The same investment in technology to measure and report vital signs, and the same deployment of nurses monitoring stations and health coaches engaging with monitored patients, can be beneficial to other patient populations in the region.
It could be health insurers looking to start up monitoring without the start-up headaches. It might be nursing homes trying to prevent readmissions to the hospital or adult sons or daughters worried about elderly and ailing parents alone at home.
An Indiana home health agency well along in the use of remote monitoring is exploring those possibilities and more, says Fred Cantor, manager of telehealth and patient coaching for Franciscan Visiting Nurse Service, a unit of Indianapolis-based Franciscan Alliance. On the positive side, market forces are in its favor during the next several years, with the federal government making laws and policy pushing for “alternative payment models” and private-sector payers gradually following the lead.
On the negative side, current reimbursement formulas treat monitoring, and telemedicine generally, as added costs and leave little room for such services to wedge themselves into provider budgets. “There’s any number of applications where a patient can be greatly helped with telemedicine, but we don’t necessarily have a payment mechanism in place to take advantage of it,” says Jonathan Linkous, CEO of the American Telemedicine Association.
Creative expansion of the monitoring infrastructure has stalled thus far because of budget considerations and lack of current business impact, though Cantor has tried mightily to break through those barriers. “The biggest hold up right now for telehealth is that it’s so new,” he says.
When patients leave the hospital, they immediately lose the greatest advantage of inpatient care: the close attention they receive from caregivers. But emerging advances in technology are enabling health care professionals to remotely monitor patient vital signs, easing the transition to outpatient care.
With proliferation of accountable care organizations (ACO) in Indiana and elsewhere, it’s a matter of time for ACO leadership to recognize the potential of remotely monitoring people discharged home from a hospital stay. Currently, the Franciscan monitoring service is offered free to home care patients managed by the two ACOs in which the alliance participates. The focus is on patients at high risk of health decline or relapse, keeping them out of the hospital. But less-sick patients should be on the radar.
“There’s this whole other huge population of medium-risk patients and, honestly, that’s probably the better opportunity,” Cantor asserts. “High-risk patients are going to go back to the hospital—they’re very sick. Medium-risk patients are the ones that you probably can keep out of the hospital indefinitely.”
The Franciscan ACOs initially reached out to ask about purchasing just the telehealth piece for their non-home care patients, he relates, and are very interested but weighing how to budget for it. Cantor also has been seeking an audience with private insurers operating in the state. “But just like everything else, it costs money, and so it’s sometimes a hard sell to start.”
In the changing business of health care, however, “these are all very realistic potential opportunities,” says Jay Sanders, M.D., a telemedicine consultant and pioneer in that health technology field going back 30 years. The successful expansion of remote monitor- ing depends, in part, on different approaches to selling it and out-of-the-box ideas about who to partner with, he explains.
Skilled nursing facilities can benefit from using the basic telemonitoring system for its sickest elderly patients, for example. One of Sanders’ post-acute clients is doing just that, which “has reduced by 60 percent the need for the nursing home to transfer the patient to the hospital ER.”
It’s a common scenario. “The minute a patient in the nursing home develops a fever, there’s almost a knee-jerk reaction: They send the patient to the hospital emergency room,” Sanders points out. “It’s a huge cost to the nursing home in losing payment on that bed, and a huge and inappropriate cost to the health care delivery system because the patient probably didn’t need to come in. It could have been handled by better advice to the LPN working at night at the facility.” Nurse practitioners and other care managers from the monitoring service can provide that better advice on the spot, he says.
The Franciscan-owned ACO brought up that possibility in meetings held to brainstorm how to provide better care at post-acute facilities it manages or contracts for services, Cantor says. But overshadowing the prospect of reduced readmissions is the financial pickle of post-acute care, in which reimbursement rates have been declining. At mention of a daily fee, “their smile turns to a frown pretty quickly.”
But what if the program is pitched on a shared-risk basis? Sanders says the recovered revenue and cost savings quantified as a benefit of reducing emergency transfers can drive the business case—rather than a fixed overhead cost, the nursing home operator returns some of the savings to the monitoring service. “You can turn his frown into a smile by saying, ‘Look, I’ll do this on a cost-savings basis.’ You’ve already paid for your infrastructure, so you might as well use the infrastructure for all the things it can do.”
Among the other unmet needs a well-developed patient monitoring capacity can address is the elderly person living alone. Sanders did some work with ADT, the home security company, to sell remote patient monitoring into its customer base. In focus groups, a contingent of sons and daughters professed to be in favor of spending $35 to $45 each month for such a system if it reduced the increasing amount of time spent checking in on a sick parent.
“Number one, it provides peace of mind,” says Sanders. “Number two, it dramatically reduces their cost because, otherwise, they have to take off from work, and they’re spending a lot more time with their elderly parent. So just having the sense of security is very, very import- ant to them—and forget the insurance policies, they will take out of their pocket the $35 to $45 a month to do this.” Partnering with a non-traditional business that already is making calls to prospective customers would reduce the marketing and sales costs as well, he adds.
Cantor says he gets phone calls on occasion from children whose parents had a recent significant medical event and are worried about their welfare. Given a source of payment, “It’s something we are very much in a position to do. It’s not something we’re marketing, but if we had an interest or a need, we could literally be ready to flip a switch and do it tomorrow.”