The Trump Administration has taken a modest step towards expanding the use of remote monitors to track blood pressure and other vital signs for Medicare recipients living at home. While there is little evidence so far that remote monitoring improves health outcomes, advocates for seniors as well as device manufacturers believe the tools can make it more likely that frail older adults can continue to live at home rather than move to assisted living facilities or nursing homes.
However, the proposals include important limitations. Only certain devices would be eligible, and the rule makes no provision for Medicare recipients who do not use home health agencies.
The Centers for Medicare and Medicaid Services (CMS) has proposed a new rule that would allow home health agencies to include the costs of monitoring devices when they report their expenses to the government. The rule would not directly reimburse home care companies for the added expense, but would make it possible for CMS to consider the expenses when setting overall reimbursement rates. Earlier this year, CMS created a new billing code for remote monitoring devices prescribed by physicians.
Fostering emerging technologies
The new proposal would apply to equipment for “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver.”
While CMS says the payment change “is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data is shared among patients, their caregivers, and their providers,” it is, in fact, a very modest step forward.
For example, the proposal applies only to devices that monitor vital signs such as blood pressure. But for many chronically ill seniors, it may be more important to track their ability to move around their home. For example, it may be more useful to know whether someone is at risk of falling when they get out of bed to go to the bathroom in the middle of the night. Or whether a person with dementia has forgotten to turn off her stove. Or if someone is unable to answer a phone or swallow a pill.
This is not the kind of clinical medical monitoring CMS seems to have in mind, but it may be at least as important for many frail seniors.
I’ve fallen, and can’t get up
Tools exist to collect this information. For instance, cameras and devices measure how long someone has been out of their bed in the middle of the night, or on the toilet. Already, some firms provide not only monitoring but will send assistance if a client triggers a warning by unusual behavior.
These go well beyond the well-known medical alert systems—those pendants that let you report a fall that already has happened. And, by the way, traditional Medicare won’t pay for those either—though some Medicare Advantage managed care plans may.
Of course, these new devices raise important privacy issues. But that’s a story for another day. The question for CMS is should Medicare pay for services that collect this kind of non-clinical information. It would not under the proposed new rule, both because the monitoring devices are not eligible and because they are not typically provided by a home health agency. Indeed, in some respects, these devices and services may substitute for a traditional agency.
What of the monitors that do track medical vital signs? Do they improve patient outcomes or save money by reducing emergency room visits or allowing people to remain at home? The jury is still out, which may be why CMS is acting so cautiously.
Of course, wearable monitors are all the rage. But FierceHealthcare.com reports that one extensive literature review found little evidence that wearables improve patient outcomes. That 2018 paper, in the journal NPJ digital medicine, found few robust studies of the benefits of biometric devices. And even those had important limitations and ambiguous results. For instance, one study of patients with chronic lung disease found few measureable benefits for those who used wearables:
“Patients in the intervention group experienced reductions in hospitalizations, emergency department visits, and length of stay, but none of the reductions were statistically significant when compared to the control group.”
Given technological advances, the growing shortages of personal care workers, and the expense of using them, remote monitoring eventually will play an important role in the care of older adults with chronic conditions. But first we are going to have to learn much more about what really works. And then we are going to have to figure out how to pay for it.
To its credit, CMS is paying attention to the issue. But it is moving very slowly.