Last week I wrote about the importance of workflows to ensure success with Remote Physiological Monitoring (RPM), so it is timely that this past Friday, Modern Healthcare posted an article on the same topic: How hospitals are having a hard time navigating the high cost of remote patient monitoring.
The RPM ROI Formula
Now, on the back of a napkin, the RPM ROI calculation of “hard dollars” is quite simple.
There’s a one-time investment into the monitoring equipment (a scale, a blood pressure cuff, a pulse oximeter, a glucometer, etc.). There is, of course, also a one-time investment into the design and implementation (a.k.a., training) of the workflows, though I (a) suspect that this is done mostly internally vs. with experts like our team and (b) does not get the level of systematic scrutiny that we put on it. So for the sake of the ROI calculation, let’s omit that for a minute.
On the operations side the investments include fees for the RPM platform (for a general overview of an RPM system, see my article on “Dashboard Medicine”), as well as the time for a monitoring nurse to monitor, intervene, and escalate as needed. Note that this role can also be outsourced but, as the Modern Healthcare article highlighted, there are clinical quality advantages to keeping the monitoring in house.
On the “return” side in a fee-for-service environment, multiple reimbursement elements are available, depending on the scope of the service (RPM, CCM, CCCM, RTM) and on the insurer of the patient — Medicare, Medicaid, or Commercial — plus the type of organization: FQHC/RHC or “none of the above”.
In a nutshell — for Medicare (since 2017) and Medicaid (varies by state) in most cases good RPM reimbursement is available for multiple different services, such as the setup, the monitoring, etc. For commercial insurances it is still hit or miss (and mostly miss).
New, as of 2024, is that FQHCs and RHCs can also now bill Medicare, though reportedly payment processors are still having a hard time catching up with that reality (especially since CMS made it super-confusing by implementing it through the multiple billing of the same code in the same period for the same patient).
Providing RPM and Other Care Management Services
For the scope of service, aside from RPM reimbursement codes, many programs on the outpatient side have the ability to also bill for Chronic Care Management (CCM) or Complex Chronic Care Management (CCCM) in parallel with RPM. For some patients clinicians can also bill for Remote Therapeutic Monitoring (RTM).
Here’s a short list of RPM codes from CMS that can be used for RPM:
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99454 RPM fee, 16 measurements, monthly
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99457 RPM treatment & management, 20 min, monthly
And here’s a select list of CCM codes:
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99490 CCM services, 20 min, monthly
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99491 CCM services, 30 min, monthly
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99487 Complex CCM services, 60 min, monthly
At current (2024) Medicare reimbursement rates even without any additional treatment & management beyond the initial 20 min, the total monthly amount for 99454 and 99457 is $95 per patient, per month. The CCM/CCCM services 99490, 99491 or 99487 can add between $64 and $134 per patient, for a total of $159 to $229 per patient month.
One often forgotten aspect in the ROI calculation is also that patients in the program will also be seen much more frequently, potentially every 4-8 weeks (or 6-12 times a year), compared to 2-3 times a year (at best). Most likely some of these patients visited the ER more often than their clinician’s exam room. So, adding another 3-10 Evaluation and Management Visits (99212 etc.) can add another $188 to $627 per year, plus any additional lab tests.
Overall, a patient’s participation in a comprehensive RPM + CCCM program with regular office visits can yield a total average revenue of roughly $1,200 every 6 months, or $200 a month (i.e., 6 x ($95 + $64) + 4 x $63).
On the inpatient side of a health system, enrolling patients in post-discharge monitoring to avoid unreimbursed readmissions usually pays off very quickly. According to my last conversation with a hospital CFO, the cost of an readmission can quickly exceed $10k of net cost to the hospital. Here, the ROI is all but guaranteed when the readmission of just a fraction of patients is prevented.
The Cost of Care
On the expense side, the fees for the RPM platforms can typically range from $10 to $50 per patient per month.
One of the most critical variables on the expense side is obviously the time of the monitoring nurse to manage the patient’s care and ensure the patient’s continued participation. Since the 20 minutes of 99457 is billed “incident to” (i.e., under the general supervision of the clinician), the clinician does not actually have to spend 20 min. with the patient’s data, unless prompted by the nurse.
The biggest variation I have seen is how many patients a single nurse can handle. On the high end I know programs where each nurse has a panel of 150-200 patients. Other programs stop case loads at 80 patients, which obviously can make a big difference.
The highest numbers I’ve seen are from programs that (1) employ designated, well-trained nurses, (2) highly reliable, user-friendly monitoring devices and RPM software, (3) superb patient enrollment practices.
The Three Secrets to Success
As one CEO of a Remote Patient Monitoring puts it in the Modern Healthcare article: You have to be “really good at technology, really good at process and really good at people. Doing all three right is where the success really comes from.”
The workflow aspect we covered in last week’s article and the reliable and user-friendly technology was described here, though I’ll probably go a little bit deeper in a future article.
As to the people part — we are big fans and ardent practitioners of the ADKAR® change management model to ensure that all key stakeholders are engaged. This includes the clinical leaders that can set an example, the participating clinicians, the monitoring nurses, and the team involved in onboarding the patient and providing technical support along the way. Everybody on the team needs to understand why this is important.
My Analysis of RPM Underperformance
From my vantage point, health systems are frustrated with the performance and cost of an RPM program for a variety of reasons:
Reason A – Too many patients: With a total patient population of tens of thousands of patients, the initial outlay for even just 10% of their patients that have two or more chronic diseases can quickly reach millions of dollars in investments.
My Antidote: build a robust ROI model that includes ALL factors (including downstream revenue and indirect benefits, such as outcomes data, patient satisfaction scores, etc.) and launch a Proof-of-Concept to validate assumptions regarding reimbursement and cost; patient enrollment; patient satisfaction and engagement; etc.
Reason B – The technology is too cumbersome or training patients is done poorly. While they are on their way out, many RPM programs still use monitoring devices that rely on Bluetooth to connect to a Smartphone or other hub to transmit their data. While Bluetooth connections have improved over the years, most challenges and frustrations are with the connectivity of these devices. But even with cellular technologies, patients with low digital literacy that are not properly oriented will quickly feel frustrated and stop their participation.
My Antidote: Definitely invest in cellular-connected devices and ensure that the training is designed and delivered by experts in patient education and relentlessly quality controlled.
Reason C – Patients are not engaged, are dropping out. When this happens, clinics oftentimes cannot bill (the minimum is 16 readings and 20 min of time for the core codes) and the labor intensity (trying to reach the patient) increases — also leading to a great dissatisfaction on the monitoring nurse’s side.
My Antidote: This part is in my observation the most crucial part for success, and it is in my experience grossly overlooked: It should be all about the patient.
The Needs of the Patients Come First
Building the patient’s commitment to participate in the RPM/CCM program starts in the clinician’s office.
It is here where the trusted clinical provider offers the patient the opportunity to improve their health and create (or restore) the ability to live a good, normal life despite their chronic disease. No more scary ER visits. No more hospitalizations. Less shortness of breath. More energy.
If that enrollment does not happen in the exam room or the doctor’s office, that patient’s long-term participation beyond 6-8 weeks is greatly questionable and will tank the program’s ROI.
The most important aspect of a successful RPM program is to ensure that all participating clinicians are properly trained in having these types of enrollment conversations with patients. It’s a 3 minute conversation that can go a long way, and it takes clinical leadership to ensure that it happens consistently.
But the enrollment does not stop there. Next, patients need to be gently led through a series of necessary forms and consents. Then they receive their first orientation as to how to use the technology, which needs to be delivered with a great understanding of the patients cognitive abilities and their digital literacy. For some patients, a home installation, while costly from the clinic’s perspective, will not only ensure a proper set up but can deepen the patient’s resolve to not let the team down that so nicely helped them with all of the various aspects.
Last, but not least, the personality and training of the monitoring nurses is key to the success of the program. Conveying empathy over the phone when someone is confused about their medication or is having technical difficulties can be trying. Discovering, sharing, and practicing best practices is key to ensure the best possible monitoring support.
How are you ensuring that your RPM program remains patient-centric? What metrics are you monitoring to verify that your patients are not dropping out of the program pre-maturely?
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Christian Milaster and his team optimize Telehealth Services for health systems and physician practices. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.
Contact Christian by phone or text at 657-464-3648, via email, or video chat.
