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Remote control: The growth of home monitoring

Insurers increasingly are using home systems to track their members' health. But with this emphasis on cost control, some fear the physician is being bypassed.

By Tyler Chin, amednews staff. Nov. 18, 2002.

The concept of home monitoring for patients with chronic conditions has been around for several years, but insurers now are aggressively adopting the practice to stem soaring medical costs.

Patients with chronic conditions account for a disproportionate share of health care costs. So if insurers can lower those costs, they will be able to retain more of the premium dollars that employers and members pay, and Wall Street also will reward them with higher stock prices.

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Employers are not specifically asking health plans to do home monitoring, but they do ask HMOs about possible cost savings through disease management, of which remote monitoring is a tool, said Kathy Cartelli, director of health management at PacifiCare Health Systems Inc., Santa Ana, Calif., which, since 2000, has monitored patients with congestive heart failure.

Despite many physicians' mistrust of insurers, some applaud this remote patient monitoring. But physicians are concerned they would not be treated as equal partners with the health plan and the disease management company, and that nurses handling the monitoring for insurers could unintentionally circumvent the treatment plan.

Related AMA policy, which speaks generally about disease management, "strongly encourages health insurance plans and managed care organizations that provide disease management to involve the patient's current primary or principal care physician in the disease management process as much as possible, and to minimize arrangements that may impair the continuity of a patient's care across different settings."

That physician involvement is key, said Jack Lewin, MD, executive vice president and chief executive of the California Medical Assn.

90 million Americans have chronic conditions.

"These projects are really very well-intended, very exciting and offer great promise in the future. That said, I have great reservations about any program that works around the patient's physician," Dr. Lewin said. "If PacifiCare or anyone else wants to do this and really succeed, they should make the program friendly to the doctor and the patient so it strengthens the patient-physician relationship and becomes part of an evidence-based approach to chronic disease management."

Remote monitoring "should be a fully integrated program that is part of the patient-physician relationship so that the nurse might call the doctor when something isn't right and talk it over [before calling patients]. That would be a far better way to present a unified position to patients and not confuse them," he said.

"We can take this good idea and take it one step further by making it a true partnership that includes the physician instead of having the physician as an appendage to a program that will save the health plan money."

Heart check at home

But saving money is the reason why insurers -- and some large hospitals and group practices -- are monitoring patients with chronic conditions.

According to the Centers for Disease Control and Prevention, there are 90 million Americans with chronic conditions, and their medical care consumes more than 75% of the country's $1 trillion in costs.

About 20 insurers use remote monitoring, up from just three insurers in 2000, said Al Lewis, director of Disease Management Purchasing Consortium, a Wellesley, Mass.-based group that helps insurers evaluate and negotiate contracts with disease management firms.

Chronic medical care costs account for more than 75% of the country's $1 trillion in medical care costs.

Most remote monitoring programs involve patients with congestive heart failure.

One reason is the clear link between hospitalization and an easily monitored symptom. "No other chronic disease has that nexus between weight gain and hospitalization as congestive heart failure does," Lewis said.

PacifiCare hired Alere Medical Inc., based in Reno, Nev.-based to install monitoring devices in the homes of 4,000 members around the country. PacifiCare has 3.3 million members, about two-thirds of them in California. The monitoring device is hooked to an electronic scale and plugged into a telephone jack. The system is activated when patients step on the scale.

Patients weigh themselves at least once a day and answer several yes-or-no questions by pressing buttons on the device. The data are automatically transmitted to a secure Web site Alere operates.

Access is restricted to PacifiCare, Alere and the patient's physicians, Cartelli said. PacifiCare receives weekly, monthly and quarterly reports from Alere, while doctors get monthly reports unless there is an emergent problem.

When PacifiCare identifies patients eligible to participate in its monitoring program, it first informs their physicians, Cartelli said. Some doctors like the idea, some are neutral and others don't want the insurer to call their patients because they don't want a third party intruding between them and their patients.

About 20 insurers monitor patients remotely, up from just 3 insurers in 2000.

But PacifiCare reassures doctors that they control the treatment plan while Alere ensures that patients comply with it, Cartelli said. Physicians are asked to specify weight levels and symptom data that should trigger a call to them by the Alere nurses.

But it is up to patients, not the doctor, to decide whether to participate in the program, she said.

Patients who chose to participate generally have a compliance higher than 95%, Cartelli said. When patients fail to transmit their data, nurses call to find out why.

"If it turns out that the patient isn't going to be compliant, then we're not likely to continue [having] them in the program," Cartelli said. "The program is completely voluntary."

Regardless of whether patients drop out on their own or are dropped for noncompliance, they still retain their health insurance, she said.

If a patients want to visit their physicians or hospitals, even though vital signs and symptom data do not indicate that is necessary, they may. PacifiCare will pay for the services, as long as they're covered under the patient's health insurance plan.

Liability remains the physician's concern

PacifiCare is not worried about potential liability because it is not practicing medicine, Cartelli said. "This is really an educational and monitoring program. The nurse can't change medications. She can't do any kind of treatment. She can only alert the physician, and that physician makes any treatment modifications that are necessary."

As a result, the liability risk rests with the physician. "If the doctor ignores the information that's provided to him, that's the risk that he takes," Cartelli said. "He has to make a choice with what he does with that information."

The company will not say how much money it may have saved through this system. PacifiCare's medical-loss ratio -- health care expenses divided by premium revenue -- did fall to 87.5 % for its HMO in the first half of this year, down from 89.3% last year, and its Medicare HMO ratio fell to 88.8%, down from 90.5%, in the like period, but the company attributed those trends to premium increases and pullouts from unprofitable markets.

Although the primary plus for physicians is improved patient care, some practices could see a financial benefit from remote monitoring.

The Palo Alto Medical Foundation, one of PacifiCare's contracted groups, has the potential to benefit because half of the multispecialty group's business is capitated, said Aria DiBiase, MD, a PAMF cardiologist who also has worked as a consultant to Alere since 1997. "If we have fewer hospital admissions, then we do not use our hospital pool for the various health plans."

There is no financial benefit for fee-for-service practices because insurers don't pay doctors for remote monitoring.

"For those who are not capitated, the issue primarily is around good patient care. This really provides an opportunity for them to provide a higher level of patient care," said Paul Bluestein, MD, chief medical officer of ConnectiCare Inc., Farmington, Conn.

ConnectiCare, however, is thinking of launching a remote monitoring program next year that would not only reimburse doctors for monitoring diabetic patients remotely over the Internet, but also transmit patients' data directly to doctors' computers.

The insurer is looking to test remote monitoring technology because it thinks the industry needs to change its approach toward treating patients with chronic conditions, Dr. Bluestein said.

"If we're going to take the traditional approach to these chronic illnesses that we've taken for the last 50 years, then why should we believe we're going to get any better results in the next 50 years?" he asked.

ADDITIONAL INFORMATION:

Chronic costs

Insurers, hospitals and health systems are exploring remote monitoring of patients to determine if it is clinically effective -- and cost-effective.

                   Number
                 affected      Cost     
                ----------  ------------
Asthma          15 million   $13 billion
Cancer           8 million  $180 billion
Cardiovascular                          
  disease       60 million  $300 billion
Diabetes        16 million   $98 billion

Source: Centers for Disease Control and Prevention

CMS grants help large hospitals try out remote monitoring

Some large hospital organizations are trying to reduce health care costs by targeting patients with chronic conditions for at-home remote monitoring programs implemented with the help of grants from the Centers for Medicare & Medicaid Services.

Although it may seem against hospitals' financial interest to keep patients out of the hospital, the opposite is true because of the way Medicare pays, said Julie Fieldsend, RN, manager of health and disease management services at Avera McKennan Hospital and University Health Center. CMS reimburses hospitals based on diagnosis-related groups, rather than the actual cost of care.

The Sioux Falls, S.D., hospital is conducting one of 16 disease management and remote monitoring demonstration projects that CMS funded this year. The grants pay for the equipment and personnel costs.

Avera McKennan is hoping that its four-year randomized trial involving patients with congestive heart failure will help reduce the number of hospitalizations. When patients do need to be admitted, the hope is that they won't be "in such terrible shape medically that it takes a long time to get them back under control," Fieldsend said.

No one expects remote monitoring to be a panacea. "There will be some train wrecks that we will never stop. People are going to get really sick, and sometimes we just can't do anything about that."

Weblink

AMA policy (H-285.944) on disease management and demand management

E-Disease Management from the California Healthcare Foundation and First Consulting Group, November 2001

Article "Emerging Trends in Medical Device Technology: Home is Where the Heart Monitor Is," FDA Consumer, May-June 2001 (http://www.fda.gov/fdac/features/2001/301_home.html)

Hearing "Disease Management and Coordinating Care," before the U.S. Senate Special Committee on Aging, Sept. 19 (http://aging.senate.gov/events/107th.html)

Disease Management Purchasing Consortium (http://www.dismgmt.com/)

Disease Management Assn. of America (http://www.dmaa.org/)