A push to improve reimbursement for remote patient monitoring programs has stalled, and that could prompt health systems and hospitals to think twice about launching or expanding their platforms.

The roadblock is coming from the American Medical Association's 21-member CPT Editorial Panel, which hasn't been able to agree on amendments to the CPT codes covering RPM services. The panel indefinitely suspended the proposed changes at its meeting last month.

RPM was initially recognized in 2019 by the Centers for Medicare and Medicaid Services through a small set of codes for remote physiologic monitoring services, enabling clinicians to seek reimbursement for gathering data from patients through certain medical devices outside the hospital setting.

CMS has slowly amended and expanded those codes since then, adding codes for remote therapeutic monitoring.

The issue has hampered the development of new RPM programs, as health systems and hospitals often rely on Medicare reimbursement to sustain those programs. Without that financial support, some organizations may decide against launching or expanding their platforms.

Oren Nissim is CEO and cofounder of Brook Health, a remote patient monitoring company, and is an expert in the realm of RPM reimbursement. We sat down with Nissim to discuss the issue this is creating for RPM providers, caregivers and patients, and how the speed of innovation is finally appearing but these debates are slowing the progress down for everyone.

Q. Please describe what was considered at the May CPT Editorial Panel meeting and what happened.

A. At the May CPT Editorial Panel meeting, proposed changes to the CPT code language covering services like remote patient monitoring were reviewed. The proposed changes aimed to adjust the requirements for reimbursement, such as the number of data points needed to be gathered from a patient each month, and the amount of time a provider must spend on the data to qualify for reimbursement.

The panel discussed whether these requirements were warranted or if reimbursement could be provided with less constraints on the patient and provider.

However, the panel did not reach an agreement or resolution during the meeting. Many stakeholders in the market have expressed that the current requirements seem too high and that more flexibility and reasonability should be introduced. The panel has not yet concluded whether this is indeed the case.

The main issue appears to be the lack of a clear definition of the form of engagement required to provide effective RPM services. RPM was not designed merely as a means to pay for devices placed in patients' homes; while these devices are necessary to provide the services, they are not the service itself.

The panel likely needs more data and a better description or decision on what constitutes a good form of engagement in order to make an informed decision on the proposed changes to the CPT code language for RPM reimbursement.

Q. The May CPT Editorial Panel meeting could prompt hospitals and health systems to think twice before launching or expanding RPM. Please elaborate on your feelings regarding the meeting outcome.

A. The outcome of the May CPT Editorial Panel meeting should not necessarily prompt hospitals and health systems to reconsider launching or expanding RPM programs. Instead, it should put pressure on those involved to focus on the form of engagement that drives outcomes and understand that providing a device and connectivity in the home is merely the cost of creating an engagement model.

RPM was designed to save money, through engagement on both the patient and the provider side, that would lead to the right health outcomes.

The panel is likely hesitant to make changes because they believe the feedback they have received is not entirely accurate. The language in the CPT codes was designed to define the form of engagement, and while some flexibility may be needed, significantly lowering the bar is not the right answer.

Lowering the bar too much would not create a good form of engagement but would instead make it easier to obtain reimbursement without providing the intended value.

The focus should be on drafting a better form of engagement and working together to achieve this goal, rather than pushing for limitations on the current form of engagement. The current form was meant to initiate a discussion, which is now happening.

However, the discussion should not be one-sided, with stakeholders simply pushing for more flexibility. Instead, the focus should be on the original objectives of RPM: achieving better outcomes and cost savings. If programs cannot demonstrate support for these goals, they should not be participating in RPM.

Q. What are a couple real-world examples of how the reimbursement issue is impacting patients and clinicians?

A. The reimbursement issue is impacting patients and clinicians in various ways, particularly in regard to co-payments for RPM services. While the May CPT review is not directly driving this issue, a bill proposed in Congress to remove co-payments from RPM has brought it to the forefront.

Patients, especially those on Medicare, may struggle to afford the monthly co-payments for RPM services, which are provided to help manage their chronic conditions at home. In the past, these patients would have been placed in nursing homes or received expensive, labor-intensive home visits from nurses.

While using technology for RPM is the right approach, penalizing patients with co-payments can be detrimental, particularly for those living on pensions or with limited income.

Although the co-payments for RPM are relatively low, ranging from $10 to $30, they are still a barrier, especially considering that these are monthly recurring costs. The perception of being taxed for these services can deter patients from participating, ultimately detracting from the success of RPM programs.

Q. You also suggest the speed of innovation with RPM is finally appearing. Please discuss the state of the technology and where it's heading.

A. The speed of innovation in RPM is accelerating, with technology playing a crucial role in extending and expanding the human engagement model. AI, in particular, has the potential to enhance the conversation between care providers and patients, allowing for more efficient collection of information without the need for in-person meetings.

By using AI correctly, healthcare providers can gather more signal and less noise from patient data, leading to better insights and improved care.

The adoption of RPM technology is accelerating and expected to reach mass market scale within the next five years. As technology becomes more accessible and affordable, the friction in implementing RPM solutions is being removed. The focus now shifts to ensuring the correct and responsible implementation of these technologies. AI is an accelerant, enabling healthcare providers to deliver more efficient and effective care.

It is crucial to recognize that while AI can automate certain tasks, human involvement remains essential to oversee care protocols at the home and address healthcare concerns and medical feedback. AI can assist in collecting information and asking routine questions, but while we see promising evolution, AI cannot replace the human touch entirely.

As RPM technology becomes more widely available, it has the potential to transform the care of patients with chronic conditions, much like how GPS technology has changed navigation. The correct utilization of AI and other RPM technologies will be key to unlocking this potential and improving patient outcomes while reducing healthcare costs.

Follow Bill's HIT coverage on LinkedIn: Bill Siwicki
Email him: bsiwicki@himss.org
Healthcare IT News is a HIMSS Media publication.