Exploring RPM Benefits & Barriers, From Population Health to Payment

With healthcare moving increasingly outside the four walls of the hospital, remote patient monitoring (RPM) tools are becoming indispensable.

How hospitals employ these tools are diverse, from chronic disease management to providing hospital-level acute care at home. But implementing and scaling RPM solutions can be complex, particularly in the current reimbursement and regulatory environment.

At Xtelligent Healthcare Media's 3rd Annual Remote Patient Monitoring Virtual Summit in June, healthcare industry leaders discussed the rise and benefits of RPM use, as well as the hurdles to implementation, including patient education and engagement challenges and reimbursement barriers.

RPM IS DISRUPTING HEALTHCARE AS WE KNOW IT

Though RPM is not new, its use soared alongside other virtual care technologies during the COVID-19 pandemic. This increase has set the stage for a new normal in healthcare delivery.

"[RPM] is disruptive because it is the acknowledgment that patients are free range and now for the first time, so must we too be," said Zenobia Brown, MD, associate chief medical officer at Northwell Health and executive director of Heath Solutions, the health system's care management organization, during a keynote address. "And what I mean by that is we have existed in a healthcare structure for the most part, up until COVID…that was organized around the provider."

RPM enables patient-centered care — a critical factor in achieving value-based care — in the truest sense.

During the pandemic, RPM enabled overrun healthcare organizations to manage COVID-19 patients in their own homes, reducing hospitalizations and readmissions, Brown said. Now that the worst of the pandemic appears to be behind us, healthcare providers are turning their attention to other uses of RPM, particularly in the chronic disease management space.

Brown noted that about 40 percent of adults suffer from two or more chronic illnesses, and another 40 percent have inadequate access to healthcare services.

"When you put these two things together, the promise of RPM is massive because we have this huge problem, and we need new tools, we need new technology to address it," she said.

"If you're targeting high-risk populations [though RPM], you are accurately detecting declines in health, you are providing responsive, timely care," Brown said. "That's a big one because we like to think of healthcare as 24/7, but you know, not every practice is open on Saturday or Sunday."

Thus, amid the ongoing shift to value-based care, technology that puts the patient at the center is essential.

"[RPM's] enhancing self-management, right? So again, we get back to this [model where the] patient is at the center. This is what is disruptive, this is what is good, and then it's ensuring collaborative and coordinated care," she said.

RPM PLAYS A KEY ROLE IN POPULATION HEALTH MANAGEMENT

Like Northwell Health, Providence, too, saw a rapid uptake of RPM during the pandemic. But now, in the post-public health emergency (PHE) era, the 51-hospital system is directing its RPM efforts toward population health management.

During a keynote address, Eve Cunningham, MD, chief of virtual care and digital health at Providence, described the health system's use of RPM to enhance population health among hypertension and congestive heart failure patients.

"We took a population health-based approach to identifying the patients that would be enrolled," she said.

Health system leaders worked with the clinicians to standardize criteria for patient enrollment in the RPM care pathways. Initially, the health system cast a wide net, offering the program to any patient with chronic hypertension or congestive heart failure.

But they found that some of these patients already had good control over their conditions and remained in good control during the pilot programs, Cunningham stated. Thus, leaders worked with clinicians to define criteria to help identify patients who would benefit most from RPM.

Overall, the patient retention rate in the pilot RPM programs was high at 80 percent.

"When you talk to patients who are in these programs, they tell you that they love continuing the program because they feel like somebody's there watching over them, checking in on them," she said. "They really appreciate that close touchpoint that they get with having people who can reach out to them more frequently and check on them and adjust their medications in real-time."

As Providence looks to scale RPM, it plans to expand its chronic hypertension and congestive heart failure care pathways to more clinics across the system and grow the types of disease states addressed using RPM.

When expanding current pathways across the system, Cunningham noted that Providence would first focus on care sites ready to take on an RPM program.

"We're really thinking about making sure that we find sites that are operationally ready for this model of care, that have the right culture for it," she said. "You want to go to the path of least resistance first — go to the early adopters, go to the places where people are enthusiastic and will measure the impact and demonstrate the value."

With regard to new disease states, diabetes will likely be added next to Providence's RPM care pathways. Diabetes is a widespread issue in the United States, making it a good use case for RPM.

"Pick [an RPM use case] that has a larger patient population impact," Cunningham said. "So, you can get to scale first. Sometimes people will go after these use cases that are very narrow and impact a very small patient population, and it's hard to prove out the ROI [return on investment]."

PATIENT ENGAGEMENT IN RPM IS KEY

RPM organizes care around the patient and can boost outcomes, but the success of these programs depends on an engaged patient population.

A lack of health literacy is one of the biggest barriers to patient engagement in RPM programs.

Ochsner Health's digital medicine program combats this issue by ensuring all patient-facing materials are easy to understand for people of varying health literacy levels.

"You need to develop content that is designed for a low literacy audience in a way that uses multiple modalities, such as print, infographics, video, and then the manner in which you actually disseminate the content [should be] small bite-sized pieces," said Julie Henry, chief operating officer at Ochsner Digital Medicine, during a panel discussion.

For instance, Ochsner uses resources like quizzes with immediate feedback and micro-education features to ensure engagement in RPM programs.

Henry also emphasized the importance of customizing RPM engagement efforts.

"We've certainly realized that personalization to the type, the cadence of outreach and interventions, need to be specific to where that patient is in their chronic disease management journey," Henry said. "We've had to consider things as we take care of patients all over the United States — there are different time zones, non-traditional work hours, accommodations that happen with life events that would need us to sort of pause some of our outreach and education while still ensuring that patients are sending us their readings where appropriate."

Further, Ochsner provides patients access to its O-bar — inspired by Apple's Genius Bar — which offers technical support related to virtual care services.

According to Henry, the O-bar gives patients the necessary human interaction to help them grow more comfortable with digital health technology, including RPM tools, thereby ensuring that they can reap the benefits of virtual care.

Examining social determinants of health (SDOH) challenges and implementing strategies to mitigate them is a crucial aspect of successful patient engagement and education strategies, noted Tearsanee Carlisle Davis, DNP, director of clinical programs and strategy at the University of Mississippi Medical Center's Center for Telehealth.

"I think it's fair to say that social determinants of health affect everything," she said during the panel discussion. "If a patient is worried about whether they can pay a bill or whether they can have the lights on, they're not really paying attention to what we're doing. They're not going to be very engaged or as engaged as they could be."

The UMMC Center for Telehealth has embedded SDOH assessments into its onboarding process for RPM programs focused on chronic disease management. The facility's registered nurse (RN) care coordinators conduct these assessments and connect patients with SDOH needs to resources in their community that can help.

"We learn things like, this is a grandmother who's taking care of her five grandchildren because her daughter is in prison, and she's stretching whatever she has to make ends meet, or they do have food insecurity," Davis said. "But then we know that there's the Mississippi Food Network or food banks out there where they can get resources because if those basic needs are not met, they are not thinking about that insulin prescription."

Davis further noted that engagement in the RPM program sometimes requires a mindset shift among patients. Some patients, especially those in rural or underserved areas, may not consider that there are alternative methods to control their chronic conditions, and they may have resigned themselves to their fate, she explained.

Thus, patient education sometimes needs to move beyond training on how to use RPM devices or technical support and focus on raising awareness of the benefits and capabilities of RPM.

"Many patients living with diabetes, especially if they're elderly, have accepted the fact that they may lose a limb," Davis said. " That's one of the things that we get excited about. When we see someone who was going down that path, to turn it around and for them to become motivated and excited, that that doesn't have to be what happens."

As patient engagement efforts continue to evolve at adult hospitals, pediatric hospitals face unique challenges in this arena. There are several reasons for this, including that tracking pediatric health metrics tends to be more involved than tracking adult health metrics.

"Like with [tracking] heart rate, we [also] need patient weights because our kiddos are growing," said Eric Jackson, Jr., MD, chief innovation officer at Nemours Children's Health, during the panel discussion. "That's a red flag symptom for cardiac congenital heart disease patients in nutrition, whether the weight's going up or down."

Additionally, Nemours requires daily videos of pediatric patients in its RPM programs, as patients' skin color, the sound of their breathing, and other physical attributes can help clinicians track patient outcomes.

But these data collection and sharing protocols can be overwhelming for patients and their families, especially the parents or caregivers, as they are typically tasked with providing the information to clinical teams.

"So, we engage in deliberate practice rehearsal," Jackson said.

Before patients enrolled in RPM leave the hospital, the families must demonstrate the necessary protocols to collect and share data. The clinical team at Nemours also has specific criteria for RPM patient selection. This includes considering various constraints facing the patients' parents and caregivers, such as other children in the home that need attention, Jackson noted.

RPM REIMBURSEMENT CHALLENGES, LESSONS LEARNED

One of the primary reasons for the massive spike in RPM use during the pandemic was the flexibilities lawmakers enacted to support care provided outside of healthcare facilities.

"I think we have seen a real evolution of public policy in the years leading up to the pandemic that was supercharged by the pandemic and allowing for, what we call, modality and tech-neutral policies to take hold that allowed for licensed medical professionals to deploy tech in the best interest of their patient," said Kyle Zebley, senior vice president of public policy at the American Telemedicine Association (ATA) and executive director of ATA Action, during the panel discussion.

These flexibilities included adding remote therapeutic monitoring (RTM) codes to expand the types of remote monitoring that could be billed for and waivers that enabled provider organizations to launch hospital-at-home programs. Alongside Medicare coverage of RPM, Medicaid and commercial health plans significantly expanded their coverage of the care modality.

But, while the waivers and coverage expansions helped accelerate RPM use during the pandemic, more permanent changes are needed to sustain use post-PHE.

There are two major RPM reimbursement pain points, Zebley noted. The first is that payment rates are not high enough.

"The payment rates are not at that level where putting aside profit [is possible]," he said. "It's not even covering the cost of the deployment of the tech itself…[And] there comes a point in time where the economics just don't make sense."

The second is the regulatory restrictions around RPM use. For instance, Medicare requires providers offering RPM services to submit 16 days' worth of data every 30 days.

According to Zebley, numerous clinical use cases for RPM should not be bound to the 16-day threshold, which adds to the administrative burdens facing healthcare providers.

Thus, provider organizations are implementing various strategies to mitigate RPM reimbursement challenges and continue to provide these services to their patients.

At Mayo Clinic, technology is used not only to deliver RPM services but also to help rein in costs associated with the programs.

"The bulk of our costs to provide RPM is in two spaces," said Sarah Bell, nurse administrator, Virtual Nursing, Remote Patient Monitoring, and Home Hospital at the Mayo Clinic, during the panel discussion. "One is the technology. And that's a hard cost to [contain], right? We have to have a technology stack that can provide these services…The other is the cost of FTE [full-time equivalent] employees to do the monitoring."

It's that second bucket that provides opportunities for lowering costs. For instance, instead of tasking staff, Mayo Clinic uses automation to educate patients on how to fill out symptom assessment questionnaires, give reminders to complete the questionnaires, and prompt patients to schedule appointments with healthcare providers if necessary, Bell shared.

The health system also works with a vendor partner to send out RPM-related device kits to patients, get those kits back, clean them, and ship them out to new sets of patients.

"I always say to the nursing team: my goal is to have us take care of the most patients that we can, but that doesn't mean I want you to work harder," she said. "That means we're making our workflow better so that you can care for the patients and be actually talking to the patients who absolutely need you."

Another key strategy provider organizations are using to address RPM regulatory and reimbursement hurdles is research.

According to Jennifer Junis, senior vice president at OSF OnCall Digital Health, embedding research into the RPM care delivery model is essential as it is still a relatively new mode of care delivery.

"It's really about now taking the model that we know works really well, anecdotally for our patients, and embedding qualitative and quantitative research in that to prove the outcomes and the quality are above standard as well as then the cost at a scaled model can be lower," she said during the panel discussion.

OSF Healthcare has seen success with its RPM program for obstetrics. The program provides pregnant patients living in rural areas access to a team of midwives and OB-trained nurses who leverage RPM to provide wraparound care, Junis stated. Now, the health system is working to conduct research on programs like this one.

She further noted that larger health systems could play a vital role in extending RPM use in hospitals with fewer resources.

"We have a B2B arm, so we are partnering with some of our smaller rural hospitals that are never going to have a virtual command center," Junis said. "Or small practices that haven't invested in the technology or the clinical staff that can be available 24/7. So, really partnering with them and using our infrastructure in partnership with them to care for their patients."

As RPM regulations and reimbursement continue to evolve, Junis noted that key changes must support true patient-centered care.

"I do think the…payer system has to recognize the care that can be provided for patients when we put the patient in the center and meet them where they are," she said.

However, creating a patient-centered care system will also require physician licensing flexibilities.

According to Zebley, strict enforcement of licensing rules that prevent RPM and other virtual care services from being provided across state lines impedes the benefits of these technologies.

"If we just keep in mind what is of most value to the health and wellbeing of the patient and transition to a healthcare system that's more responsive to the needs of the patient in that manner, I think, [it] will go a long way towards allowing effective deployment of innovative tech, like remote monitoring," he said.

Bell also noted that keeping up with the licensing requirements of each state when trying to launch and scale RPM services is a "headache" and a costly one at that.

"[Licensing flexibilities] would be a huge propeller for not just remote patient monitoring, but virtual care in general, which, I think we can all agree, that this is the future," she said. "And the future is now, and we need our laws to support that."