The Day The Remote (Monitor) Disappeared

So my wife relies on remote monitoring to keep track of my questionable decisions, like that time I brought a running chainsaw into the kitchen or nearly killed Aunt Nancy with that uncooked chicken. New restrictions on remote monitoring caught my attention this week if only because I too rely on it for my folks just as my bride uses it to keep us alive.  

UnitedHealthcare covers remote monitoring but starting next year says it will restrict its use, no longer paying doctors to remotely monitor the data that patients collect at home about their Type 2 diabetes or general hypertension. They’re saying it’s not reasonable, citing a lack of evidence of efficacy for these uses – which ironically is sort of like my argument to my wife about the actual effectiveness of monitoring the kids on her find-my-phone app. The insurer says it will continue to reimburse providers for remotely monitoring heart failure and hypertensive disorders during pregnancy.

A source familiar with the decision says it can have more to do with “yield – or lack of it” for patients. “At some point the monitoring happens, the disease doesn’t change, the patient’s health doesn’t change or the physician isn’t really doing anything – they are monitoring every few weeks but it’s not a super acute situation, so the incremental benefit from the monitoring itself, like flagging changes in BP, can be handled in other ways, probably at lower cost and the same benefit.”  That’s the thinking anyway.

Not everyone agrees. 

Doctors we polled last night – only about 12 – not surprisingly all think it’s just another shot at physicians who need help figuring out what patients do when they leave the clinic. “Not everything has to yield savings or an action,” Holly Gristol, a neurologist said.

For context, health insurers have for years paid for what you might call monitoring-light. Like if a physician orders a lab or talks to a patient about their family history and runs a test like a calcium CT scan to check for blockages and finds a high score, then that’s reason to do a stress test and echo. 

“You’re establishing a baseline based on family history and using a test to make a clinical judgment. That’s good managed care for doctors to be doing – they are monitoring results and reacting,” medical director Karen Creeger said. “But ongoing monitoring for type 2 and general hypertension is nuanced, it’s different – if it isn’t generating information in a meaningful way to lead to therapeutic interventions or positive changes to the patient’s health and scores and risks, then it becomes a cost, and maybe it isn’t reimbursable.” 

Type 2 diabetics are usually seeing the doctor every 3 or 6 months so the monitoring is the intervening support system but there are questions about how often physicians are making changes and intervening. “It’s more often just discussed during the visit,” a PCP said, but it “gives us some assurances and the patients like the security.”   A spokesman for UnitedHealthcare did not return our request for comment in time for our deadline. The change may lead other insurers to review their own coverage policies but probably not after policymakers weigh in, maybe CMS. Said a regional BCBS medical director, “I would rather see how this plays out.” 

The reaction is interesting given what we know from history. 

Back in 2014, nurse Cindy Zydel, RN, had this idea to remotely monitor Medicaid dual eligibles in western Pennsylvania, those with depression and diabetes. “We’d use the remote monitoring to check on vitals, weight changes – prevent falls and have an MSW jump in if needed.” The company, Wellbridge, got a data feed from Gateway Health Plan with the names of people who had cost the insurer $40,000+ a year. The $2,500 Gateway paid the social worker company was peanuts and made an impact using an iPhone 6 (yes kids, 6),  plus a misfit bracelet that transmitted data through an apple product called the cloud….do these conditions and solutions sound familiar?

This was the infancy of innovation in payment for tech and care and it worked, but the likely difference to consider is these patients were all flagged as high risk and frequent fliers into hospitals. Remote monitoring was the only way to stop the train wreck as Cindy said. She was right.  Who’s right here might be a matter of perspective. 

Personally, I think monitoring would give me peace of mind about my older folks to monitor their BP at home but there are bigger issues impacting their BP – like lack of eating. In our straw poll of 7 medical directors last night after the announcement, 5 said they disagree with the policy for their members if only because they are not seeing issues with yield and spend. They agree that if monitoring is not leading to change and not preventing events, then coverage should be at least addressed….

…I am not fan of remote monitoring outside of healthcare personally even though I’ve come to rely on it.  For context, even if I’m lucky to find the remote controls, using them is getting harder than finding central parking at Logan Airport. You see there are 3 remotes and deciphering how to find the game or turn back to Netflix forces me to face time with a child – any of them – in a kind of remote monitoring intervention. “It’s the left arrow dad, the left!”  I’m becoming my dad in these months since the nest emptied, but my pain is meaningless compared to people who actually rely on remote monitoring for real things.  Like disease.

My wife likes to monitor my cooking decisions, which takes the fun away even if there was that time she prevented me from killing everyone with that uncooked chicken. So that was a nice save.  She uses the iphone app to monitor where the kids are at 2am on a Thursday. “Nothing good can be going on at that time,” she says.  But what we do with that intel for 18-23 year olds spreading their wings and making dumb decisions – as we once did – well that’s different. So we invariably do nothing with the info. We sit on it, sometimes stress, sometimes laugh, sometimes find out their whereabouts are actually quite lame – like they were in an all-night study cram session at a coffee spot. It’s a false positive I suppose. But candidly there are sometimes we can’t intervene – sometimes I think they just need to fall down, like we all did before there were phones and remote monitoring gadgets. When our parents knew little of where we were and when doctors diagnosed based on training and judgment, and intuition.