Shifting Care to Home or Remote

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

When access to in-person healthcare service shutdown almost completely in the early days of the COVID-19 pandemic, the impact of remote patient monitoring, or maybe more accurately remote patient engagement, was thrust to the fore. The positive effects from remote engagement have started to gain momentum as well with more evidence as to the actual health benefits.

Prior and Refining Existence
While remote engagement appeared to gain more traction during the pandemic, it existed prior to the pandemic. Of greatest importance, the Centers for Medicare and Medicaid Services (CMS) included remote patient monitoring (RPM) and chronic care management (CCM) in Medicare fee schedules prior to the pandemic. Some relatively severe restrictions were included in the process for being able to bill for RPM and CCM such as initiating with an in-person visit first, setting a minimum number of days of data recording, and requiring a certain amount of interaction between patients and members of the care team.

At the same time, RPM or CCM requires use of a distinct set of devices for recording data from individuals in their daily lives. The devices need to be some form of accepted medical device, though not necessarily requiring a prescription or other form of restricted access. It is possible to use over the counter products that appropriately record and transmit the data.

CMS has continued to refine the requirements for RPM and CCM, though not as much as might be preferred. There are still restrictions on how data may be collected (must transmit automatically, no manual recording) and the number of recordings per month is arguably too high for what is practical. For purposes of payment, understanding and meeting the exact requirements imposed by CMS is necessary, even if not reflective of what could be viewed as the best means of working with patients.

Recognizing that remote services are beneficial is not sufficient to achieve implementation though. Getting the process up and running requires investment and commitment by the care team and each patient. Setup is needed from a process and procedure point of view in the practice or facility to, among other things, get data flowing, check in with individuals on a timely basis, and understanding how to respond to the data. It is clear that each step adds some process to regular operations and necessitates modification to workflows.

On the patient side of things, the individual likely needs to use new devices and remember to connect those devices to an application or other means of automatically gathering, then transmitting the information. Concerns about where data could go may create reluctance to engage with a remote service along with potential barriers of time and commitment to set all of the equipment up.

The concerns from both sides can drag out the process of implementing remote monitoring, whether RPM, CCM or something, but that is where a well designed system can come in to be a facilitator. The first question there is whether the system just takes over implementation and operation of the services or if a solution can be layered in that enhances the existing connection between the care team and patients. It is not an easy question to answer, though not interrupting an existing relationship would seem more beneficial. Why disrupt the hopefully already close relationship and bring in an unknown team to provide care when the time and resources available to the current care team could be made more efficient? The answer will vary from location to location, but it should be considered seriously.

Leaving aside the initial implementation steps, modifications to ongoing workflows should be considered upfront too. Given the necessity of collecting data on a regular basis and tracking time carefully, those steps as well as others should be considered upfront and not on the fly. If done on the fly, missing a step or doing something not exactly right is a real possibility.

While some could easily believe that a simple (honest?) mistake is harmless, that situation will not remain very long. The Office of the Inspector General of the Department of Health and Human Services (OIG) announced that it will begin fraud reviews of RPM and other telehealth based services. While the OIG is not assuming that fraud is occurring, its review will look for compliance with all of the requirements, no matter how small or trivial they may seem. If the OIG finds any component missing or not done correctly, it will call for recoupment. Given that reality, careful attention to detail and documentation are both essential during implementation and ongoing operation.

The Benefit
Leaving aside the potential revenue influx from remote services, the true benefit can likely best be seen from the perspective of the patients. After a remote engagement program is put into place, patients can report feeling not so isolated, empowered by the changes to their lives, and overall improvement in their health. That is where the true power of remote engagement can be found. Instead of just being told about the health benefits of making lifestyle changes or receiving something that could feel like a lecture from the care team, the remote engagement establishes a more collaborative process where individuals can be drawn more actively into decisions.

The ability to be more collaborative is one of the bigger benefits of remote engagement. When an actual dialogue can occur between an individual and the care team unexpected issues could arise along with the chance to allay concerns around participation in new means of care interaction. Once the discussion starts and the conversation builds, it cannot always be predicted where things will go. However, the direction can often be one where willingness to participate arises.

Feeling engaged and understood in the delivery of care is an important development. Instead of proscribing actions, when collaboration and active listening occur the positive impacts can occur with more speed. Further, the chance for an individual to take things more to heart can increase the likelihood of the changes becoming permanent.

Forging Ahead
The path ahead requires an openness to new means of collaboration and delivery of care. Additionally, the shift of care outside the walls of traditional healthcare facilities has clearly started and should be expected to continue expanding. If that is the situation, then start exploring and experimenting now. A willingness to new discussions and dialogues will lead to hopefully positive surprises.

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