Is it finally Remote Patient Monitoring’s moment?
We’ve been talking about RPM for as long as I can remember. Given the tailwinds from Covid-19, the space is really getting interesting.
We’ve been talking about Remote Patient Monitoring for years as being poised to transform health care. But as with all things in health-tech, it might make all the sense in the world but it won’t work until incentives align. In non-health care lingo, that basically means we gotta find a way to pay for it and incorporate it into the provider’s existing workflow.
But before we get ahead of ourselves, let’s dive in by defining what we mean when we talk about Remote Patient Monitoring or “RPM.” Simply put, it’s a set of tools to make it easier to monitor patients outside of the clinical setting, whether it’s on the move or at home. The big promise is to keep patients out of high-cost settings, like the emergency room, by picking up on symptoms and intervening before it gets serious.
Health care isn’t known for adopting new technology quickly, no matter how promising. So here are a few things I’ve been mulling in recent months: Is Remote Patient Monitoring really happening today beyond the marketing hype? If so, are patients benefiting from these approaches? And are providers getting adequately compensated?
To understand all that and more, I reached out to Jami Doucette, President of Premise Health, and Myoung Cha, Chief Strategy Officer of Carbon Health. Both Premise and Carbon have a hybrid brick-and-mortar/virtual strategy when it comes to delivering care, and their teams are closely following developments in the space. Prior to joining Carbon, Myoung worked at Apple Health, so he also has a sense of the consumer-focused technologies on the market today.
Note: Premise is part of the OMERS Private Equity group.
Here’s my Q&A with Jami (JD) and Myoung (MC), edited for brevity.
CF: We’ve been talking about Remote Patient Monitoring for a while. What makes it interesting to you now?
Myoung Cha (MC): “COVID, of course. While telemedicine got a lot of the headlines during the pandemic, RPM also gained traction once CMS [Centers for Medicare & Medicaid Services] relaxed a number of restrictions, including what kinds of patients were eligible for reimbursement and allowing providers to order RPM services for new patients without a pre-existing relationship. With this catalyst, many health systems and practices adopted RPM during lockdowns and shelter-in-place orders when hospital ERs and ICUs were full with COVID patients -- to extend overstressed hospitals and clinics and to provide care to non-COVID patients remotely who still needed care from their providers, even when they couldn’t see them in person. During COVID last year, we at Carbon Health distributed pulse oximeters and thermometers to monitor key vital signs and symptoms of COVID-positive patients who could be managed at home and triaged for hospital care. COVID patients were asked their symptoms through our mobile app, and their oxygen levels were monitored multiple times a day. We improvised like everyone else at the time, but I believe we had better real-time data on our patients than a daily phone call would have accomplished.”
CF: Anything other shifts to mention outside of Covid COVID?
MC: “For our chronic disease patients in particular, we needed to find a way to take care of them remotely, so we distributed connected blood pressure cuffs, glucometers, and scales that uploaded data to our EMR that allowed our physicians and nurses to monitor their treatment. We were initially concerned that patients wouldn’t be able to use the technology or would lose interest, but we found that patients absolutely loved it and we still have patients who are using RPM after more than a year. Based partly on this experience, we added hardware as the third leg of our omnichannel stool because we believe it is a critical component of delivering great care in the home. We made one of our first bets in this direction in June when we acquired Steady Health, a CGM-connected virtual endocrinology clinic for insulin-dependent diabetes patients.”
CF: What are the bigger trends that make RPM a solid bet?
MC: “Stepping back, there are some longer-term macro trends that are bringing RPM to the fore -- hardware devices that are getting cheaper and easier to use, lower-cost internet connectivity allowing the data to stream into the EMR, sensor-based clinical pathways getting developed and validated to drive better outcomes for patients, and reimbursement for RPM maturing and becoming more mainstream. Beyond these trends, the most important consideration is that patients really value it. A friend told me recently that he had experienced massive headaches due to what he believed to be variations in his blood pressure, and his previous physician dismissed his concerns and said that his in-clinic blood pressure looked normal and his medications looked like they were working just fine. ‘It’s in your head’, he was told. Needless to say, he switched doctors and got prescribed an RPM solution with a bluetooth-connected blood pressure cuff and after just a few months of measuring his blood pressure at home and discussing the data with his doctor, he was able to find a different medication that kept his blood pressure more stable and didn’t cause the headaches.”
CF: I know you’ve been looking at some of the new codes for RPM. What’s promising – and why?
Jami Doucette (JD): “When it comes to codes, there isn’t a silver bullet. It’s true there have been some promising changes. But the codes have always been nonsensical and complicated, and that’s unlikely to change or improve.
What is incredibly promising is that CMS [the U.S.’s largest health care payer] was willing to create a level of parity between digital and physical engagement. The progress that has been made in this sphere in the last year is stunning, and it has expanded digital access dramatically. The important thing now is to show the clinical value, and ensure we continue moving forward instead of going back.”
MC: “CMS has been iterating on the RPM codes for several years now, and while Medicare has been the forerunner for reimbursement, it has been a pleasant surprise to see commercial payors follow Medicare’s lead and provide coverage for the service. The CPT codes are pretty specific in some ways and in other ways, they are ambiguous, which CMS has tried to address with each iteration. The codes do not limit the applicability to a specific condition or disease, but there are some clear rules of the road. The service must be medically necessary of course, and the hardware must be FDA approved with the ability to automatically collect and transmit data to the provider. It is also important that the service captures at least 16 days of data per month, which is what the provider is paid to monitor for at least 20 minutes per month.
Beyond the monitoring codes, there are separate codes that cover the hardware and the setup, which go a long way to mitigating the financial cost to the practice and the patient in getting started. While not every patient will qualify or be eligible in a provider’s panel, the financial upside in the fee-for-service context can be significant -- more than $1,000/year per patient in revenues. And of course in the value-based context, the value proposition is that real-time monitoring leads to better management of the patient, preventing expensive readmissions.”
CF: Are there specific conditions where RPM makes more sense?
JD: “Remote patient monitoring makes sense for conditions where it is easy to monitor the patient and gather accurate data, and where a provider can take specific action based on that data. For example, Type 1 and Type 2 diabetes. They are easy to monitor, we can trust the accuracy of the data, and when blood sugar hits a certain level there is a clear action to take. Remote patient monitoring may also make sense in a couple of other scenarios. The first is trend identification. Where remote patient monitoring can help a patient and provider identify trends and make decisions together, it can deliver value. The second is as an extension of digital access, to facilitate care from home or a remote location – either for convenience, or to overcome access challenges. There are good reasons to consider remote monitoring in these types of scenarios. However, as a medical community, we’re still studying this use and working to understand what truly drives to better care.”
MC: “With the widening of RPM to post-acute care beyond chronic disease, I expect a wide variety of providers will deploy these solutions across many specialties going forward. The big chronic conditions like diabetes and hypertension are some of the obvious ones where companies like Livongo have shown the benefit of a hardware-enabled solution in the employer context. I think you’ll see more specialties beyond cardiology (which pioneered remote monitoring with Holter monitors and ECG patches) integrate RPM, such as OB/GYN, nephrology, and pulmonology. Health systems focused on freeing up hospital beds and improving readmissions rates will deploy these solutions increasingly for post-discharge management and even potentially in the pre-surgical context. In the long-run, a lot of these different threads will converge to a point where the home is a viable site of care and access point for a range of conditions and needs.”
CF: And less sense?
JD: “Remote patient monitoring makes the most sense with conditions that are easy to monitor, where we can trust the accuracy of data, and where a provider can take specific action based on that data. Unsurprisingly, then, it doesn’t make much sense for conditions that don’t fit that criteria. For example, behavioral health.”
MC: “It may seem obvious, but injuries and illnesses where an in-person exam will help identify the cause. Things like lacerations, broken bones, or new onset abdominal pain may make less sense under the RPM model, since a clinician would need to intervene with additional diagnostic or treatment options beyond medication management or behavioral changes. This highlights one of the benefits of the Carbon Health omnichannel approach that allows us to toggle between different modalities depending on the patient’s needs. Medical care is broad and no one approach will be sufficient for all patients and conditions.”
CF: Can RPM help close the gap when it comes to health care inequities?
JD: “Yes. If we think of remote monitoring as part of digital access, it does have the potential to help more people get care. It can eliminate the need to take off work, to find transportation, or to travel a long way for an appointment. At the same time, there is a risk that remote patient monitoring could exacerbate existing inequities. If only those who are tech-savvy can access these types of tools, it may instead widen the gap. We need solutions that work for all.”
MC: “While not yet universal, more than 25 states have some form of reimbursement for RPM in their Medicaid programs and we hope that number continues to grow. With digital health generally, there is the risk that non-digital natives get left behind. Not everyone has smartphones, and not everyone is great with apps. One way to close the gap is making the hardware cellular-enabled and simple enough to use that anyone can use it with a committed support team, whether you own a smartphone or have internet access at home. Connecting a blood pressure cuff to the internet like a Kindle without needing to pair it to a phone would eliminate a lot of the upfront friction to getting people onboard with the technology.”
CF: Myoung, you’ve worked in wearables for a long time too, most recently at Apple. Do you think the RPM space will be dominated by wearables developed for consumers with health features (e.g. Apple) or by medical device companies (e.g. Dexcom)?
MC: “Is it a cop-out to say both? There is a continuum of biometric sensing and monitoring that spans consumer wearables and medical devices, and there are increasingly shades of gray between the two. Wearables like the Apple Watch are incorporating regulated features like ECG, while medical devices like the Abbott Freestyle Libre are getting smaller and cheaper and more consumer-friendly.”
CF: How do you differentiate between the various RPM solutions on the market? And any advice to entrepreneurs looking to pitch you?
JD: “Yes, we’re fielding hundreds of pitches. We differentiate in several ways when we’re evaluating a company and product, including quality metrics, regulatory compliance, the scale of the company, and the use cases for the device. My advice to provider organizations is to think about the experience from the perspective of both your patients and providers. Will it truly enhance the experience for both? Does it support quality care? Is it easy for the provider to use the data, or does it add to data overload? Many organizations make the mistake of only thinking about the member. But if a remote monitoring device does not deliver meaningful, actionable data to the provider, he or she is not going to use it. You have to remove friction for both the patient and the provider to drive engagement and value. For entrepreneurs, think about the needs of your customer. For example, Premise Health is an aggregating entity and a provider. The first thing I will want to know is whether your device integrates with our electronic health record, which is a requirement to be able to work in our environment. You want to position yourself in a positive light and reduce hurdles to implementation.
One final piece of advice is to think about devices as part of an ecosystem, rather than part of a single, linear journey. Many clinical remote monitoring devices are built to do one thing, and one thing only. That is a problem when we start thinking about the need to scale digital health across a population. Premise Health serves 11 million people. We are pushing for flexible solutions that scale, bringing together software and hardware to serve a variety of needs. We’re used to this type of function in consumer devices, with watches and rings that can monitor a variety of health inputs. Clinical devices, however, are behind the curve. We need greater aggregation.”
MC: “There are a lot of RPM companies out there with different focus areas and value propositions. If I had to boil my advice down, it comes down to these questions:
Do you have a solution that solves an important clinical problem? Giving patients devices and visualizing data on a provider dashboard is only half the loaf. It’s important to identify the key moments where the data leads to a clinically meaningful interaction that improves or changes the outcome. This may not be as obvious in the fee-for-service context, but will be absolutely critical as the market increasingly shifts to risk-based models.
Does the technology play nicely with the provider’s existing tech stack? What makes this hard is that the solution needs to be woven into a clinical, operational, and financial workflow that the provider can execute to care for the patient and get paid. This usually means an integration with a legacy EMR or workflow that was created years ago before RPM was on the radar.
How good is your patient support? There is a real human element to how patients engage with the solution. How good are you at getting patients enrolled and onboarded? How sticky are patients once they are using it?”
CF: Any favorite companies in the space to call out?
JD: “I haven’t yet seen any company that has truly cracked the code for success with remote monitoring. We’re still missing clinical remote monitoring devices that aggregate hardware and software to serve more than one purpose. The ability to drive engagement and change behavior are also still challenges. My favorite company is the first to do one of those things.”
MC: “100Plus just got acquired and they raised the most initial capital. Overall, I think the space is super fragmented and it’s still too early to say.”