Remote monitoring (RM) could revolutionize the way care is provided for people with chronic disease, particularly for people of color and low-income people, who experience worse outcomes than the general population as a result of systemic racism and discriminatory policies.
Unfortunately, scarce provider reimbursement for RM services and devices presents a barrier to adoption and risks perpetuating health disparities.
Simply put, if healthcare providers can’t get paid by public insurers for performing remote services, they will opt to perform services they do get paid for, leading to inequitable access to RM and other virtual care services.
Until reimbursement structures fully support the implementation of RM across private and public insurers, we’ll continue to see differential RM access while patients invariably suffer.
Changing CMS coverage for RM – and making RM a standard of care beyond COVID-19 – is essential to improve health inequities. As a country, we need to broaden and clarify the coverage and reimbursement for RM services and devices on a permanent basis.
Patients and providers are ready for RM, but incentive structures are failing them
RM manages patient health by using digital medical devices to automatically transmit information on patient status back to the provider for ongoing monitoring, early warnings and interventions as needed.
RM has been associated with improved outcomes including: decreased hospitalization rates [Disclosure: Jarrin, Barrett and Nunez all have ties to ResMed, which is affiliated with this study], higher medication adherence [Disclosure: ResMed affiliated study], reduced body weight and A1c, and fewer days with symptoms [Disclosure: ResMed affiliated study].
Among physicians there has been a significant shift in the attitude toward remote care. More doctors now feel it is very important to incorporate digital health into their practice and are willing to use these tools.
Patients are ready for adoption too: 81% of adults in the U.S. have a smartphone, and 60% of them have used a smartphone to manage their health.
But while CMS – the country’s single largest health insurer – has made great progress in the last year in reimbursing telehealth and addressing the needs associated with COVID-19, it is not enough to address the growing health crisis among vulnerable populations.
Health disparities are growing ever wider in the U.S.
Recent data from the CDC show a record decline in U.S. life expectancy due to COVID-19, with the most striking decreases among Black men. Although health disparities in the United States existed long before COVID-19, they continue to widen, leaving the most vulnerable people without access to quality healthcare.
Disparities exist by income, education, and race across a variety of chronic conditions. For example, in respiratory disease, Black children are three times more likely to be hospitalized for asthma as white children, and people with a lower socioeconomic status or education level suffer from greater severity and poorer lung function through conditions such as chronic obstructive pulmonary disease (COPD).
When it comes to cardiovascular disease, Black Americans are 30% more likely to die from heart disease than white people. Moreover, Black, Hispanic, and Native American people are all more likely to suffer from diabetes, as are people with less than a high school education.
Disparities exist geographically as well. The 46 million Americans living in rural areas are more likely to die from heart disease, cancer, chronic lower respiratory disease, and stroke than people in urban areas. They also have less access to healthcare and are less likely to have health insurance.
Challenges with transportation, hourly or seasonal job insecurity, a lack of culturally sensitive providers, difficult access to COVID-19 vaccines, and higher morbidity and mortality from COVID-19 all impede access to in-person healthcare services for vulnerable populations and worsen healthcare disparities.
Remote monitoring could help improve health disparities
While there is no easy solution to these complex, systemic issues, RM can reduce the negative impact of these barriers to care if it is adequately and equitably reimbursed.
In a recent article for NPJ Digital Medicine, we argued that the existing CPT codes for remote physiologic monitoring (RPM) were narrow and ambiguous, and that CMS either needed to broadly define the term “physiologic,” or adopt and fund a new set of codes that did not rely on this measure for reimbursement. [Disclosure: study is affiliated with ResMed and Social Innovation Ventures. Ostrovsky is a managing partner at the latter.]
Recently, the American Medical Association (AMA) announced the creation of five new Current Procedural Terminology (CPT) professional service codes – 989X1, 989X2, 989X3, 989X4 and 989X5 – which will report Remote Therapeutic Monitoring (RTM) and Remote Therapeutic Monitoring Treatment Management Services, including set-up, patient education, device supply and treatment management.
These new codes go into effect January 1, 2022, and will address remote monitoring of condition status in therapeutic areas such as respiratory and musculoskeletal care.
Later this year, CMS will have the chance to consider coverage and payment for RTM services and devices in its annual rule update for payment policies.
CMS coverage and payment for RTM services and devices is essential to reducing healthcare disparities. Presently, RM is reimbursed only by private plans and large, self-insured employers. Not surprisingly, Medicaid patients are the least likely to have access to RM, with only 35% of states reimbursing for RM codes.
If CMS does not provide coverage and adequate reimbursement for RTM or clarify the definition of “physiologic,” access issues will continue to be prominent for those who struggle to access quality care, such as the almost 30 million Americans who are uninsured, as well as people of color and people of lower socioeconomic status. Without adequate coverage and payment for RTM services, providers won’t have the monetary incentive to provide these services.
If deployed effectively within vulnerable populations, coding constructs for RM, RTM and RPM could help patients overcome healthcare access issues resulting from systemic racism and improve early disease detection and intervention. RTM and RPM could also contribute to identification of upstream determinants of health, such as environmental risk factors [Disclosure: study affiliated with ResMed], and empower patients to better self-manage their conditions.
If CMS opts to cover and sufficiently pay for these new codes, they will significantly increase access to remote monitoring for patients across the country, regardless of insurance.
Adequately covering and reimbursing RM is just one step toward improving equitable healthcare. Digital products need to continuously refine their tools for diverse populations, including those with lower technology access, but comprehensive program design has shown promise.
To ensure more systematic reduction in disparities, CMS must insert equity expertise into the policymaking process by creating a Technical Expert Panel (TEP) of beneficiaries with lived experiences and providers to review and make recommendations on diversity, equity and inclusivity as they relate to the various CMS programs and valuation methodologies.
Additionally, CMS should routinely utilize professional service designers to research, deeply understand, and iteratively design policy to meet stakeholders’ needs. Finally, it is essential that CMS require the American Medical Association to adopt similar processes for code review and creation.
A commitment for the future
The Biden Administration has made an unprecedented commitment to improving equity in healthcare. Given our current public health emergency, expanding and cementing reimbursement for RM, regardless of insurance coverage, must be a national priority.
RM must become a standard of care beyond COVID-19. As a country we need to broaden and clarify the coverage and reimbursement for RM services and devices on a permanent basis.
We encourage CMS to continue expanding upon existing reimbursement codes and to adopt, cover and pay for the new RTM codes. Doing so will not only ensure we get through COVID-19, but will establish a way to provide remote care permanently and equitably to the millions of people who currently struggle with chronic disease.
Andrey Ostrovsky, M.D., is the former Chief Medical Officer of the U.S. Medicaid program. He is the Managing Partner at Social Innovation Ventures, where he invests in and advises companies and nonprofits dedicated to eliminating disparities. He also advises federal and state regulators on how to incorporate human centered design into policymaking.
Robert Jarrin is a strategic advisor on digital health and medicine to various companies, associations and medical organizations. He formerly served for nearly 20 years as a Senior Director for Government Affairs for Qualcomm Incorporated.
Carlos M. Nunez, M.D., is Chief Medical Officer for ResMed. A digital health patent holder, Dr. Nunez received his medical degree from the University of Miami and completed postgraduate training in anesthesiology, critical care medicine and clinical research.
Theresa Guilbert, M.D., M.S., is a professor and the Director of the Cincinnati Children’s Hospital Asthma Center. She has 20 years of experience in providing clinical care to children and adolescents with preschool, childhood and severe asthma and conducting clinical and epidemiologic research. She is currently the PI for several multi-center asthma pediatric trials.
Linda Hotchkiss, M.D., is a Board-certified psychiatrist and has been involved in healthcare management and executive roles over the past 20 years. Most recently, Dr. Hotchkiss was Managing Medical Director at Anthem/Wellpoint, one of the largest health-benefits companies in the United States, where she developed and implemented cost and quality initiatives and oversaw the utilization and care management teams.
Meredith Barrett, PhD, is the Vice President of Population Health Research at ResMed, a global digital health company focused on improving outcomes for people with asthma, COPD, sleep apnea and other chronic conditions. She spent over six years as VP of Research at Propeller Health, which was acquired by ResMed in 2018, developing its clinical and population health research efforts.