision for AmeriHealth Caritas Louisiana, according to Kyle Viator, the healthcare payer's market president.

"Ochsner is highly respected and the largest provider in our network in the state," said Viator in an interview. "And so, to have someone with the sophistication and the technology that is based in Louisiana available to our membership was just a no-brainer in terms of bringing them on."

The partnership went live on Jan. 1, 2024, offering AmeriHealth Caritas Louisiana members with hypertension and type 2 diabetes access to Ochsner Digital Medicine's RPM program.

How the RPM program works

Typically, chronic disease management occurs within the primary care setting. But Shields noted that the severe primary care provider shortage nationally and in most states is a significant barrier to ongoing chronic care.

According to data from America's Health Rankings, there are 216.9 active primary care providers per 100,000 population in Louisiana. As a result, PCPs are struggling to meet the demands of the chronic disease population in the state.

"You're dealing with a world where the average primary care provider just doesn't have the time with their patient that they'd ultimately like to have, and he or she has to deal with an awful lot ... So, what we realized as a health system, just looking at our patient population, was that there might be a better way to leverage technology to treat these conditions," Shields said.

The RPM program targets hypertension and type 2 diabetes. Patients with these chronic diseases who had a potentially preventable admission, readmission or emergency department visit event within the last 18 months can be enrolled by their care manager or referred to the program by their PCP.

We do not see any difference in terms of access and availability. I think that, especially when it comes to a personal device, it is really the norm in our society today, whether it's the Medicaid population or any other payer.

Once enrolled, the patient receives monitoring devices from the health system. For example, hypertension patients receive a blood pressure cuff, and type 2 diabetes patients receive a glucometer. The devices connect to the patient's smartphone or tablet, transmitting readings that are submitted to the Ochsner Digital Medicine care team.

"And that's really where the difference comes in because remote patient monitoring is not new," said Shields. "That's been around for a while. When we start getting those readings in, we actually surface that to a care team that's dedicated to this program, [which includes] a licensed clinician and health coaching to focus on the diet, exercise -- the things that contribute to the condition."

If the readings are abnormal or the patient's health is trending down, the care team jumps into action.

"Our care team can change medications, change dosages, change frequency to really do everything we would normally do to manage the condition in a primary care setting or a clinic setting," Shields said. "But we're doing it remotely."

As a result, patients can manage their condition from the comfort of their homes, and clinicians can make decisions based on relevant, timely data. Through the RPM program, the Ochsner care team receives data at least once or twice a week, whereas, in the primary care setting, that data is typically only collected every six months or so, Shields noted.

According to the CDC, about 22.5% of hypertension patients in the U.S. have their hypertension under control. Shields stated that during the pilot, Ochsner's RPM program resulted in about 80% of hypertension patients being able to bring their hypertension under control.

Breaking down barriers and achieving program goals

Implementing technology-supported clinical care programs is challenging due to various factors, not least of which are the SDOH barriers facing patients. The Medicaid population, in particular, experiences several SDOH barriers, including income instability and the digital divide.

The digital divide -- the gap between those with access to technologies and the digital literacy to use them and those without -- can significantly stymie RPM efforts. However, Shields and Viator note that Medicaid patients are more technologically savvy than people give them credit for.

"Medicaid members get a bad rep, candidly, as being not sophisticated enough or not being able to embrace these technologies," Shields said. "We saw exactly the opposite -- high engagement, frankly."

Shields added the success rate for self-setup -- the ability of patients to set up the RPM devices on their own with instruction from an app -- was high among Medicaid patients and on par with that of any other patient group.

Viator echoed Shields, noting that the smartphones needed for RPM efforts are also common among Medicaid beneficiaries.

"I mean, it's in the way that their lives are lived every day [as it] is with all of us [that] have the devices in hand," he said. "And so, we do not see any difference in terms of access and availability. I think that, especially when it comes to a personal device, it is really the norm in our society today, whether it's the Medicaid population or any other payer."

Further, Ochsner has multiple tech support options for patients needing extra help. Shields said that patients can access tech support through a chatbot, the telephone or Zoom.

As a result, Ochsner has a high Net Promoter Score among its Medicaid patients, which Shields believes is because it offers this population services that have not been provided to them before and the necessary support.

Another significant challenge to deploying RPM efforts is reimbursement. According to Viator, convincing the state Medicaid agency to cover the RPM program as a benefit was not difficult, especially when shown the high rate of potentially preventable events that diabetes and hypertension patients experience in terms of emergency department usage or hospital admissions and how the program can help reduce these.

However, Shields noted that while there are billing codes associated with the RPM aspect of the program, there is no pathway to bill for the clinical management that follows.

"The current reimbursement structure does not cover it," he said. "It's not there. So, I know that we as an organization are part of efforts to kind of change how digital health is covered, especially with how we've embraced it."

As efforts to expand RPM coverage gain momentum, Viator noted that RPM is increasingly being viewed as a critical mechanism to expand access to chronic disease management among Medicaid patients.

The outcomes of Ochsner's RPM partnership with AmeriHealth Caritas Louisiana could provide further evidence to support expanded RPM access for Medicaid populations.

According to Shields, the organizations hope to see improved clinical outcomes and, as a result, reduced healthcare utilization. Reduced healthcare utilization will also lead to cost-savings for the health plan, which is important for publicly funded healthcare insurance programs.

Whether the partnership can achieve these lofty goals as it scales RPM and offers the program to more Medicaid patients across the state remains to be seen. But if it succeeds, the program will be vital in expanding accessible chronic disease management to a medically underserved population.

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.