As the Internet of Things (IoT), rising healthcare costs and value-based payment reform converge, it’s clearer now, more than ever, that healthcare organizations need innovative approaches to provide higher-quality yet more cost-effective care.
To stay ahead of the innovation curve and respond to the “consumerization of care” that patients are expecting, many organizations are turning to virtual care models, such as telehealth and remote patient monitoring (RPM), to change where and how healthcare is delivered, provide further access to care, improve outcomes and reduce costs using patient-generated health data (PGHD).
Telehealth and RPM reimbursements accounted for just 0.003% of the Centers for Medicare & Medicaid Services’ (CMS’s) $990 billion budget in 2016. However, after announcing the Physician Fee Schedule for 2018, CMS—the largest payer in the United States—is starting to get on board with digital health technology adoption.
Beginning January 1, 2018, CMS is actively incentivizing the use of RPM in two major ways:
- CMS unbundled CPT code 99091, meaning fee-for-service clinicians can be reimbursed $58 a month per Medicare patient if they spend a cumulative 30 minutes reviewing data collected via RPM.
- CMS approved a new Improvement Activity to reward clinicians participating in the Merit-Based Incentive Payment System (MIPS) for using RPM technology to engage patients, called “Engage patients and families to guide improvement in the system of care.”
MIPS aims to tie payment updates to value by introducing a scoring system that incorporates care quality, total cost of care, “Improvement Activities” and meaningful use of certified electronic health record technology (CEHRT).
Each clinician (or group of clinicians) earns a final MIPS score for the performance year, resulting in a positive or negative update on Medicare Part B professional services rates. The updated rate will apply for a full calendar year, two years following the performance year. The first MIPS performance year was 2017, and healthcare organizations are reporting to CMS in the first three months of 2018, which will drive the first MIPS payment updates in 2019.
Patient-Generated Health Data, Improved
The Improvement Activities category within MIPS is worth 15% of the final score in each of the first two years of the program, and is meant to reward activities that drive clinical practice improvement for all patients seen. To earn points, clinicians choose from 93 activities, including care coordination, patient engagement, safety and more. Bonus points are available for using CEHRT.
While some of the CMS Innovation Center’s test models, such as the Comprehensive Primary Care initiative, have experimented with promoting PGHD over the past few years, clinicians could not gain “credit” in the mainstream Medicare program for the collection and use of PGHD until now.
After a swath of positive evidence that PGHD utilization improved outcomes, CMS convened a workgroup with industry representatives and crafted a new Improvement Activity called “Engage patients and families to guide improvement in the system of care.” This new activity will enable clinicians using digital tools to collect PGHD to receive 25% of their Improvement Activities points. Clinicians attesting to this improvement activity using CEHRT can also qualify for the available 10% bonus score in the Advancing Care Information (ACI) performance category for the 2018 reporting year.
To be eligible for MIPS credit under this new Improvement Activity, a clinician must use digital health tool(s) that:
- Engage patients and families to deliver ongoing guidance and assessments outside the encounter.
- Collect and use PGHD in an “active feedback loop” with the patient (e.g., provide PGHD in real or near-real time to care team members in a way that they pay attention to it, incorporate it into the medical record and/or generate clinically endorsed automated feedback to the patient).
- Are “clinically endorsed” (e.g., can inform the patient or care team in a timely manner about a patient’s “clinical status, adherence, comprehension or other indicators of clinical concern”).
Clinicians also must be able to attest that they have completed this approach for at least 90 days within the reporting year.
This Improvement Activity will carry a “Medium” weight for reporting year 2017 and a “High” weight for reporting year 2018, according to the CMS Helpdesk.
Eligible Digital Health Tools
While many digital health solutions have the potential to meet the aforementioned criteria, the best eligible tools will transmit both clinically valid and contextual data back to care teams. RPM, use of patient engagement platforms, and use of cellular or web-enabled bidirectional systems are all activities that could potentially fall within the bounds of the Improvement Activity.
A few solutions that clinicians could use to meet CMS’s criteria include:
- Noteworth, an RPM platform to prescribe and deliver virtual care to patients at home, and
- Wellpepper, which develops clinically validated mobile care plans that incorporate PGHD.
Additional Guidance Needed
CMS has not yet released any additional clinician-facing guidance for this new Improvement Activity, which begs implementation questions as clinicians become more aware of and interested in attesting to it. For example, “clinically endorsed,” “active feedback loop” and “near-real time” are only loosely defined, which they have in common with many terms used across the Improvement Activities category.
Despite these gray areas, we believe that the clear intent of this new activity is to encourage a broad variety of RPM activities, so long as they are “clinical” in the sense that they directly connect to the patient’s care team and plan of care. For example, exchange of glucometer and blood pressure readings would clearly fall within the intent of “clinical,” whereas fitness tracking data—although potentially helpful—would not. In the short term, we expect CMS to take a relatively light touch when monitoring compliance under this category, as long as clinicians can reasonably back up their attestations if audited.
Barriers to Adoption
Now that CMS has worked to remove one of the major barriers to digital health technology adoption by rolling out new financial incentives, healthcare organizations should be further motivated to actively implement patient engagement and RPM tools. Healthcare organizations in the process of selecting tools to implement face the uphill job of not only discovering and vetting the functionality of those solutions, but also choosing those that fit their business goals, reimbursement structures and clinical workflows.
A few critical things healthcare administrators should keep in mind when considering a digital health solution include:
- Funding for digital health technologies: Does the organization have a flexible budget cycle? Are there funds dedicated to exploring digital health innovations?
- Clinical staff buy-in: Does this new tool fit into clinicians’ existing workflow? Will the addition of a new tool be disruptive to their day-to-day operations, or will it alleviate administrative burden? Who will handle any necessary education, awareness and training?
- Patient readiness: Are patients interested in using digital health tools and remote monitoring to share PGHD? Are there specific service lines or patient populations within the organization that would be a particularly good fit?
- Security and interoperability: Does the digital health tool being considered integrate with the organization’s core financial and clinical management systems, or will it be another silo of data? Does it meet the organization’s security and interoperability goals and standards? Are there sufficient IT resources necessary to support the integration of a new tool?
- Defining success: Can executives and stakeholders come to a consensus on the clinical and business goals for the new technology? What are the agreed-upon expectations, milestones, objectives and success indicators? How will the tool be evaluated?
- Billing and documentation: Does the tool integrate with the organization’s internal infrastructure to track and aggregate quality measures toward its target reimbursements, such as the Quality Payment Program (QPP)/MIPS?
One Small Step for Value-Based Care, One Giant Leap for RPM
With the shift toward value-based reimbursement already underway, this latest change signals CMS’s recognition of RPM technology as a fundamental component of high-quality care delivery systems that achieve the Triple Aim: healthier patients, an enhanced patient experience and reduced costs of care.
The update to MIPS demonstrates a significant advancement not only toward making digital health technology an integral part of a patient’s care experience, but also incentivizing clinicians to leverage cutting-edge tools more effectively to improve care quality and outcomes. We see the introduction of the Improvement Activity as a small but concrete step forward in improving the policy environment (and therefore the adoption rate) for RPM.