For more than 10 years, White Pine has offered patient engagement solutions that include remote patient monitoring for glucose, blood pressure and other physiological measures. It has never developed into the market we hoped it would because most payers, particularly Medicare, have not been willing to pay for it. That may be about to change. This is big news.
Giving credit where credit is due: To the Trump Administration
During the first 18 months of the Trump Administration, healthcare has been characterized by confusion, uncertainty and risk that receives worthy attention in the media and political circles. Nonetheless, the Department of Health & Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) have accomplished some noteworthy things that may benefit patients, providers and payers for years to come.
Proposed rules announced for Medicare billing in 2019
CMS just released two proposed rules updating Medicare billing models for 2019. The proposed rules create billing codes for new products and services that cover remote patient monitoring (RPM) including the cost of setting up and training people to use devices, the monthly cost to use the technology and transmit results to providers and the provider labor cost for reviewing and evaluating the results of the data from these devices. The costs cover both physician groups and home health agencies. And it is likely that these Medicare rules will have implications for state Medicaid agencies as well as private payers, thus affecting almost all of healthcare. (The Veteran’s Administration should be considered separately.)
Remote patient monitoring
Remote Patient Monitoring refers to the technologies and processes by which patient generated health data is collected through monitoring devices and integrated into the clinical practice. Traditionally, this includes glucose meters for patients with diabetes and heart or blood pressure monitors for patients receiving cardiac care. Looking at the proposed rules, these devices could soon include accelerometers and geospatial sensors to measure physical activity and motor function. They include continuous passive monitoring as well as point-in-time monitoring. Data can be sent to a physician’s office using a special telehealth computer system or by using a special software application installed on the patient’s Internet-capable computer, smartphone or tablet PC.
Payment for RPM in 2018.
For the 2018 calendar year, Medicare will pay a qualified physician group $59 per patient per service period (30 days) for RPM services (subject to geographic variations). There are two significant limitations to the 2018 rule: First, the reimbursement is available only for physician groups and does not apply to non-physician group organizations including home health agencies that are also likely to provide the service. Second, it does not allow for the reimbursement of the underlying costs to set up, train, collect and transmit the information to the physician group. Thus, the revenue opportunity is so small compared to the uncompensated labor and risk that many provider conclude it just isn’t worth it.
Proposed payment improvements for 2019.
In the first two weeks of July, CMS released two sets of proposed rules for adjustments to the Medicare payment model for 2019.
- Proposed rule relating to physician groups Physician Fee Schedule (PFS). The following three CPT codes  are added[i]:
- “Remote monitoring of physiological parameters, e.g. weight, blood pressure, pulse oximetry, respiratory flow rate, initial.” This includes the cost to set-up RPM equipment and provide initial patient education and use of equipment.
- “Remote monitoring of physiological parameters, device supply with daily recording(s) or programmed alerts transmission, each 30 days.”
- “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
Because these services are not inherently face-to-face services, they are expressly not considered to be telehealth services. They are just plain Medicare eligible services. That means that constraints that apply to telehealth, such as limitations to rural and underserved communities or delivery through an approved local office, do not apply to these services. They are available nationally in all communities from any location.
2. Proposed rule relating to home health agencies (HHA) to modify the Medicare Home Health Benefit as follows:[ii]
- Proposes to “define remote patient monitoring under the Medicare home health benefit as ‘the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the HHA.’”
- Proposes that “the expenses of remote patient monitoring, if used by the HHA to augment the care planning process, must be reported on the cost report as allowable administrative costs (that is, operating expenses) that are factored into the costs per visit.”
The proposed rule includes the cost for both the technology and the labor associated with providing, configuring, training and reviewing data from RPM systems in the calculation of the HHA’s Medicare Home Health Benefit charges. The proposed rule also provides guidance about how HHAs should engage with physicians based on the information received through the RPM system.
Limitations in the proposed rules.
Neither of the proposed rules include the dollar amounts for these new services. The rates for physician groups are established based on recommendations from certain American Medical Association committees. The Medicare Home Health Benefit used by home health agencies has its own calculation methodology. Providers will need to know the estimated payment amounts for each item before they can work through a financial model and establish a strategy and work flow. (We have sent a request to CMS for clarification of when and where the proposed dollar amounts will be available.)
The proposed rule creates one set of CPT codes covering all forms of RPM. It treats one form of monitoring, e.g. continuous glucose monitoring, the same as every other form of monitoring, e.g. periodic blood pressure or pulse oximetry, as having the same technology cost and labor requirements.
Further, only one charge is allowed per period whether for one device or six. For example, if a patient uses a glucometer for diabetes, there is no incremental revenue opportunity to add an activity tracker to measure movement for Parkinson’s disease. We believe this is one of the biggest limitations in the proposed rule and should be the subject of many comments during the comment period. Also, the same rate applies whether the technology provides continuous monitoring or episodic monitoring, which seems intuitively illogical given the significantly different technology and monitoring requirements. Because the two rules follow different payment models (i.e., CPT codes for physician groups versus the Medicare Home Health Benefit for home health agencies) two separate comments should be developed.
The proposed rules for 2019 are stepping stones, not a final position
These proposed rules should be viewed as stepping stones, not a final vision of pricing models for RPM or other patient engagement solutions. The scope of the proposed RPM rules is limited to physiological measures. They do not include behavioral measures such as those that might apply to addiction or mental illness. Further, they do not extend to query-based assessments such as screening tools or health risk assessments. Today, these are bundled with other services including a set of CPT codes that are referred to as “evaluation and management.”
While the proposed rules make reference to the automated triggering of alerts, no consideration is given for the development of response protocols for these new alerts. The implications are profound not only for work flow and documentation but also for professional liability. While these are areas of great risk, they are also opportunities to show industry leadership.
Thus, all providers pursuing this opportunity should evaluate the clinical benefits as well as the revenue and gross margin potential in 2019 but also have an eye on the potential for a more refined and rewarding system in subsequent years. Ultimately, this is just an early step in the development on the road to a truly patient centric health delivery system.
Time is of the essence to get in front of this opportunity and be ready for January go-live. White Pine Systems stands ready to provide consulting services and technology to meet this great opportunity. The comment period runs until about the end of August. The final rules will be announced around the first of November, effective January 1. We encourage you to study these rules and submit comments both in support of the general direction and requesting improvements that can make them more valuable quicker. Now is the time.
For more information, contact Doug Dormer, firstname.lastname@example.org , 734.730.2207
 CPT stands for “Current Procedural Terminology.” 5-character CPT codes are established by the American Medical Association for healthcare procedures and services. CMS uses CPT codes as one of the main billing units in the Physician Fee Schedule (PFS) for billing and payments.
[i] Centers for Medicare & Medicaid Services, Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements;
Quality Payment Program; and Medicaid Promoting Interoperability Program. Released 7/12/2017, to be published in the Federal Register 7/27/2018.
[ii] Centers for Medicare & Medicaid Services, Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations, released 7/2/2018, published in the Federal Register, 7/12/2018.