Making Remote Patient Monitoring Scalable and Sustainable

Complex federal and state regulations, confusing reimbursement rules pose challenges to RPM, hospital at home growth.

Editor's note: This article appears in the March/April 2022 edition of HealthLeaders magazine. It is a sidebar to the cover story: “Home Sweet Home: Healthcare Moves Away From the Hospital”

Partly in response to the pandemic, healthcare organizations have been launching remote patient monitoring (RPM) and hospital at home programs as a means of providing more services to patients at home and reducing hospital crowding. But federal and state governments have long had a heavy hand in regulating how healthcare can be delivered to the home.

Both federal and state regulators have kept firm control on telehealth by enforcing where it can be used and who can use it, to the point that advocates have long argued that government is hindering telehealth adoption. Only certain types of healthcare providers are allowed to use the technology to deliver healthcare services, and those services often must come from and go to specified healthcare settings, like a hospital, doctor's office, or clinic.

"Generally speaking, the hospital is a place," says Rachel Goodman, a partner with the Foley & Lardner law firm, specializing in digital health regulation. "In order to have a hospital license, you have to have that address," and regulators are cautious in approving services that extend outside that physical location.

In addition, she says, some within healthcare are questioning whether healthcare services for acute or critical care patients should be permitted at home, where the opportunities for clinical errors and even fraud are much more apparent.

The pandemic allowed for a surge in telehealth because the federal government and most states enacted several emergency measures aimed at expanding telehealth access and coverage. Those actions gave more care providers the freedom to use the technology, expanded the list of sites to include the home, and even expanded the types of technology that providers could use to include audio-only telehealth (e.g., over the phone) and RPM platforms.

Those measures are only in place until the end of the public health emergency (PHE), and while several states have permanently amended their telehealth rules to keep those expanded freedoms in place, there's still a lot of confusion—particularly at the federal level—about what happens when the PHE ends. This, in turn, has kept some health systems from developing long-term telehealth and RPM plans.

"It's certainly complicated," says Goodman. "We're not going back to the way we were [before the pandemic], but it's hard to tell what will happen right now."

This includes the Acute Hospital Care at Home program launched by the Centers for Medicare & Medicaid Services (CMS) in early 2020, as the pandemic was taking hold. The idea behind that new payment model was to give hospitals more leeway to treat patients with acute care needs at home, rather than having them take up a hospital bed at a time when those beds were in high demand for COVID-19 cases.

While hundreds of health systems have signed on to the program, there's little indication from CMS as to how long it will last. CMS is typically slow to reimburse for innovative services like telehealth, preferring to wait for several large-scale studies that prove the value of the new service in both reducing cost and improving outcomes. With the Acute Hospital Care at Home program just now gathering steam, that may take a few years.

As for RPM, CMS only began recognizing what it calls "remote physiological monitoring" services with a handful of CPT^© (Current Procedural Technology) codes in 2019, giving care providers limited opportunities to be reimbursed through Medicare or Medicaid for the collection of data from patients at home. CMS has since added some CPT codes for "remote therapeutic monitoring" services, expanding the field to cover certain limited RPM functions, but again the available reimbursements are nowhere near enough to cover the time and energy that health systems put into these programs.

Beyond the pandemic, Goodman sees the most growth in RPM around post-discharge services, such as rehabilitation and chronic care management, which are ideally suited for home monitoring. That's because those services apply to patients who have been discharged from the hospital.

"That's all really postacute care under a different name," she says.

For hospital at home and other services addressing acute care needs, she says, federal regulators will have to more clearly define whether a patient is discharged from a hospital into a home program (as opposed to a skilled nursing facility or similar rehab site), or whether that patient is still considered a part of the hospital's inpatient platform. That affects everything from quality and safety benchmarks to hospital staffing requirements.

Goodman expects it will take a few years for CMS to signal more aggressive adoption of hospital at home-style services. That'll prompt many health systems to go slowly with those platforms, as they need Medicare and Medicaid coverage to be able to sustain and scale up the offerings.