Reimbursement Getting in the Way of Value

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

Remote patient monitoring (the very impersonal nature of that phrase will not be discussed right now) has risen to the forefront in many discussions about how virtual care positively impacts the delivery of healthcare. RPM, as it is more commonly referred to, involves giving patients at least one device to help track a certain condition with data being automatically transmitted back to the care team. With the data, the care team and look for trends that call for intervention as well as generally be able to get a more complete picture that would not otherwise be collected about the patient. Evidence is mounting about RPM’s ability to promote better overall health and wellbeing.

Despite the growing support about the positive impacts, coverage of RPM is spotty. The Centers for Medicare and Medicaid Services includes specific RPM reimbursement codes in the Physician Fee Schedule for Medicare. However, on the Medicaid front, states are all over the place. Some do not cover RPM at all, others only cover in very specific instances or for limited purposes, while a handful provide the same scope of coverage as Medicare.

What is RPM

Before getting more into the specifics around reimbursement, giving some additional detail around what RPM is will be helpful. As briefly described already, RPM is meant to provide ongoing monitoring of a patient around a specific condition. Using hypertension as an example (which incidentally seems to be one of the more common use cases), the flow can be described. A patient with hypertension may be approached about participating in RPM. The care team will let the patient know that they will be provided with a blood pressure cuff to take their own blood pressure readings at home. The cuff may be Bluetooth or cellular-enabled to let the readings be automatically transmitted to an app or other central database. Typically, RPM programs require a patient to take at least 16 days of readings in a given calendar month. As the data are collected, the care team will analyze and also engage in interactive communications with the patient throughout the month. For billing purposes, the care team will need at least one 20 minute block of time, which does not have to happen all at once, to bill for the services.

As part of the data collection, care teams may flag when a patient misses a reading for more than a c couple of days in a row. The data may also show some other trend or concerning pattern that calls for a virtual visit or other intervention. The goal will be to keep the patient on track with the care goals for RPM.

From that grounding, RPM has been marketed as a way for physician practices or other organizations to easily increase monthly revenue. For what is described as a relatively light touch, organizations can enroll patients in RPM and add revenue. The marketing of those benefits does not delve much into the specifics of RPM or the time investment required by organizations to effectively deliver RPM.

The Billing Concerns

The suggestion that RPM can quickly boost revenue is part of the billing concern. Picking on state Medicaid programs because of the recent report, there is a concern that organizations will just seek to enroll all patients in RPM to boost revenues, which in turn increases the cost of running the various Medicaid programs. The argument goes that organizations will throw patients in RPM, push hitting the bare minimum requirements for billing, and just keep churning through that cycle.

The generalized fear is driven by marketing approaches that can be seen in the market around RPM. Many companies will throw out figures in the millions of dollars of additional revenue that an organization can make. The eye-popping figures are usually obtained by supposing a few thousand Medicare patients in an organization, assuming that all of the patients are RPM-eligible and will be enrolled, and then billing all of the available RPM codes on a monthly basis. Those unsupported assumptions then allow the calculation of large dollar sums as the (keyword) potential revenue.

The assumptions are just that though, assumptions. Experience has not borne out the reality of being able to enroll every patient in RPM or even that every patient should be enrolled in RPM. Additionally, no organization would have sufficient staff time to actually handle that influx of information and be able to meaningfully act on it. If the assumptions are not based in reality, then the massive rise in expense from RPM also will not occur.

Another challenge with RPM in the fee for service world is the often adopted requirement for 16 days of readings to trigger the ability to bill some of the codes. Not every condition that calls for tracking needs that much data. Many times, clinicians will say a couple of readings per week would be more than sufficient to get a good picture of what is happening and enable better proactive care.

Pivoting to Value Based Care

If RPM can help drive more proactive care that improves health and well-being, maybe the problem isn’t RPM, but the reimbursement model. The argument against RPM seems to be that more organizations will want to do it, in turn causing more reimbursement claims to be submitted, and ending with more dollars being paid to care delivery organizations. How can that cycle be addressed, but also recognize the improved quality of care?

The answer seems a bit obvious: value based care models. When value based care models are implemented, the focus shifts to what is the best care that can be provided at the appropriate time to foster better health for patients. The strong incentive is built into value based care models to become proactive and work to resolve issues before requiring more intensive intervention. The model seems tailor-made for RPM.

Along with supporting the delivery of proactive care, value based care models also don’t focus on trying to drive a lot of fee for service base billings. Instead, value based care models should encourage organizations to focus on and have funds available to fuel interventions that increase patient and care team interactions while maintaining health. That description is almost identical to the aim of RPM. Taking it a step further, if an organization is in a value based care model, it will also not be focused on trying to meet all of the requirements to bill all of the RPM codes. Instead, the organization will likely have greater freedom to structure the RPM intervention in a way that will optimize patient involvement and meet the actual care aims, not an artificial target imposed by billing regulations.

Further, value based care deals with a pre-established pot of money and costs don’t rise with the delivery of more services. As such, even if every patient is somehow enrolled in an RPM service, no big unaccounted-for bill is placed onto the payor, whether government or commercial. Instead, all of the care provided counts against the capitated payment given under the value based care model. Even if there is a cost associated with the RPM service, it runs against the capitated payment and does not result incremental cost. That is good for the payor. For the care delivery organization, if the RPM intervention keeps a patient healthy or prevents a costly event such as an emergency department visit, then more of the capitated payment is retained and the organization does better financially.

Hope for the Future

The alignment of RPM and really many virtual care-based interventions with value based care offers a lot of hope for the future. Promoting a shift in focus away from maximizing revenue by churning through services has beneficial impacts all around. It allows care delivery to focus on what is best for patients, patients can access services that promote their overall health and well-being, and reimbursement does not suffer from unknown numbers of patients being thrown into RPM solely for purposes. With the healthcare system increasingly focus on high quality care, the opportunities presented by the strategic implementation of RPM make a lot of sense. Will the system adapt and allow those benefits to be realized?

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