Evolution of Patient Engagement

By Matt Fisher, General Counsel, Carium
Twitter: @matt_r_fisher
Twitter: @cariumcares
Host of Healthcare de Jure#HCdeJure

Remote patient (or physiologic per Medicare) monitoring (RPM) is an area of telehealth receiving a fair amount of attention. The basic premise of RPM is to record and obtain physiologic data about in an individual in their daily life that is then fed to the care team, which in turn enables management of an identified condition. The premise builds upon goals of improving health while also beginning to meet patients where they are.

Adoption of RPM has not necessarily been as quick as expected, though data are starting to be generated as to the benefits that can be derived. Anecdotally, patients and clinicians are happy with the interactions and results that can be obtained.

Before diving into the past, present, and future it is also helpful to consider whether calling the interaction remote patient monitoring is even accurate. The service is arguably a lot more comprehensive than just monitoring. While patients are certainly recording data and having that data transmitted for review, there are also direct interactions whether by audio/visual visit or in-person along with recommendations for lifestyle changes. In many solutions, patients are also able to access and interact with the data collected, enabling the opportunity to self-identify trends or share with additional care teams. When the panoply of options begins to be built out, RPM is really full scale patient engagement and collaboration.

Current RPM Standing

As of mid-2021, RPM is largely driven by standards established through Medicare. The standards focus on the requirements for types of devices that can be utilized, how data must be recorded, the scope of interactions, and the types of conditions that qualify. Many summaries of RPM requirements can be found, but a brief recap can be as follows:

  • RPM is acceptable for chronic of acute conditions;
  • Devices used must meet FDA definition of a medical device, not necessarily be an approved device;
  • Data must be digitally recorded and automatically transmitted by the device (no manual entry permitted);
  • A minimum number of days worth of data must be collected each month; and
  • Patient consent necessary.

As should be expected, there is more nuance involved and the specific details are very important. However, RPM should be a relatively easy addition to the scope of services offered by a particular healthcare practice.

COVID Experiences

As with many forms of telehealth, RPM saw expanded use during the COVID pandemic. Since patients were encouraged (if not prohibited) from coming to see a clinician, different means were needed to keep an eye on what was happening. In particular, waivers instituted by the Centers for Medicare and Medicaid Services (CMS) opened up RPM for actual or suspected cases of COVID, which allowed patients to be tracked from the comfort of their own home. Not only could patients remain at home, but the number of days of data from which data were needed. The reduction in data days arguably aligned with the needs for COVID monitoring, but was a favorable change that some interpreted to apply to any RPM use case until CMS clarified that point.

On top of the modification of RPM requirements, the scope of payors covering RPM also expanded. Specifically, Medicaid and commercial payors often included RPM in the package of telehealth services covered, which was not necessarily the case pre-COVID. The more patients and clinicians that experienced the benefits of RPM meant that RPM had the opportunity to become entrenched in the menu of care options available.

Next Steps for Patient Monitoring

CMS is proposing to expand patient monitoring in the FY2022 Medicare Physician Fee Schedule with the addition of brand new (created in late 2020) codes for remote therapeutic monitoring (RTM). As described by CMS, the codes and requirements for RTM largely mirror RPM, with a few very important distinctions.

The first distinction is that RTM as the name states covers therapeutic interventions. Turning to therapeutic monitoring means that RTM expands to include non-physiologic data. Breaking it down further, data can include medication adherence, mental status, or more information that can be self-reported, not just digitally uploaded. The scope of data, therefore, are much broader and touch on different areas of a patient’s life as well as different conditions. From that perspective, RTM is an expansion of monitoring or engagement to any condition impacting a patient, not just ones that can be measured through a particular device.

The opportunity to expand monitoring to a broader array of health conditions could result in ongoing engagement that promotes better health and wellbeing. That outcome could be achieved by engaging patients in their care journey as equal collaborators and facilitating more efficient interactions or interventions.

The second difference with RTM is the potentially broader group of clinicians that can initiate and oversee the service. CMS specifically identifies that it expects RTM to primarily be utilized by nurses and physical therapists. If more clinicians can start a proactive interaction with a patient, then it stands to reason that more issues can be prevented or caught earlier on as opposed to developing into a crisis moment (it is fully recognized that evidence will be needed to prove out the validity of that statement).

Launch Pad

If RPM and RTM or engagement writ large redirect focus to managing or preventing issues before a major problem occurs, then it should rightly be viewed as another means of driving healthcare into value based care. If the big blow-ups can be minimized, then it becomes easier to take on risk because the care teams have a better, more in-depth understanding of the patient population. Further, if a risk-based or capitated model is adopted, then RPM and/or RTM could theoretically be put into place with any patient because there is no need to worry whether the service is reimbursable. Instead, keeping patients healthier helps with the risk and enables the practice involved with the arrangement to manage spend in a more positive manner.

Thinking about the routes to better health and wellbeing is why remote monitoring or remote engagement is gaining traction as one of the forms of telehealth expected to stick regardless of what happens with pandemic related relaxations or changes. Getting to that point requires many parties to work together, which must include patients, care teams, and developers of the technology solutions. Working in isolation does not work. Hand in hand is what will create a better future for all.

This article was originally published on The Pulse blog and is republished here with permission.