ATAs Federal Policy Recommendations for Home Telehealth and Remote Monitoring

Executive Summary The American Telemedicine Association supports the following position on the use of home telehealth and remote monitoring: 1) Medicares 8th Scope of Work, indicating interest in moving forward with the use of telehealth in requiring Quality Improvement Organizations (QIOs) to assist home health agencies in implementing and utilizing telehealth as a tool for reduce acute care hospitalizations, should be recognized and supported. 2) That home telehealth (including remote monitoring) should be used as a part of a coordinated, comprehensive care program designed to reduce health care costs (through decreased hospitalizations and hospital days of care) and improve clinical outcomes. 3) That any practitioner who would otherwise be entitled to receive payment under Medicare for inperson services delivered in the home should be entitled to be paid for such services if they are provided using appropriate remote monitoring technology. 4) Remote telehealth visits provided by homecare agencies or related organizations should be treated by Medicare similarly to in-home, face-to-face visits for purposes of eligibility and payment. 5) The related cost of telehealth equipment should be reported as a reimbursable cost in the home health agency cost report. 6) The cost of telehealth equipment should be taken into consideration in establishing the agencys Home Health Resource Group (HHRG) rate. 7) Any individual who would otherwise be entitled to receive coverage under Medicare for in-person encounter-based monitoring services should be entitled to receive such services through the use of remote monitoring. 8) The cost of remote vital sign monitoring devices should be reimbursed as a technical component fee and included within either the cost reports of the home health agency or included within the reimbursement rate of independent diagnostic testing facilities (IDTFs). a. For those beneficiaries ineligible for the Medicare Part A home health benefit, reimbursement for telemonitoring equipment and the creation of HCPCS codes for the associated clinical monitoring performed by a health care professional would allow for reimbursement under a new Medicare Part B telemonitoring benefit. 9) Congress should encourage the use of medically-appropriate self-care technology that is designed to keep individuals healthy and remain in their own homes. Such support for medically prescribed technology could be provided either as a covered benefit or through a tax deduction for the cost of the purchase. 10) Medicare must implement a payment structure for disease management programs provided by remote monitoring systems/programs. The current Medicare reimbursement model excludes these highly efficient, patient centered and cost effective approaches to dealing with chronic disease.

Background

The Centers for Medicare and Medicaid Services estimates total national health expenditures for home care was $40 billion in 20031, an increase of almost ten percent over the previous year. An additional $111 billion is spent for nursing home care. Over 60% of home care monies come from public funds. Home cares rate of growth in expenditures has accelerated over the past four years, surpassing the growth of other health care services. With the aging of the population, this rate of growth will only accelerate. Of concern is the human and financial cost of coping with long-term, chronic diseases, especially chronic diseases such as diabetes and congestive heart failure. Type II diabetes mellitus is quickly becoming the most common chronic disease in the United States. It affects more than 7% of the adult population. Nearly 16 million people in the United States have been diagnosed, but an additional 8 million do not yet know they have the disease.2 With Americas obesity rate increasing, the incidence of Type II diabetes is expected to increase as well.3 Diabetes can lead to several secondary complications including blindness, kidney failure, coronary artery disease, stroke, nerve damage, and infections.Congestive heart failure affects about 5 million Americans each year. About 20 percent of hospitalized patients who are over 65 have heart failure. Each year, another 550,000 people are diagnosed for the first time. It contributes to or causes about 300,000 deaths each year.

Overcoming these growing challenges is a major barrier facing health care today. Home telehealth can help meet these challenges. Through remote monitoring of vital signs and the use of technology to allow patients more appropriate access to a health care professional, patient care can be significantly improved while the costs of providing that care reduced. Quality of Care: Home telehealth, used as part of a coordinated, comprehensive care program, has 1) demonstrated quality improvement; 2) allows the individual the dignity of remaining in their own place of residence for as long as possible; and 3) provides care that is equal or superior to approaches that rely solely on health providers coming into the home for scheduled visits. An independent analysis of monitored and non-monitored patients conducted for a telemedicine equipment vendor4 assessed OASIS data from over 178 home health agencies using remote home monitoring and 300 agencies that do not use home monitoring. The study concluded that use of remote monitoring has proven to reduce hospitalization and emergent care visits while improving functional status when compared with a comprehensive clinical management program.5 For diabetes care, the average improvement/stabilization rate in Activities of Daily Living (ADL) for patients using remote monitoring was 77.2% compared to 70.4% for those patients not using remote monitoring. For chronic obstructive pulmonary disease, the improvement for remotely monitored patients was 80.3% vs. 71.8%. A study published in the Journal of the American College of Cardiology looked at a group of patients suffering from grade 3-4 congestive heart failure for a two year study period, 12 months prior to the use of home monitoring and 12 months after the introduction of the home telehealth monitor. After the use of the remote monitor, the mean total annual hospitalization rate was reduced from 3.2

Table 2: National Health Expenditures Aggregate Amounts and Average Annual Percent Change http://www.cms.hhs.gov/statistics/nhe/historical/t2.asp 2 Leontos, Wong, Gallivan, & Lising, 1998 3 Leontos et al., 1998 4 Independent Analysis of monitored/Non-Monitored Patients, January 1, 2002 March 31, 2004, Strategic Healthcare Programs, Santa Barbara, CA. Study conducted on behalf of HomMed. 5 Ibid. p1

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hospitalizations per person to 0.8 hospitalizations per person. The days of care per person per year was reduced from 26 days to 6 days (p<0.001 for both). Cardiovascular admissions decreased from 2.9 per year to 0.8 per year and duration from 23 days to 4 days/year (p<0.001). The functional status (the ability to perform daily activities, expressed in a 1-4 ratiing scale) was improved from a selfreported 1.4 to 2.3 rating (p<0.001).6 Efficiency: Remote monitoring programs for the elderly are particularly cost-effective. A demonstration in Tennessee of the use of home telehealth for congestive heart failure patients identified significant cost savings and identified potential national savings. Based on hospital days per patient per year with and without intervention, and the cost of intervention by telehealth, it was projected that the national cost of care for CHF hospitalizations could be reduced from 8 billion dollars to 4.2 billion dollars.7 Kaiser Permanente of Sacramento, California, conducted a study from May 1996 through November, 1997. The study was comprised of intervention and control groups of one hundred patients, each with chronic conditions. The control group continued to receive home-care visits according to their existing plan of care, while the intervention group was remotely monitored with a home telehealth system as a supplement to home-care visits. The data revealed that home telehealth provided instant access to care, created considerable efficiency in the delivery of home care and reduced hospitalization by two hundred days in the intervention group. Total mean cost of care was $1948 in the intervention group and $2674 in the control group.8

Recent Federal Interest and Support for Home Telehealth and Remote Monitoring
Medicares QIOs: Operating through Quality Improvement Organizations (QIOs), the Centers for Medicare and Medicaid Services (CMS) recently indicated its interest in the use of home telehealth. QIOs work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time and help ensure payment is made only for medically necessary services. Starting this year, CMS has directed the QIOs to assist home health agencies in implementing and utilizing telehealth as a tool to help reduce acute care hospitalization and work with home health agencies to facilitate organizational culture improvement and implementation and use of telehealth technology. Department of Veterans Affairs: Direct medical services provided through the Veterans Administration are making significant advances in the use of home telehealth and remote monitoring through their care coordination program. The agency has established such programs in all 21 regions as part of their Care Coordination Home Telehealth strategy. These programs focus on veterans with diabetes, chronic heart failure, chronic obstructive pulmonary disease, PTSD, depression and spinal cord injury.

ATAs Federal Policy Recommendations

Intensive Home-Care Surveillance Reduces the Need for Hospitalization in Elderly Patients With Severe Congestive Heart Failure, JACC, Feb. 1994, 433A, 966-78 7 Dimmick, S.L., Burgiss, S.G., Robbins, S., Anders, M., Black, D. & Jarnagin, B. (2003). "Outcomes of an Integrated Telehealth Network Demonstration Project" Telemedicine Journal and e-Health. 2003. Spring;9(1):13-23 8 Johnston et al. 2000. Archives of Family Medicine

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Changes in federal policy are needed in order for other health providers and patients to take advantage of the benefits offered through the use of remote health services. The proposals presented below make distinctions between two types of services: Home telehealth visits refer to the use of remote devices to allow the patient to communicate and provide medical information, including vital signs, to a health professional via live interactive telecommunications. Such visits may be provided by home health agencies, disease management programs or individual practitioners for the purpose of follow-up care. Remote monitoring may be periodic or continuous and provide one or more objective physiologic data such as vital signs or subjective data such as disease management education assessment, symptom assessment and knowledge assessment from the patient to a distant location using a capturing device and telecommunications links. Such services may be provided by home care agencies, independent diagnostic testing facilities (IDTFs) or other health providers. Home telehealth visits Any practitioner who would otherwise be entitled to receive payment under Medicare for in-person services delivered in the home should be entitled to be paid for such services if they are provided using appropriate remote monitoring technology. Reimbursement for such services should be subject to the same guidelines stated within the physicians fee schedule. Such services should be allowed, provided that the service: 1. meets required documentation criteria for an in-person visit; and 2. does not substitute for needed in-person care or in-person home services. Remote telehealth visits provided by homecare agencies or related organizations should be treated by Medicare similarly to in-home, face-to-face visits for purposes of eligibility and payment. Such services should be allowed provided that the service: 1. is ordered as part of care certified by a physician; 2. meets required documentation criteria for an in-person visit; 3. does not substitute for needed in-person home health services; and 4. is considered the equivalent of a visit under criteria developed by the Secretary. The related cost of telehealth equipment should be reported as a reimbursable cost in the home health agency cost report and reflected in the agencys Home Health Resource Group (HHRG) rate. Under Medicare Part A, home health agencies should be able to continue to utilize telemonitoring equipment and provide clinical management services with no charge incurred by the patient for these services. The current lack of compensation for home health agencies or other providers creates a significant disincentive to making telehealth more broadly available to homebound patients. The current situation should be amended.

Remote vital sign monitoring Any individual who would otherwise be entitled to receive coverage under Medicare for in-person encounter-based monitoring services should be entitled to receive such services through the use of remote monitoring. Reimbursement levels for the health care provider monitoring vital signs at a distance should be established using existing resource-based payment methodologies used for inperson monitoring; such services should be subject to the same guidelines developed on the frequency of billing for the in-person encounter-based monitoring service.

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If the remote vital sign monitoring is prescribed and delivered under Medicare as part of approved home care services, the costs of delivering the services, including the costs of the equipment, should be classified as allowable costs and included in the appropriate section of the home health cost report. Prescribed remote vital sign monitoring, used for such single-purpose functions as cardiac, glucose and pulmonary data, and provided by the appropriate provider type, should be reimbursed as a covered benefit for patients not requiring Part A home care services. The cost of remote vital sign monitoring devices should be reimbursed as a technical component fee and included within either the cost reports of the home health agency or included within the reimbursement rate of IDTFs. For those beneficiaries ineligible for the Medicare Part A home health benefit, reimbursement for telemonitoring equipment and the creation of HCPCS codes for the associated clinical monitoring performed by a health care professional should be developed to allow for reimbursement under a new Medicare Part B telemonitoring benefit. The level of payment to IDTFs, or other appropriate providers of remote monitoring services, should reflect the costs of providing the service on a continuous, 24-hour basis, where medically prescribed. Medicare payments to IDTFs or other appropriate providers of remote monitoring should be based on medically prescribed services, reflect specific disease qualifiers, and include the total costs of providing either intermittent or continuous monitoring, as needed.

Self-care technology Congress should encourage the use of medically-appropriate self-care technology that is designed to keep individuals healthy and remain in their own homes. This is particularly important for individuals with diagnosed chronic diseases. Such support for medically prescribed technology could be provided either as a covered benefit or through a tax deduction for the cost of the purchase. Consumer-driven self-care technologies can prevent acute exacerbations of an individuals condition, thereby preventing costlier health care interventions. Individuals affected by chronic disease -- and their caregivers -- become more engaged in the management of their health when empowered with tools that are proven to make a difference.

Disease management Medicare must implement a payment structure for disease management programs provided by remote monitoring systems/programs. These programs have been shown to improve quality of life and to decrease the overall costs of health care. The current Medicare reimbursement model excludes these highly efficient, patient centered and cost effective approaches to dealing with chronic disease. People with chronic disease consume a significant amount of the national health expenditures, and although several studies have demonstrated improved health outcomes and a more cost effective environment, Medicare is preventing expansion of these programs by not providing reimbursement for these programs. Product offerings from disease management and home health organizations emphasize technology as a tool to strengthen the bridge between patient and clinician, encourage interactive case management, and solicit patient information and feedback as a means of self-empowerment, particularly for those patients with chronic conditions. The dearth of Medicare payment mechanisms for reimbursement of remote management services provided by a physician, practitioner, or care provider is a great inhibitor to the adoption of these technologies as instruments in disease management approaches. Medicare must institute reimbursement for remote monitoring services for

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people with chronic diseases. Also, coverage parity between comparable face-to-face and remote patient management services should be established where appropriate.

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