The use of mobile devices and automatic reporting of biometric readings is introducing new costs to health care that beg the question of how these instruments and services will be paid for. Who will pay for the clinical time and technology associated with remote patient monitoring? How do hospitals and physician practices recoup their expenses?
Wrong questions, say health plan executives. The mHealth options to keep tabs on patients beyond the hospital, nursing home and doctor’s office are getting their push from emerging population health models that pay for the results of value-oriented services, not the specific investments marshaled to achieve those results.
For example, the way Aetna constructs its arrangements with accountable care organizations “would certainly be incentivizing this type of activity,” says Andrew Baskin, M.D., vice president and national medical director for quality performance. But deployment of mobile technology has to be tied into the bigger picture of improving health.
“To go back to the old days when we would pay for every little individual thing a doctor did — so if a doctor decided to use one of these devices, that we should somehow or other pay piecemeal for use of the device — doesn’t make sense in the new world,” Baskin says. “It would be paid for in the sense that if you do well in some sort of pay-for-performance or shared savings that improved care and lowered health care costs, that’s where you would get your financial reward for using these devices, as opposed to being paid for just the use of the device whether it worked or not.”
Health plans are piloting their own experiments into whether they work, and building monitoring options into their partnerships with providers. A care management subsidiary of Humana, called Humana Cares/Senior Bridge, focuses on plan members representing “the top 25 percent of the sickest members” — the most prone to frequent hospitalizations and emergency department visits — and “as part of that care management program, we are providing telehealth solutions for managing our members,” says Eric Rackow, M.D., the management company’s president and chief executive officer. Humana and Aetna are representative of health plans in testing a variety of monitoring approaches. Hospitals “need to help their patients be able to be well at home and, for example, avoid readmissions.”
The mHealth route is part of the bigger map of care management directions. In a payer-ACO discussion, the health plan might draw attention to but not “recommend one way or the other” the use of mobile devices, Baskin says. For congestive heart failure care, to pick an example, part of improving health would be to put a scale in the home and transmit weight on a daily basis to disease-management nurses. “But,” he says, “we wouldn’t specifically say, ‘Hey, we think an automated scale at home is the way to do it.’ ... If they decide that this kind of device will help them manage the CHF population and, therefore, meet the quality metric — which eventually flows into their earning their shared savings portion — then that’s kind of how it works.”
Patient-facing mechanisms for connecting with plan members is a business-minded as well as clinical course of action, says Daniel Garrett, who leads the health care information technology practice of PricewaterhouseCoopers. “It’s definitely picking up a head of steam; the payer out there has a strategy for member engagement, and this is part of it.”
As payers put providers on the spot for prevention, early intervention, best practices and use of near real-time information, mHealth is “a very logical rollout,” Garrett says. “First, the payers are looking for a way to better serve their members; that’s what it’s all about. The payer community, in general, always has been in search of more value for their members, more ‘stickiness,’ and also has been looking for a better way to add value to provider networks. This is certainly a platform and a technology to do that.”
Consumer adoption of mHealth is exploding around fitness devices, “but that’s not taking a chunk out of the cost of treating cancer, diabetes, asthma and congestive heart failure,” he says. For payers, “their task at hand is to move [consumers] from fitness and wellness applications to the core treatment of chronic disease.”
Remote monitoring requires technical expertise and resources to set up and run, but physicians don’t have to worry about the operation of the monitors and the constant stream of data coming from them. “That’s not how we do it,” says Rackow of Humana. “The physicians don’t have to look at the data streaming into their offices on all their patients every day.”
A remote monitoring platform sets alerts based on what a patient’s primary care physician considers an out-of-range reading, and a call center filters that information, then alerts care managers to situations that require attention. Care managers first talk to the member to find out what’s happening and often take care of a problem right then. “If there’s a problem after that process, then the doctor is notified,” Rackow says.
“It’s a system set up to support the doctors and alert them when we discover a problem, including the fact that we talk to the member to confirm what the issue is,” he says. A lot of data “noise” streams into the data center, and true alerts have to be vetted first. “If someone gets on a scale one morning wearing pajamas and the next day after dinner with shoes on, his or her weight’s going to change. That is filtered out.”
A program for mHealth deployment can’t happen in a vacuum. Solid care management capability for many is the first priority and a foundation upon which mobile device connections can be built as “an extension of the care management and care coordination work,” says Juan Serrano, M.D., senior vice president for payer strategy and operations with Catholic Health Initiatives, Englewood, Colo.
CHI is working its way toward remote patient monitoring, but “we’re spending time and energy and resources on a basic customer relationship management model,” Serrano says. “We need to know that we have access to the people who rely on us for their care or who have been assigned to us as part of a defined population.” The CRM system furnishes extensive information about people in the community, including not only phone numbers, but also how they need to or prefer to be contacted, even extending to calling the phone of a next-door neighbor in cases where someone may be hard of hearing or not have a mobile phone. The resulting patient-manager relationship “creates good channels for us to know what’s going on,” he says.
To emphasize the relative value of care management vs. technology, a study of Aetna Medicare Advantage members demonstrated that care of heart failure patients using nurse case managers supplemented by telemonitoring produced no real difference in clinical outcomes and quality of life compared with case management alone, says Randall Krakauer, M.D., Aetna’s national medical director.