Blog

The 2027 Physician Fee Schedule Would End Remote Monitoring Where It Is Needed Most: Rural America 

By Jon-Michial Carter, Co-Founder and CGO, ChartSpan

There are 5,650 Rural Health Clinics (RHCs) in the United States. They exist because Congress recognized, nearly fifty years ago, that market economics alone would never sustain primary care in the communities that need it most. Today those clinics sit at the intersection of two hard realities: the patients they serve carry the heaviest chronic disease burden in the country, and the organizations caring for them operate on the thinnest margins in American healthcare.

Remote Physiologic Monitoring (RPM) is one of the few tools that works with, rather than against, both of those realities. It brings daily clinical data to patients who live far from care, and it does so through a delivery model rural clinics can actually afford to operate.

The Calendar Year 2027 Physician Fee Schedule Proposed Rule (CMS-1848-P), released in July 2026, proposes a set of changes that would make RPM operationally and financially unworkable for Rural Health Clinics. I do not believe that is CMS's intent. The agency has legitimate program integrity concerns, and some of its proposals deserve support. But intent does not change arithmetic. If these provisions are finalized as proposed, remote monitoring in rural America will not shrink. For most RHCs, it will end.

The data makes the case better than rhetoric can. So, let's look at the data.

The state of the rural health system

The 2026 Chartis Rural Health State of the State report found that 41.2 percent of rural hospitals operate at a loss, that 417 are vulnerable to closure, and that 206 have closed or converted away from inpatient care since 2010. 

The service line erosion is just as telling: 331 rural hospitals have eliminated obstetrics since 2011, and 448 stopped offering chemotherapy between 2014 and 2024. More than 80 percent of rural census tracts are designated shortage areas for primary care, and 89 percent lack behavioral health professionals.

The national numbers land state by state. Texas operates 387 Rural Health Clinics, the most in the nation, and a July 2026 analysis by the Center for Healthcare Quality and Payment Reform found 84 Texas rural hospitals, 55 percent of the state's total, at risk of closing. Iowa, where 38 percent of residents live in rural communities, depends on 213 RHCs; Michigan on 212; Wisconsin on 146; California on 279, with 27 percent of its rural hospitals at risk. The same analysis puts 42 percent of Maine's rural hospitals, 43 percent of New York's, and 35 percent of Pennsylvania's at risk of closing, and Pennsylvania has also lost 42 percent of its rural obstetrics units since 2011, among the steepest declines in the country. Ohio (79 RHCs), Virginia (89), Colorado (62), and Arizona (52) show the same pairing of a substantial clinic footprint with a strained rural hospital system. And in frontier states like Alaska, where nearly a third of residents live in rural areas and care runs through a lattice of Critical Access Hospitals and community clinics, the distances involved make remote monitoring less a convenience than a necessity.

Rural Health Clinics are the ambulatory layer of that same fragile system. Their Medicare patients average 71 years of age and see their clinic a median of three times per year. In a 2019 University of Minnesota Rural Health Research Center survey, 64 percent of RHC staff reported difficulty finding specialists to whom they could refer patients. When an RHC loses a service, there is rarely another access point down the road. Often there is no access point for an hour in any direction.

The most vulnerable patients in Medicare

The patients these clinics serve are not simply rural versions of suburban patients. They are measurably sicker, poorer, and farther from help.

• CDC data shows that 34.8 percent of rural adults live with multiple chronic conditions, compared with 26.1 percent of urban adults, a gap of nearly nine percentage points. 
• By 2019, the overall mortality rate in rural areas was 20 percent higher than in urban areas. 
• CDC's analysis of the five leading causes of death found that the most rural counties experience 44.9 percent potentially excess deaths from heart disease and 57.1 percent from chronic lower respiratory disease, deaths that would largely not occur at urban rates of prevention and treatment.

The socioeconomic picture compounds the clinical one. Rural areas have persistently higher poverty rates than urban areas, and 17.9 percent of rural adults were uninsured as of 2020, the highest of any geography. These are patients with high rates of hypertension, diabetes, and heart failure, limited transportation, and long distances between themselves and the clinicians managing their conditions.

That combination, high chronic disease prevalence and low access to in-person care, is precisely the problem remote monitoring was designed to solve.

The evidence is that RPM works for these rural patients

The clinical record here is substantive, and much of it comes from exactly the populations RHCs serve.

• In a nine-site health system serving underinsured patients, hypertension control improved from a 46 percent baseline to 55.3 percent with remote monitoring in place, surpassing the organization's year-end goal six months early("Remote Patient Monitoring Works: Clinical Evidence from Three Health Systems," July 2026). The same report documents
• In a large integrated system, 6,463 monitored diabetes patients saw average HbA1c fall from 9.3 to 8.4 in roughly two months; and
• a regional cardiology service where 66 percent of monitored heart failure patients improved their ejection fraction. 
• In a separate cohort cited by the HHS Office of Inspector General itself, the share of monitored patients with uncontrolled hypertension fell from 66.3 percent to 40.2 percent after 90 or more days of monitoring.

The clinical activity data tells the same story. A 2023 study in the Annals of Internal Medicine examined nearly 20,000 Medicare patients with hypertension in high-RPM practices and found significant relative increases in blood pressure medication fills, days' supply, and unique medications received, along with more primary care visits. Monitoring does not replace the patient's relationship with their provider. It feeds it.

The evidence is that RPM expands access and saves money 

The cost data closes the loop. 

• A 12-month analysis at a 24-cardiologist practice found that monitored cardiac patients were readmitted within 30 days at half the rate of unmonitored patients, 7 percent versus 15 percent, against an average cardiac readmission cost of roughly $15,000. For a rural population with 44.9 percent potentially excess heart disease mortality, avoided admissions are not an abstraction. They are the difference between managing a condition at home and a costly 60-mile ambulance ride.
• As Senators Blackburn and Warner put it introducing bipartisan legislation last year, “Rural Medicare patients face high rates of chronic conditions like heart failure, hypertension, and diabetes. In particular, Medicare patients living in rural areas have limited access to healthcare because of roadblocks like lack of transportation. Remote Physiologic Monitoring (RPM) helps patients manage chronic conditions and eliminates unnecessary hospital visits. A recent study of over 4,000 hypertension patients found that RPM decreased patients’ total monthly cost of care by more than 50%.”

One more data point deserves attention. OIG's own 2025 analysis shows that Black and Hispanic beneficiaries and dual-eligible patients receive RPM at roughly twice the rate of white beneficiaries. RPM is one of the rare Medicare benefits reaching underserved populations first. Rural, low-income, chronically ill patients are not at the margins of this program. They are its center.

What the Proposed Rule would do

Against that backdrop, the Proposed Rule advances four changes. First, it would require that RPM services be furnished only by clinical staff directly employed by the billing practice, ending the third-party support model that CMS's own regulation expressly permits today (42 C.F.R. § 410.26 defines auxiliary personnel "regardless of whether the individual is an employee, leased employee, or independent contractor," a position CMS reaffirmed in the CY 2021 Final Rule). Second, it would require a separately billed initiating visit before monitoring can begin. Third, it would revalue the RPM codes by crosswalking their inputs to self-measured blood pressure codes, codes that involve no cellular device, no connectivity, no logistics, and no monitoring platform. The valuation analysis at SaveRemotePatientMonitoring.com projects the device supply payment (CPT 99454) falling from roughly $47 to roughly $26 per month. Fourth, CMS is soliciting comment on consolidating the component codes into all-or-nothing bundled G-codes.

Any one of these would strain a rural program. Together, and for RHCs specifically, they are terminal. Here is why.

RHCs cannot in-source monitoring. A median practice runs about 2.19 clinical FTEs per provider, and rural clinics sit below that benchmark in the most severe workforce shortage areas in the country. A two-provider RHC in a county where 89 percent of census tracts lack behavioral health clinicians is not going to hire, train, and retain dedicated staff for 24/7 physiologic monitoring. For rural clinics, the third-party organization is not one delivery channel among several. It is the delivery system. An employment mandate does not bring monitoring in-house at an RHC. It discontinues the program.

The initiating visit penalizes distance. RHC Medicare patients already average only three visits per year, and rural patients routinely travel long distances for each one. Requiring a separately billed face-to-face visit as the gate to monitoring asks the patients with the least access to purchase additional access before they can receive a benefit designed to reduce their travel. It also generates new Medicare spending, with new patient cost sharing, in the name of fiscal discipline.

The economics stop working entirely. RHCs only gained the ability to bill RPM codes individually in 2025, when CMS unbundled the old G0511 care management code, and clinics invested in workflows on the strength of that policy. Cutting the device supply payment roughly in half, while stripping practice expense from the treatment management codes, drops reimbursement below the fully loaded cost of a compliant program: FDA-cleared cellular devices, shipping and logistics, data platforms, and licensed clinical staff. For a clinic where 41.2 percent of the surrounding rural infrastructure already operates at a loss, payment below cost is not a discount to absorb. It is a signal to exit.

There is an irony in the timing. In the CY 2026 Final Rule, CMS created new codes (99445 and 99470) precisely to pay for legitimate monitoring that fell below the old 16-day and 20-minute thresholds, acknowledging that real patients, especially older and sicker ones, do not transmit data with perfect adherence. The 2027 bundling concept would repeal that fix barely a year after it took effect, and it would make the sickest, least adherent patients the least economical to monitor.

Integrity and access are not opposing goals

CMS grounds these proposals in two OIG reports. Those reports raise fair questions, and targeted transparency measures, such as carrying an identifier on every claim for the organization supporting the monitoring, are inexpensive and worth supporting. Yet, the requirements in the proposed rule would not stop fraud; they would strain a rural program. 

• Requirements that push enrollment onto the clinician take them away from practicing medicine without adding a dollar to integrity. Compliant enrollment means verifying primary and secondary coverage and disclosing a patient's actual co-pay and deductible obligations before consent. That is benefits administration; and an unnecessary distraction from practicing medicine without any cost savings. 
• Requirements end care, rather than prevent fraud. A rural clinic with two physicians and no capacity to hire, train, and manage a monitoring team can still offer monitoring today because a partner provides that clinical staff under the practice's direction. Take that away, and those patients simply lose access. No fraud is prevented. Care is removed.  
• Requirements for an initial in-person intake restrict access. It puts a barrier in front of the patients who need monitoring most: the homebound, the rural, the mobility limited, and the frail. These are exactly the people for whom getting to an office is hardest, and exactly the people remote monitoring was built to reach. A physician's order and documented patient consent already establishes that the service is medically necessary. Forcing an extra in person visit on top of that delays care for some patients and denies it to others. That is not a safeguard. It is an access barrier.
• Neither reviewed medical records, estimated improper payments, or confirmed fraud. The OIG's 2025 data snapshot states explicitly that its measures "do not confirm that a particular medical practice is engaging in fraudulent or abusive practices". Of the 4,639 practices OIG examined most closely, each outlier measure flagged roughly one percent or less. 
• The problem visible in the data is underuse, not overuse. RPM in total represents about $536 million in a program that spends over a trillion dollars annually, five hundredths of one percent, while CMS estimates roughly $31 billion in annual fee-for-service improper payments overall. And more than 60 percent of Medicare beneficiaries carrying a hypertension diagnosis and fewer than 1.5 percent receiving any RPM in 2024.

RPM’s Scale Doesn’t Justify These Restrictions, and Other Federal Programs Are Investing in It, Not Limiting It

Total 2024 RPM payments were $536 million against roughly $1.1 trillion in total Medicare spending — about five one-hundredths of one percent — compared with CMS’s own $31 billion FY2022 fee-for-service improper-payment estimate. More than 60 percent of Medicare beneficiaries have a hypertension diagnosis; fewer than 1.5 percent received any RPM in 2024. The problem visible in the data is underuse, not overuse.

That makes it notable that six states — Arkansas, California, Kansas, Michigan, New Jersey, and North Dakota — have already dedicated Rural Health Transformation Program funds (created by Section 71401 of the One Big Beautiful Bill Act) specifically to expand remote patient monitoring. The federal government is investing new money in RPM as rural health infrastructure in one program while this rule would restrict it in another.

A Better Instrument 

None of this is an argument against oversight. The OIG identified real gaps worth fixing, and the industry should welcome fixes that target bad actors rather than the service itself.  

There is a better instrument available. The Save RPM Coalition has proposed that CMS require the organizations supporting remote monitoring to register, meet enforceable accreditation and supervision standards, carry a unique identifier on every claim, and submit to outlier-focused audits with real termination authority. That framework gives CMS more integrity tools than the Proposed Rule does, at a fraction of the cost to access. CMS has built exactly this kind of structure before, for Opioid Treatment Programs and Medicare Diabetes Prevention Program suppliers. It can build it again.

The comment window closes September 14

Roughly one million Medicare beneficiaries rely on remote monitoring today, and the patients who depend on it most are the ones an RHC sees every day: older, chronically ill, low-income, and far from care. If the 2027 Proposed Rule is finalized as written, those patients will not be protected from fraud. They will simply be unmonitored.

Two actions matter now, and both take minutes.

First, join the coalition. The Save RPM Coalition brings together the organizations, clinicians, and practices working to protect compliant remote monitoring for the patients who depend on it. Sign up at SaveRemotePatientMonitoring.com, where you will also find the coalition's policy analysis and comment resources.

Second, file a public comment on the Proposed Rule before September 14, 2026, at 5:00 p.m. ET. Here is exactly how:

1. Go to the Proposed Rule's page on Regulations.gov: regulations.gov/document/CMS-2026-2377-0002 (docket CMS-2026-2377).
2. Click the "Comment" button at the top of the page.
3. Write your comment in the text box, or attach a letter, and reference file code CMS-1848-P.
4. Speak from your own experience. The most persuasive comments are concrete: your staffing reality, your device and connectivity costs, the distances your patients travel, and what monitoring has changed for them.
5. Enter your contact information, click "Submit Comment," and save the confirmation receipt and tracking number Regulations.gov provides.

Individual comments from practices count, and CMS is required to read them. If you lead or practice in a Rural Health Clinic, your comment carries particular weight, because you can describe what these proposals mean in staffing terms, in miles, and in patients.

Sources

1. Rural Health Information Hub, Rural Health Clinics (RHCs) Overview (5,650 RHCs as of March 2026; RHC Medicare patient age, visit, and travel data): https://www.ruralhealthinfo.org/topics/rural-health-clinics
2. Chartis, 2026 Rural Health State of the State (rural hospital margins, closures, vulnerability, service line losses, shortage areas): https://www.chartis.com/insights/2026-rural-health-state-state
3. CDC, Preventing Chronic Disease, "Prevalence of Multiple Chronic Conditions Among US Adults, 2018" (rural 34.8% vs. urban 26.1%): https://www.cdc.gov/pcd/issues/2020/20_0130.htm
4. Rural Health Information Hub, Rural Health Disparities Overview (20% higher rural mortality; potentially excess deaths; poverty and uninsured rates; specialist referral difficulty): https://www.ruralhealthinfo.org/topics/rural-health-disparities
5. "Remote Patient Monitoring Works: Clinical Evidence from Three Health Systems," Save RPM Coalition, July 2026 (hypertension control 46% to 55.3%; HbA1c 9.3 to 8.4; heart failure ejection fraction findings): https://saveremotepatientmonitoring.com
6. Tang M, et al., "Effects of Remote Patient Monitoring Use on Care Outcomes Among Medicare Patients With Hypertension," Annals of Internal Medicine, November 2023: https://www.acpjournals.org/doi/10.7326/M23-1182
7. Cardiac Solutions / MD Revolution 12-month cardiac RPM analysis (30-day readmissions 7% vs. 15%), reported in Medical Economics: https://www.medicaleconomics.com/view/rpm-cuts-hospital-readmissions-by-50-for-heart-patients-study-finds
8. CMS, CY 2027 Medicare Physician Fee Schedule Proposed Rule fact sheet (CMS-1848-P): https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2027-medicare-physician-fee-schedule-proposed-rule
9. DLA Piper, "Medicare proposes significant restrictions on and lower device reimbursement for remote monitoring services," July 2026: https://www.dlapiper.com/en-us/insights/publications/2026/07/medicare-proposes-significant-restrictions-on-and-lower-device-reimbursement-for-rpm-and-rtm
10. HHS OIG, "Additional Oversight of Remote Patient Monitoring in Medicare Is Needed" (OEI-02-23-00260): https://oig.hhs.gov/documents/evaluation/10001/OEI-02-23-00260.pdf
11. HHS OIG, "Billing for Remote Patient Monitoring in Medicare," Data Snapshot, August 2025 (OEI-02-23-00261): https://oig.hhs.gov/reports/all/2025/billing-for-remote-patient-monitoring/
12. 42 C.F.R. § 410.26 (auxiliary personnel): https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B/section-410.26
13. Prevounce, "What's Happening With Care Management Code G0511" (RHC/FQHC transition from G0511 to individual CPT codes, deadline September 30, 2025): https://blog.prevounce.com/whats-happening-with-care-management-code-g0511
14. Rimidi, "CMS Finalizes RPM Code Expansion in 2026" (new CPT codes 99445 and 99470): https://rimidi.com/news/2026-rpm-code-expansion
15. Rural Health Information Hub state guides (state RHC counts and rural population shares, HRSA Data Warehouse, January 2026): https://www.ruralhealthinfo.org/states
16. Center for Healthcare Quality and Payment Reform, "Rural Hospitals at Risk of Closing," July 2026 state analysis, as reported by Becker's Hospital Review: https://www.beckershospitalreview.com/finance/700-rural-hospitals-at-risk-of-closing-by-state/
17. Save RPM Coalition policy analysis and valuation crosswalk (99454 projected reduction; staffing benchmarks; proportionality figures): https://saveremotepatientmonitoring.com
18. Federal Register, CY 2027 PFS Proposed Rule (comment docket CMS-2026-2377; file code CMS-1848-P; comments due September 14, 2026): https://www.federalregister.gov/documents/2026/07/16/2026-14327/medicare-and-medicaid-programs-cy-2027-payment-policies-under-the-physician-fee-schedule-and-other