Why Remote Patient Monitoring (RPM) is a Wolf in Sheep’s Clothing

A candid conversation about RPM

By Jon-Michial Carter, CEO-ChartSpan

The steady stream of effusive praise for Medicare’s new Remote Patient Monitoring (RPM) program seems endless.

“Remote Patient Monitoring Industry Will Drive Huge ROI” 

– EIN PressWire

“Remote Patient Monitoring Market Likely to Touch New Heights” 

– Express Journal 

“Docs Praise Remote Patient Monitoring System.” 

– Modern Healthcare

Beware. These headlines are baloney.  

Background

Medicare’s Remote Patient Monitoring (RPM) program uses digital devices and technology, in a patient’s own home, to collect medical data from patients. These devices can capture metrics such as blood sugar and heart rate. The data is then electronically transmitted to healthcare providers for assessment and intervention. 

The premise of the program is that RPM technology allows providers to have a more frequent and comprehensive view of the vital signs associated with a patient’s chronic conditions- like COPD, hypertension, congestive heart failure, and diabetes. Imagine being able to see a diabetic patient’s blood glucose levels slowly begin to climb. But before the levels get out of control (and the patient incurs a high-cost acuity medical event) the provider intervenes and proactively helps the patient get their levels back under control. In theory, it’s a smart and efficient way to deliver healthcare. 

Device manufacturers LOVE Medicare’s RPM program because it’s a way to sell their wares. CMS has been purposely vague about what constitutes an eligible RPM device, but currently, everything from scales, wearable blood pressure cuffs, pulse oximeters, glucose readers, and pill counters are being used to collect patient health data.  

Third party clinical service providers LOVE the program because Medicare allows third parties to deliver the monitoring and assessment services associated with the service, under “General Supervision, Incident To,” on behalf of a provider.   

RPM patient devices notify service providers when the health data shows a problem, the clinical service provider intervenes on behalf of the provider, the patient ideally changes behaviors, the provider is notified of the intervention…and the perfect cycle of preventative and real-time health maintenance occurs.  Almost. 

The Problem

Because ChartSpan is the largest provider of Medicare Chronic Care Management (CCM) programs in the United States, RPM device vendors come knocking on our door frequently.  They come knocking because they know the hard part of delivering an RPM service isn’t the device used for RPM or the clinical service provided. The overwhelming barrier to successfully operating an RPM program is patient enrollment – not only enrolling patients but keeping them enrolled. 

Medicare requires that any patient who enrolls in an RPM program (consistent with the rules for CCM) must “consent” to be in the program.  This is because 80%+ of all Medicare patients enrolled in an RPM program have a monthly financial obligation in the form of a copay.  Additionally, patient deductibles apply. Medicare patients typically pay 20% of the total Medicare reimbursement paid to the provider, in the form of a copay.  In the case of RPM, that equates to a $20 to $30 monthly patient financial obligation. For 90%+ of Medicare patients that is a showstopper. How do I know? Because our company spends significant time, resources and costs enrolling patients into Medicare programs and we understand the friction points.  We have worked hard to perfect the patient enrollment process and we are experts at it.  

Patients who consent to enroll in Medicare’s CCM program agree to pay, on average, an $8 per month copay. Sometimes the monthly CCM patient copay can fluctuate.  For instance, there are many Medicare Advantage payers who force patients to pay $20 to $30 in monthly copays if they consent to be in a CCM program. ChartSpan sets the bar high, consistently averaging a 52% enrollment rate for all eligible patients. While that number may seem unimpressive, we don’t have a single competitor who comes close to that number, because enrolling patients in a preventative care program with patient financial responsibilities is hard. Excruciatingly hard.  

When copays escalate to $20+ per month, the data proves patient enrollment plummets.  Less than 10% of eligible patients will enroll in a program with a high copay. Telling an eligible RPM patient, who is likely a senior on a fixed income, that they have a new $300 per year financial burden to manage will go over like a lead balloon. 

Keeping Patients Enrolled is Even Harder

Pay attention to Net Patient Churn.  It’s likely another critical challenge in running an RPM program. 

I recently wrote an in-depth piece about Net Patient Churn. It’s a complicated subject, but the thesis is that Medicare patients churn in and out of Medicare eligibility every day in your practice.  Your expertise in managing patient churn and the associated gains and losses in RPM enrollment will be an absolute requirement to success.  If you don’t master Net Patient Churn, your RPM program will fizzle within months.  And trust me, with $30 monthly patient copays, you will have massive patient churn-out to keep up with. Patients may like the idea of an RPM program when first introduced, but by the second or third time they get a monthly EOB statement, it’s likely they will unenroll from your program.  

And It Just Got Harder

RPM is a preventative program designed to monitor the physiologic data of patients with chronic diseases, identify problems, and prevent exacerbation of their conditions. If a problem exists, then an intervention is required. CMS shocked us in August when they released the Proposed Physician Fee Schedule where they indicated their intent to require that beginning in 2021, patients enrolled in an RPM program must engage with clinicians delivering the service monthly in order for the provider to charge for the service. In this new rule, CMS is basically asserting that a provider will complete all the labor associated with the monitoring of patient health data, assess that data, and attempt to contact the patient. But if the patient doesn’t respond and engage, then the provider has to eat all the labor costs associated with their work effort.  

I asked ChartSpan’s talented General Counsel, Jon Hammond, for legal commentary on the proposed RPM change.  While he doesn’t provide legal advice or opinions outside of our business, he offered a few thoughts on the challenges RPM providers may face under the Proposed Physician Fee Schedule:

“Here are some of the RPM proposed rule changes for RPM that will make it especially challenging to perform in 2021:

While CPT Codes 99457 and 99458 can be furnished by clinical staff under the general supervision of the physician or non-physician practitioner, those codes still require at least 20 minutes of interactive communication with the patient/care-giver/medical decision-maker each month.

“Interactive communication” for purposes of CPT codes 99457 and 99458 involves, at a minimum, a real-time, synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission. SMS messaging or email alone are not sufficient.

The 20+ minutes can be accumulated over the course of the month, but it does have to be 20+ minutes of actual communication. Coordinating supportive resources and gathering information from consulting providers on behalf of the patient does not count toward the 20+ minute total.

For RPM, “time” is considered to be the “face-to-face” time with the patient or patient’s caregiver/medical decision-maker.”

CMS’ vision for RPM was already a challenging business model.  This new rule, if finalized, raises the bar beyond what is likely sustainable. ChartSpan’s leadership team has spent hours building financial models and assessing the viability of running RPM programs for customers. We cannot find a profitable path that balances earned revenue against the operational costs associated with a successful RPM program.  

Don’t get me wrong. I deeply believe in the value of RPM and the importance of early intervention to improve patient outcomes. But until we see the day when CMS reverses their stand on charging patients copays for preventive programs I suggest that you should think twice about sinking your resources and capital into a program fraught with challenges. I can attest to the fact that despite years of personal effort to inform our policy leaders, CMS does not understand nor appreciate the operational complexities associated with running a CCM program, never mind a Remote Patient Monitoring program.

I’m happy to share more details about ChartSpan’s assessment of Medicare’s RPM program.  Feel free to reach out to me, and I’d be happy to jump on a brief call to discuss.  You can reach me at JonMichial.Carter@ChartSpan.com 

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