Remote Patient Monitoring with Bernard (Bernie) Benassa | Part 2

Welcome to a virtual view where we talk about tele-health healthcare and everything in between.

Today I'm joined by Bernie Banas who you may have heard in a recent episode that we just published on remote patient monitoring. Bernie has agreed to do a part two where we're gonna dive into a little bit more on the return on investment for remote patient monitoring technology, as well as how. Overcome hurdles when you're implementing the technology. So Bernie, thanks so much for joining us for this two part episode.

I appreciate the opportunity here to participate again. And there's so much information to share about RPM and, virtual care components around RPM that yeah, I could probably. Write a few volumes, but I do appreciate the opportunity to to come back for part two.

Absolutely. And, we talked a lot about, what is remote patient monitoring? We talked about some basics when it comes to, how are you reimbursed for it? What are some of the benefits, but for organizations that are looking to implement a remote patient monitoring program for the first time, What really is the business case that an individual can make when they want to stand up a remote patient monitoring program for the first time.

Yeah, great question. And that, that is a key component. And one of the key hurdles, I think in just investing in an RPM program, cuz once you do an RPM program, you really have to jump in with. With with both feet, into the deep end. And it's a commitment to, a program a team that gets involved with care management and a a service to your patient consumers, right? Once you. Put it out there. You have to make sure that it's well designed. You can stand behind it and that it's sustainable and scalable. Really a business case around RPM is commonly built around a few key components like cost savings would be the first that comes to mind. Financial incentives tied to quality scores, typically reimbursement revenues. Even revenues related to patient volume patient and even improvements in patient volume. Depending on what type of provider you may be working with. The relative importance of these are gonna change or differ depending on the type of organization providing the service. And if the payment model is fee for service versus alternative value based care. So that can really dictate a different angle when it comes to ROI. But ROI. Prove ins can commonly built, be built around either scenario. So the first to look at is really cost savings. And that's what we find most service providers look at first and are motivated first to especially if it's a hospital based system or a larger health system is cost savings from reduced hospitalizations and reduced ER visits. And when you employ an RPM solution, the care team is more aware of how a patient is trending and they can intervene to head off and avoidable utilization event. That could be a hospital admission. It could be a readmission, an ER visit or other types of high costs, types of care, including, procedures. When you look at hospitalization states that cost for a chronic condition stay or a serious chronic illness stay hospitalizations can run from about 15 to $20,000 per episode. And ER visits can run about $2,000 on average for those types of conditions. So when you look at that RPM solutions and their ability to reduce those can really have a positive ROI fairly quickly. With a recent project I've worked with at a large physician network in Michigan. So it's in the U MTRC region. They'd started using an RPM solution. In a non fee for service model, it was a shared risk, value based care model. And our experience with them was that they crossed or came very, came to the point of the breakeven point for their entire annual spend for their covered patient group, which just two avoided hospital readmissions in less than six months of program usage. In a very short turnaround time there just by this was two different patients avoiding a hospital readmission because they caught the negative trend for this patient using our RPM solution and were able to intervene and basically paid for the program. For the entire year for all of the other covered patients in their program. So it, it can be pretty powerful when you see those kind of results in avoiding a hospital utilization and ER visits. The next component to look at in ROI is financial and incentives tied to quality scores. these may not be. Realized, upfront, but they clearly become part of the equation in a large way. One of the largest incentive or kind of opportunities, if you want to call that, or you can look at it in a converse way. Disincentives in the form of penalties is tied to hospital score on readmissions. There was a recent study by, I believe it was Kaiser health that that said about half of all hospitals, it was very recent. It's a 20, 22 report, but half of all hospitals are being assessed a penalty by CMS. And that penalty is averaging about a 3% reduction in their Medicare reimbursement payments for an inpatient stay. If you look at the average penalty per hospital, that was. Just a little bit over 200 K per hospital. And if you add up all the penalties for all of those hospitals that were getting penalized the amount totals about 500 million. So it's a large amount of penalties, but also a large amount of savings to CMS. So CMS is capturing that revenue. And then. they're using a lot of that to redistribute it back to the highest performing hospitals. So there's a way to be incentivized to even exceed the national thresholds. And get a bigger share of the Medicare payment pool. So when you look at RPM, there's been lots of published journal articles that have proven that RPMs had a direct influence on reducing readmissions. And actually then also affecting the quality metrics and the scores, right? You find then many organizations make an admission to use RPM to reduce the readmissions and the penalties associated with those readmissions, keeping more of their spend and again, even getting a greater Score to even beat the national threshold and get a bigger share of the the withheld payment pool. So that, that can be a big incentive using RPM probably the next component to look at and probably the most complicated as well is reimbursement revenues. So if a provider's programs are set up correctly, they can actually be fairly lucrative from a reimbursement perspective. Providers, we talked about different care models that CMS is defined and different CPT codes that can be used for building in our first part on this RPM discussion. But providers can take advantage of even multiple billing code models and even combining. The use of those care models for the same patient during the same monthly building cycle. And when even just RPM on its own, even when it's done it'll you can likely have the cost of the RPM technology solution completely offset by the monthly allowable amounts that are available from CMS for monthly use of the patient device kits. Then you can layer on the billable time that a provider incurs to, for per patient, for the care of the patient for RPM, which can be as much as around a hundred dollars a month. If they're doing a couple of sessions a month with the patient that are allowed. And if you then also layer in chronic care management on top of that, which can be also used for the same patient at the same time as RPM that can be another a hundred dollars in patient revenue per. So it's quite possible that a provider can bring in over $200 a month per patient and additional revenue per month after already getting reimbursed for the patient devices and that those get already covered in the cost of the reimbursement available for those, for that part of the program. So it can be fairly lucrative from a revenue perspective. But when you look at that, you also have to look at, okay, what additional costs might I be incurring as a provider? And organizations do have to factor in the additional cost, mainly in the area of staff resources that perform the RPM activities. But when you grow and scale an RPM program, you could, you will actually find, or it has been found. Nurses are actually able to handle a larger volume of patients in a virtual care model than they would've been able to, if all of the visits were being done in person. So there actually becomes a point on the curve where your productivity is actually going up as you scale an RPM program. When the nurses can manage a larger number of patients at one time Also most RPM vendors will offer a monitoring service so that you can outsource that service. And a lot of times, again, depending on scale, it could be less costly to outsource that service than to do it. In-house using nurses and it can free up the staff to do other. Additional preventative and even more emergent type of care as needed and be, just create a more responsive environment for the patients in general. And probably the last item to think about in terms of ROI of RPM is, can be seen in, in patient volume improvements. And this could really be achieved with, because RPM brings with it, the promise of better patient engagement. Which leads to better retention and then can lead to better volume, growth, less loss of patient volume. And RPM has been proven in studies as well to increase patient engagement, accessibility, and that helps with Patriot retention. And when you look at the Different digital first models, national models that are entering the fray now. And the new threats that are coming from these large care entities, whether it be Amazon or Walmart or Teledoc or whoever that these models are starting to penetrate. Different communities across the country and providers that have been entrenched in those communities need to amp up their game to keep a heightened patient experience and satisfaction that can be enabled by RPM to market to the patients, to keep their patients and even grow their patient volume. Using more of a high touch model. And yeah, that's a good summary. I think of most of the points that fall into our ROI of R.

appreciate that Bernie it's always important to, take into consideration not only the clinical outcomes that can come from being able to provide some of these care to patients. We have a lot of conversations with providers all across our four state region. And one of the biggest barriers that they tend to run into is, if we're gonna put in some money to buy new technology, create these new workflows, we want to make sure that we're gonna be able to recoup that. Cuz that can be some of the biggest threats to. When you're creating a new service line to make sure that it's gonna be sustainable long term so that, once you start to provide that service for patients, you're gonna be able to provide it long term and be able to continue to sustain it. So thank you for that comprehensive as walkthrough of the business case, as well as the return on investment for utilizing remote patient monitoring technology. So that individuals that are trying to have these conversations in their organizations, because it has a lot of moving parts. You have to get a lot of people on board. So having a good clinical basis, but also a strong BA a business case is gonna be important to really getting your program started to begin with.

Exactly. Yeah. And making that transition from pilot to, full operational model is a line that a lot of. Providers have not yet really executed well yet. And that is a, there's a lot of pilots that are out there that are stuck because of the uncertainty again, around how do I make that transition to scalability and fully commit. Right? And that takes working with a an established, RPM vendor and those that have walked that walk with with providers before.

So when we talk about implementing these kind of solutions, I wonder from your perspective, is this something where it can be a straight out of the box solution for folks? Or is this something that does require a lot of pre-planning and groundwork laid beforehand?

Yeah, great question. And good way to frame it. It definitely requires a ton of preplanning and involving all the right stakeholders in that. And it's funny that you use the words out of the box too, because. A component of a RPM vendor solution kind of has to be pre-built and proven and available out of the box in a way that shows that there's not a huge will build it while we're flying. Kind of will figure it out as we go, because there are some new RPM vendors out there who really haven't been in the mix that long might have some great solutions, but really Haven. Got that full support and operational model and developed a large, extensive suite of. Really almost ready to use out of the box type care solutions. So yeah, interesting term there, but yeah, so talking a little bit more about some of the challenges and the hurdles for RPM success and even some of the barriers to adoption and why we've seen some programs. Have difficulties. I can go through some of those. It is a very challenging endeavor. When you look at a provider they're used to providing care inside their four walls, and they're. Even the financial model is set up for time in the office, visiting with patients, right? So this model of course, starts to break down the walls and go into a full on virtual mode. But even beyond that, you're losing you're, it's a very uncertain environment you're losing of that control. Of the situation where now you're in the most uncertain of environments in a patient's home and you're providing a service out into, inside their home, which is a very intimate place and a very very variable environment, from patient to patient. So you really have to have a good. Foundation and a good solid plan in place to, to handle some of the operational issues that are invariably gonna happen when you go into direct to consumer type of care models, in the places where they live and work and play. But if it is designed and operated well, an RPM program can produce pretty significant results. Some of which I'd talked about before but one of the big hurdles at RPM and the one that I think gets a lot of folks stuck is how is the provider gonna get paid? And even if the organization understands a bit more about, okay how is this gonna be financially justified the providers, themselves, physicians, et cetera, have to be on board. And it has to fit with their payment model and knowing how they're gonna get reimbursed. And while. We did talk about reimbursement and how it, it can be viewed as universal and ready and in place, but really that's only at the federal level and it's only for Medicare patients typically. So you really then have to look at, okay my I'm probably not serving all Medicare patients, I've probably got mix of Medicare, Medicaid private pay in that or commercial insurance. So you do have to also look at the state level reimbursements for Medicaid and for private payer. And typically it's a patchwork right of different evolving policies per state per quarter, or however often they're getting defined or new bills are getting passed, but some good news is that 30 states have already. Have favorable legislation in place, specifically talking about RPM coverage and that's so that's even beyond just telehealth, right? So they actually have language to cover RPM usage. And if you think about, for example, here in Indiana regulations cover live telehealth, but not store and forward telehealth, but they do support RPM. So it's a bit of a, possibly a MIS some gaps in the picture there, but but RPM, which is typically defined outside of telehealth as a separate entity is why we see that defined sometimes differently and outside of telehealth in store and forward, which are both parts of telehealth. But Indiana also has a requirement as an example, that in addition to. that private payers have to cover the same services as Medicare. So Medicaid and private payers have to cover the same services as Medicare, but there's not yet a requirement for payment parity so that the private payers and the Medicaid don't necessarily have to reimburse at the same level as. The same rate, but they do have to cover the service. So that's an example turning the spotlight here a little bit on Indiana, as an example since that's where we're talking from here let's see some additional hurdles and challenges might include and I'll just run through a few things here that come to mind, but selecting the. RPM solution that can grow with your needs and it can handle a diversity of environments and care programs. I think we talked a little bit about different rural and hard to reach environments. And how do you ensure equity across your population? Because most commonly and unfortunately the highest need patients are also the hardest reach and living in the most remote areas and have lack of access. How can you get a pro a solution that can scale and address your population to truly turn that corner for those that need it most another critical component would be involving all the key stakeholders early on in the pro planning process and having them all agree on programs, objectives and supporting the need giving the support really needed to execute, fully on a programming to commit to. Part of that is the program objectives and target metrics really need to be made clear up front. And how, and then how are you gonna measure those? And know how you're doing against the objectives. You also should put in place a phasing and sustainability plan to make sure that you can grow long term and that the operational. Needs can continue to be supported. And then you have to look at a course. Where does that funding come from? Is funding only temporary? Can you get annual new funding coming around, whether it's through grants or some other types of. Internal funding. And then as far as implementation goes one of the most challenging areas is around patient adherence, right? So you could have done everything perfectly in terms of your planning and your execution and implementation, but your, the wild card you're still dealing with is patient adherence. So the ways you wanna make sure you plan for a high level of adherence, Is it really starts at the program outset with screening and selecting the right appropriate candidate targets. You'll wanna look at, claims data and a bunch of other types of factors and you'll wanna have qualification check the box areas as to whether a patient makes for a good compliant monitored patient. You'll also need to have a patient friendly outreach process. It's gotta have a clear presentation of the expectations and the benefits for the patient. You wanna ensure that the onboarding process goes smoothly and beyond that you'll need an experienced team of care managers. You just can't round up a bunch of. Med surge or floor nurses or something, and expect them to, operate almost like a call center with the right kind of dialogue and scripts to handle patients being cared for at home, which is a totally new environment for a lot of nurses. We've seen a lot of initial adopters actually hire. Nurses from the home healthcare side because of their experience dealing in home health environments. And that can be a good place to start. But so you want to fully engage the guide, the patient and educate them and on their care plan as they go along highlighting successes and being real positive. And then really your customer support has to be on task for handling usability issues so that the interest is not lost from frustration of using the device. One thing to keep in mind though, is that RPM is not for everyone. Some patients just won't want to cooperate whether you know that early on and they decline up front, or whether it's in the middle of a program. And of course it should never be used in place of, in person care when that type of setting is needed, and a patient, or if a patient really prefers that. So once you've mastered all that, then you gotta keep the providers and physicians engaged and onboard. Cause sometimes they're. The toughest folks to drag into the the new change model of providing care and making them feel comfortable with this new model.

Yeah, those are great points, Bernie and of just some different hurdles and some things I think through as you implement a new remote patient monitoring platform. Just wanna, call out some of the similarities of, there, there are some things similar between remote patient monitoring and, rolling out a telehealth solution that you're gonna want to be aware of. And you hit on several of those points. Like you want to make sure that you have, your medical providers are bought in. They're comfortable with whatever platform you're using software you're using. You wanna make sure you identify the appropriate patients for the service? It doesn't necessarily mean. So let's say you have a congestive heart failure program that your remote patient monitoring technology is mostly focused on. It doesn't necessarily mean that every single patient that has congestive heart failure is necessarily gonna be a fit for that program. You need to have, some understanding of and collecting some of that patient feedback. Is this working for you? Is this beneficial, having some of those things in place are gonna be important for the longevity of your program. And I also wanted to talk a little bit about, you mentioned some of the reimbursement pieces and the one positive trend that we've seen in our region. So Indiana, Ohio, Michigan, and Illinois is some of our states when it comes to Medicaid, there has been positive movement when it comes to, providing more coverage and payment for services for RPM. So Ohio, they now have a lot more reimbursement for remote patient monitoring for. And Indiana actually just released a bulletin in may of this year. It used to be predominantly home healthcare agencies were the only organizations that could furnish and bill for RPM consistently. Now they're opening it up to more provider types and certain patients, as long as they meet the criteria, that's out. Outlined by Indiana Medicaid and a prior authorization is completed prior to that patient receiving the service. They can now receive those RPM services, even if it's not a home healthcare agency, who's providing the care. We still have a long way to go. But at least we're beginning to see some of that positive traction on the Medicaid standpoint, as we've seen a lot of reimbursement opportunities when it comes to.

Yeah, that's great to hear about some of the new new advancements there in in regulatory stance then as far as types of entities that can bill for, and that seems to be changing all the time. So good to hear. And it's changing even with Medicare with some new Some of the new care models that are coming out, like remote, therapeutic, moderate monitoring, even.

Absolutely. Yeah, we do our best to try and keep up with all of that. I do have to put in a plug that we do have a remote patient monitoring handout where we kind of catalog some of the basic information when it comes to remote patient monitoring. That's located on our website. We do our best, but it is a moving target. depending on which day you ask that policy may have changed recently, but we do our best to keep on top of that. But in the spirit of change and evolving, which RPM definitely is how is RPM evolving as a technology and what's next for this exciting care?

Yeah. Yeah. Cam, just like you mentioned while there's been a lot of changes on the regulatory front tho those are really happening even at. Same time as RPM kind of new developments, new technologies, new capabilities are being infused into RPM. So yeah it's an area of rapid change. We're seeing, in addition to. What we've been talking about, some of the new care models that CMS has been defining and the good news is new barriers are being broken down pretty much every year. We had like new care models introduced just this past January for remote therapeutic monitoring, which we covered in the first session. So that's brand new in terms of types of providers and other care models and new billing codes that could be introduced. So there's A lot of change there that we're seeing, so that's very promising for broader use of RPM. And another area we're seeing some additional exciting evolution is around continuous monitoring and wearables. And primarily also the FDA cleared. Versions of those types of devices, right? It's still pretty early stage and providers are still trying to address the value and the use cases and try to understand those cuz technology's out running the healthcare provider ability to manage the information that can come from these devices. But that's typically the case with technology companies, right? The key thing is that providers need to understand. If we did do continuous monitoring or have wearables, are we set up to handle potentially as much as 24 by seven monitor data, it's even a tough hurdle to climb to even just. See the single point in time, data events that are being patient generated through RPM, but you could start with looking at it from there could be real value or benefits to what we call segment of time monitoring. As opposed to thinking that it's an all or nothing thing, I either take a static reading at this moment, or I gotta, Suck down 24 7, flow of data, but looking at it more from the perspective of segment of time, there can be a lot of value in that some use cases around, around that might include some that, which we're seeing like even the hospital at home models, right? Even things around activity tracking for periods of time, even just something as, as short as climbing a set of stairs. How does your vitals change looking at maybe sleep monitoring over periods of. Falls detection during certain times of day interrelationships between both activity that a patient might be doing and what physiological measurements are registering over a period of time. So there's a lot of use cases that can be looked at and can add a better more informative piece to the story and the picture over just a single moment in time. With, without needing, full 24 7 continuous monitor. Some other leading edge technology, I'd say that we're seeing in and we're seeing some RPM vendors investing in is really starting to look at AI and machine learning. To further enhance that picture of a patient's current condition and be more predictive about a direction that they're trending in. So when you can take advanced technology like that, and be able to have simultaneous processing of many more data variables beyond just simply to physiological data that's collected from the devices, you can then start to see a risk based. Assessment and prediction of a likelihood of a negative event or an exacerbation of a patient's condition. The types of variables that could be monitored beyond just a physiologic data could be qualitative answers to surveys, right? It could be compliance, it could be medication adherence. It could be other types of events around social determinants of health household. Set up things of that nature where you can look at your living environment, even food insecurities, access to transportation, whether there's a family member to help out at home and those types of things, then you can get a kind of a scored picture of the likelihood and the high risk, higher risk that might be prevalent with a certain patient over another. And then using scoring methodologies, you can actually then have the patient sorted. In pretty much near real time, according to the risk that could be changing at any point during a given day or trending in a negative direction so that you can get a informed a care team more quickly and more accurately with actionable data as to which patients need more immediate attention. And it's really these kinds of proactive tools and clinical decisions, support intelligence. that's really gonna change the game when it comes to patient care outcomes and the reduction of avoidable hospital events.

when we talk about this kind of stuff Inequalities that already exist in healthcare. Telehealth can mitigate to those to an extent. But when we talk about RPM, which is something that can sometimes be somewhat costly to the consumer, have a bit of a high barrier of entry. Does that still hold true? Is there still issues with health inequality in that sense?

We I think health inequalities are present everywhere and. In quite extreme variances as well. RPM again still is just in its infancy and it has a ways to go. However, it does hold a lot of promise for being able to reduce the inequities. I do see it as a way to start leveling the playing field for those commun communities that have been the hardest to reach, and that are the most difficult to manage from a care perspective. RPM allows for. A view into the patient's living conditions. It allows for, excuse me, it, it can a well-rounded RPM solution can have different tools that are designed to address patients that are harder to reach. You could have you could address the more tech savvy patients with a tablet and a user interface that prompts them through an electronic or digital experience. But then you're gonna have patients that don't know how to use a tablet or won't use one, or may not even have any internet connectivity. So you have to have tools where you can either. Have, a cellular service embedded in the device, or just have a excuse me, or just even have a passive device that the patient doesn't engage with that might just be listening always on in the background, like an Alexa type of device, but that's watching for any. Physiological data collection from medical devices that are attached to it for any data that's captured, it just automatically sends it to the care team dashboard. So that, that can get around a user having to use a technical device. We I've even seen solutions that use the wired phone line in the wall, to be able to interact with the patient through an automated phone script to help reach that patient. And have them respond with data about their condition. And also just being able to even have different languages that can be more readily put into the mix, at a press of a button or or even just a prepackaged solution. That's all in the native language of that particular patient without having. Unit involved necessarily an interpreter, full time, real time and have the cost associated with that. So I think there's many ways that RPM is starting to level the playing field with with health equity and long way to go still. But I think that there's great tools there to do that.

Okay. Thank you so much for that. Look into RPM. It was extremely informative and I think that all of our listeners will really appreciate having such a thorough look at both the business end and some of the future implications of this technology. But thank you so much for coming on with us today.

Thank you both. I appreciate the opportunity to to talk about RPM and it's an exciting area. So it exciting to see it make a difference in your communities as well there in your region.

Yeah, thanks so much.

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