Medicare’s Chronic Care Management (CCM) program looked like a for primary care physicians when it was launched in 2015. The Centers for Medicare & Medicaid Services (CMS) offered to pay practices about $40 per patient per month (now $45) for between-visit management of Medicare patients with two or more chronic conditions. But relatively few primary care practices have taken on CCM, partly because meeting the expansive requirements of CCM appeared quite difficult, and most groups have not been able to justify hiring extra nurses or outside services to perform the care management interactions. Medical practices that want to keep their patients healthier while also tapping into this new revenue stream are looking for ways to make CCM more efficient and less costly-which is where mobile-enabled remote patient monitoring (mRPM) comes in. This type of technology, which typically includes a dashboard for the physician practice and a patient-friendly mobile app for check-ins between appointments, can greatly enhance communication between providers and patients. In addition, patients become more aware and engaged in their own care without overburdening the practices. This technology enables consistent patient monitoring between face-to-face appointments-a key CCM requirement. Further, it is more efficient and cost-effective than phone-based monitoring, where only one patient can be contacted at a time and data must be recorded by a team member rather than automatically. Remote monitoring is an expanding element of modern care. CMS recently unbundled another level of remote patient monitoring, using a different CPT code, unrelated to CCM, allowing providers to bill separately for these broader services. CMS also increased the weighting of remote monitoring as a practice improvement option under the Merit-based Incentive Payment System (MIPS). So there are plenty of reimbursement opportunities to use mobile monitoring in a primary care practice. Will Boomers use the technology? Physicians may be skeptical about their Medicare patients using a mobile app to help manage their chronic conditions. But there is evidence that seniors are increasingly taking advantage of mobile technology in their everyday lives, whether for texting, Facebook-sharing, FitBit-tracking, or other purposes. According to a 2017 Pew survey, 42 percent of people who are 65 years or older now have smartphones-with higher usage among more affluent and more educated seniors. Sixty-seven percent of seniors use the internet, and 34 percent use social media. Based on the Pew survey, it’s safe to assume that many of the two-thirds of Medicare patients who suffer from chronic conditions also use smartphones or other mobile devices. That means practices can leverage mobile monitoring to track these patients’ chronic conditions at regular intervals. This approach taps into consumers’ embrace of mobile technology as an integral part of their lifestyles. Patients want healthcare that is easy and that they can access from wherever they are when it’s convenient for them. Whether the patients are Medicare beneficiaries or others covered by value-based contracts, this technology has the potential to help primary care practices improve patient satisfaction, reduce readmissions, and improve outcomes while generating new revenue. How the technology works Mobile remote patient monitoring is convenient for both physicians and patients and uses few resources to reach a large population and gather their data consistently and efficiently. An automated schedule uses push notifications to prompt the patient to send in specific information at a time and place convenient for them. Once the data has been received, a clinician assesses the information and, if necessary, escalates to a face-to-face visit or phone conversation. So, from the viewpoint of meeting the CMS requirements, mobile-enabled monitoring is more cost effective and more likely to meet patients’ needs than other communication methods. The technology typically includes some type of biometric data collection-weight, body temperature, respiratory measures, sleep quality, glucose readings, and/or blood pressure-that can be transmitted to the patient’s physician and automatically analyzed for concerns. This process can be done automatically: the information can be directly entered by the patient and shared with the care team via mobile technology. But biometric data alone isn’t enough. In order for the physician to gain a full picture of the patient’s health, these quick mobile-enabled check-ins should also include subjective and objective questions about their health, including details on medication adherence, care transitions, new doctors, and social determinants of health that could be affecting their treatment plan adherence. Of course, no care team needs or wants to be inundated with data every five minutes-it’s important to know if a patient is sleeping well over time, not if he or she had one night of good or bad sleep. So, for mobile monitoring to be effective and actionable, it’s important that the frequency of data collection and reporting be guided and standardized via predetermined schedules based on the patient’s condition, clinical guidelines, and provider preferences. As that data arrives, certain algorithmic flags can create alerts for intervention-such as a patient who wants her doctor to contact her, or one whose biometric readings have been creeping up, or one who reports he hasn’t taken his meds for a few days. The doctor can then call these patients or ask to see them in the office to determine what the issue is so that it can be addressed as soon as possible. Mobile monitoring makes patients feel like they are doing something to support their own health, which engages them and can lead to greater adherence to treatment plans. In addition, the technology can: Provide consistent, automated monitoring of patient progress with the current treatment plan Inform providers about patient status during pivotal periods, such as transitions of care Enable providers to intervene early on emerging issues, which can improve patient outcomes, reduce costs and prevent readmissions Flag social determinants of health issues that require early intervention (ex: the patient no longer has someone who can pick up a prescription refill or take them to a doctor’s appointment), which can be particularly important with elderly patients. CCM regulations mention RPM So how do physicians get reimbursed for using mobile-enabled remote patient monitoring? Let’s start with the CCM regulations. CCM reimbursement requires the use of one of three CPT codes-99490, 99487 and 99489-that reflect increasing levels of time and complexity. The lowest level requires that at least 20 minutes be provided to eligible patients outside the office under the supervision of a physician or other qualified health professional each month. The second code entails 60 minutes, and 99489 is an add-on code for 99487, indicating additional 30-minute increments. CMS requires practices to furnish a number of non-visit services in order to bill for CCM reimbursement. Among other things, they must “provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure internet, or other asynchronous non-face-to-face consultation methods (for example, email or secure electronic patient portal).” Mobile-enabled monitoring is one type of non-face-to-face asynchronous communication. For care management purposes, it is an improvement on traditional telephone calls, which need to be made during certain hours, often lead to playing “phone tag” with patients, and take up a lot of costly staff time. The cost-benefit ratio of mobile monitoring is much more favorable than phone-based patient monitoring. Other CMS initiatives Meanwhile, CMS is starting to reimburse for remote patient monitoring in other ways. To start with, the agency unbundled CPT code 99091, effective Jan. 1, 2018. This change allows a provider to be reimbursed separately for time spent on collection and interpretation of health data that is generated by a patient remotely, even if the provider also bills for reimbursement under the CCM or the Transitions of Care codes. CMS called this move “a first step toward recognizing remote patient monitoring services for separate payment”-so there may be more to come. In addition, the agency recently updated its scoring regulations for MIPS, granting a higher weight to patient engagement efforts within the Improvement Activities category. The CMS guidance specifically calls out the use of patient-generated health data through digital platforms. Achieving the goals of value-based care-remotely When used in conjunction with other CCM strategies, mobile-enabled remote patient monitoring can not only increase physician revenue but also help providers achieve the value-based care goals of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.At the same time, this technology allows practices to advance care in a way that is efficient and convenient both for them and their patients. Harry Sozais CEO of CAREMINDr, a health IT company focused on creating mobile technology to enable effective remote patient monitoring that gives doctors the ability to check in on patients between office visits. Irina Yermilov, MD, MPH, MS, CAREMINDr’s chief medical officer, has more than 10 years of experience measuring cost and quality related to chronic conditions.
