Remote patient monitoring has gained ground but there are plenty of challenges, including finding a balance between reimbursement and payer provision of services, according to panelists who took part in a discussion during the first day of Patient-Centered Oncology Care® (PCOC).
“How would you define what technologies or services you would include under this rubric of remote patient monitoring?” asked PCOC co-chair Joseph Alvarnas, MD, of City of Hope. “This could include software, telehealth, and other devices, including wearables. We are in a new domain of remote patient monitoring.”
Alvarnas moderated the panel discussion, “Remote Patient Monitoring: Case Studies From the Front Lines,” which explored real-world experiences with remote patient monitoring—an area that has taken on greater heft as the COVID-19 pandemic continues to affect health care delivery. He was joined by several experts:
• RAJINI KATIPAMULA-MALISETTI, MD, vice president, medical oncology, and quality medical director, Minnesota Oncology in Coon Rapids;
• STEVEN W. YATES, MD, medical director, oncology services, Intermountain Healthcare in Las Vegas, Nevada;
• ELIZABETH KWO, MD, MBA, MPH, deputy chief clinical officer, Anthem Blue Cross Blue Shield in Boston, Massachusetts; and
• GREGORY VIDAL, MD, PHD, director, Breast Cancer Research Group, West Cancer Center & Research, and associate professor, University of Tennessee West Cancer Center in Memphis.
It is not easy to shape a universal definition of what remote patient monitoring must include, the panelists agreed. And there was consensus that care and resource utilization management are important goals, particularly weighing its medical necessity to ensure that patients get the right care.
“I consider multiple categories, from the medical devices, that occur,” Kwo stated. Categories under the umbrella of remote patient monitoring include “the small and lightweight wearables and biosensors to in-home resources, such as home care and setting up a medical home.” What’s important, she emphasized, is never losing that doctor–patient connection, whether it be asynchronous (delayed delivery of patient data) or synchronous (in real time) or delivered through an app that connects the patient and their treating clinician via telehealth.
The potential of remote monitoring, too, isn’t confined to benefiting the oncology space, as the diabetes and respiratory fields are already benefi ting from automated insulin delivery and smart inhalers, Kwo added. We can see how our patients are doing, thanks to the “internet of things,” she noted.
Katipamula-Malisetti acknowledged that some clinicians may question the ability to eff ectively monitor patient care on a remote basis or that patients truly reap benefi ts from remote care. “We’ve found huge differences in patient satisfaction,” she said. And these are not just tangible, care-related worries, such as exposure to COVID-19, but also intangibles, such as not being able to make an appointment due to inclement weather.
Cancer care encompasses so much more than just addressing the patient’s disease, Katipamula-Malisetti added, which means that in addition to visits with their treating clinicians, patients may also consult with dieticians, the chemotherapy team, or genetic specialists. However, that doesn’t mean all these appointments will be kept, and to that point, Katipamula-Malisetti emphasized the importance of caregiver support buttressing patient eff orts to continue getting the most out of an altered care path by reducing
Survivorship visits, nutritionist consults, even geneticists have all benefi ted from a “second set of ears,” because as a by-product of patients not having to come in for another visit, she said, there have been gains in both patient satisfaction and engagement, especially when they feel more confi dence in the presence of loved ones to ask questions related to their care. “The no-show rate has improved significantly,” Katipamula-Malisetti emphasized.
Yates highlighted the results he has seen among high-risk patients with comorbidities, “high-fl iers, or those patients with comorbid conditions who are likely to end up in the hospital or emergency department [ED].” His perspective was infused by historical data—from a clinical trial Intermountain initiated in 2000—with results showing that daily remote monitoring helped
to reduce inpatient admissions by 67%, observation hospitalizations by 63%, and ED visits by 35%.
This extra attention, Yates stated, enabled providers to do a better job, even with advanced care planning, which was another area of improved patient engagement, which itself positively affected patients’ unnecessary use of service. “We found that patients were better able to think through their processes, and they also had less utilization of hospital and ED visits,” he said.
Vidal addressed the elephant in the room by noting that although remote patient monitoring has been shown to be of benefit to many, this may be a disproportionate result because not all patients—particularly patients of color—have access to the necessary technology to participate in virtual care, and that puts them at a care disadvantage.
This disparity, Alvarnas echoed, has potential to create “digital haves and have-nots.” This can include patients of color as well as those affected by social determinants of health. The geographic challenges presented by rural locations, for example, can adversely affect broadband internet access and limit the use of monitoring devices, thereby “relegating individuals to a diff erent level of care based upon that lack of access.”
Financial and educational challenges also present roadblocks, because even if a patient can afford the technology needed, the next patient may have a better smartphone with more data, someone else might be more digitally savvy, and yet others still prefer receiving in-person care.
Is it even possible, then, to have a best-case scenario for telemedicine? Are there patients for whom this method of care will never work? Alvarnas asked the panelists. What is the best approach to take?
Start with simple solutions, those assembled seemed to agree. Suggestions included collaborating more with rural physicians to establish remote monitoring centers for low-risk patients, which include exams performed by their primary care physicians and surveillance for those not needing chemotherapy; enabling inclusion in clinical studies by permitting remote capture of data at nearby clinical centers; designing user-friendly access solutions with seamless integration into daily routines; and equipping patients with easy-to-use electronics.
All of this is not possible, however, without the funds to fuel development. Alvarnas addressed this potential barrier from the payer perspective by asking if it was possible to achieve a balance between reimbursement and empowering greater technology use, especially in regard to saving patient
time by avoiding unnecessary in-person care or preventable admissions and focusing on what preventive services payers should cover.
Using technology to reduce total medical costs is top-of-mind, as is ongoing engagement with and monitoring of the patients with the most potential to generate very-high-cost claims, Kwo emphasized. Following claims reporting is another area, she noted, because that can inform if it’s possible to prevent higher-cost claims down the line with a certain patient monitoring device.
Katipamula-Malisetti added that she would like to see more services covered that don’t directly involve the physician—such as visits with palliative care specialists, geneticists, and dietitians—as well as those that contribute to “the big picture” by keeping patients out of the hospital.
Knowing of the looming possibility that CMS might roll back some of the flexibility it has introduced since the start of the COVID-19 pandemic, especially in regard to Medicare’s hospital outpatient prospective payment system,1 Vidal said there needs to be improvement in billing practices, because billing is frequently based on what you can accomplish during a “true physical exam.” Compensation practices also need to be adopted that adequately compensate those who deal with the information overload that practices sometimes face from the glut of patient data produced from remote monitoring.
“I think patients and payers and providers are going to revolt if we roll back too much,” Yates added. “I think COVID is here to stay, in the way that our world has changed, in the way that we deliver health care has changed. I don’t think it will go back to what it was in the past few years.”
Alvarnas echoed those sentiments, noting the changing tide in patient care. “It’s about seeing solutions that include a move toward greater patient centricity and leveraging technology to have a better understand of what patients and families seek as their goals of care and hopefully to find better
experiences of care along the way,” he said.
According to Kwo, the most important questions we need to be asking regarding the optimal benefits of remote patient monitoring and how to get the most out of a shared-savings model are: How do we best engage? What are actionable care plans? Have we really closed care gaps? Does this technology really enable a provider to better monitor patients between appointments?
“The answers to these have the potential to affect cost reductions and reimbursement,” Kwo concluded.
CMS-1753-P: Hospital outpatient prospective payment – notice of proposed
rulemaking (NPRM). CMS. Accessed October 18, 2021. https://www.cms.