Necessity for change in the U.S. healthcare system is not an issue but a necessity. The present system is wasteful, fragmented, and limits engagement between patients and providers. Results of a recent study included estimates of $765B in excess costs and over 75,000 preventable deaths.1 Inefficiency is coupled with ineffectiveness, given projections for Medicaid spending to reach $340B in 2020 from $159B in 2011, in a system in which 1% of patients consume 15% of resources.2 Lack of patient engagement in health fosters an environment in which over 90% of chronically ill individuals desire coordinated care, while less than 60% receive such services.3 (Coordination, integration, communication, and engagement are common themes cited for improving use of resources, moderating costs, and supporting enhanced outcomes through patient empowerment.4,5 Deploying mobile health stands as central in realizing these objectives. Findings of the mHealth Task Force convened through the Federal Communication Commission elevates these objectives into the single goal “that by 2017 mHealth, wireless health and e-care solutions will be routinely available as part of best practices for medical care.”6 Achieving the goal – as with many efforts targeting efficiency, effective- ness, and empowerment in healthcare – is not simple or straightforward. A comprehensive approach is needed to addressing technical requirements across capacity, access, and integration. Equally important is providing reimbursement, recognizing the value delivered through mHealth. The issue in structuring such compensation is creating structures that support coordinating care – while limiting overall consumption of services. Meeting the goal for using mHealth requires addressing broader issues in restructuring care from volume to value-based. mHealth stands as a means of facilitating this transformation by driving down waste and fragmentation while realizing the benefits through patient engagement under coordinated care.7
Reducing Hospital Readmission Rates Utilizing Mobile Health
As previously discussed, reducing hospi-tal readmissions is of key importance. CMS reported that from 2007 through 2011, the na-tional 30-day, all-cause, hospital readmission rate averaged 19 percent. During calendar year 2012, the readmission rate averaged 18.4 percent a decrease of greater than one half percent. Although claims data are not yet final for 2012, their analysis indicates that hos-pital readmission rates for all Medicare bene-ficiaries dropped noticeably during 2012.
Reducing Hospital Length Stays Utilizing Mobile Health
There are numerous ways in which mobile health can be used to reduce hospital length stays or reduce the number of readmissions as detailed below:
- Remote patient monitoring (see New Care Models section).
- Video technology may be set up in pa-tient’s homes where they can virtually be visited by their physician in a more episod-ic manner without disrupting the patient or physicians lives any more than need be
- Patients may take and transmit results of simple medical tests
- Virtual coaching which enables a healthcare professional to remotely push meal and activity plans in a prescriptive manner to better guide and focus people on what they need to be performing to have more successful outcomes
Connecting Patients to their Health Data via Mobile Devices
As patients continue to become more tech savvy, they expect to have access to their health information, and Meaningful Use Stage 2 regulations of the HITECH Act (the technol-ogy component of the Affordable Care Act) dictate that patients must be given access to their information. The ability to connect online and via mobile devices anytime im-proves communication and in some regions, patients are enthusiastically embracing it. In other regions, these patient portals are not as utilized. The reduction in unnecessary face-to-face office visits and the elimination of unnec-essary duplicate visits can potentially eliminate142 million unnecessary referral visits each year.8 The key is to provide tools that can easily enable connectivity between patients and their providers. Even very simple connectiv-ity (text messaging) can result in significant ROI increases. As previously discussed, the VA has seen significant improvements by utilizing telehealth. The U.S. Department of Veteran Affairs Care Coordination/telemedicine program for chronically ill vet-erans was able to reduce the number of days patients with diabetes spent in the hospital by 20%.9 Another example is that of a Stan-ford University study in which clinics used a home telehealth device to help care for Medicare patient with chronic diseases. This was shown to cut spending by as much as 13.3% or $524 per person, per quarter.10 Chronic conditions are utilizing many healthcare resources in today’s society and account for 75% of the more than $2.5 tril-lion spent on U.S. healthcare according to the Centers for Disease Control.11 Another way of looking at this is that five percent of the population accounts for 50% of healthcare dollars spent.12 New methodolo-gies are needed to help reduce these costs. A case study at the Cleveland Clinic has shown that remotely monitoring patients with chronic diseases (the highest segment of patients that are at the highest risk) re-sulted in the following outcomes:13
- Heart failure patients in the program were able to better detect problems that required medical attention and visit their doctor when appropriate
- Diabetic patients were able to increase the number of days between their appoint-ments by 71 percent while hypertension patients did so by 26 percent.
Baptist Health has shown remotely moni-tored patients to decrease chronic illness re-lated ER visits and hospitalizations to im-prove patient outcomes. The results indicate that after 6-12 months, diabetes patients in-creased self-management behaviors for glu-cose medical compliance by 53 percent and decreased lipids and blood pressure trends.
<Medicare’s stance on reimbursement for remote care through telehealth technology exists but only when a beneficiary lives in a Health Professional Shortage Areas (HPSA’s) or not in a Metro Statistical Area (MSA). Reimbursement outside of HPSA’s or MSA’s is generally not available. Health Professional Shortage Areas are designated by the Health Resources and Services Administration (HRSA) as having shortages of primary medical care, dental or mental health providers and may be geo-graphic (a county or service area), demo-graphic (low income population) or institu-tional (comprehensive health center, federally qualified health center or other public facility). Medically Underserved Areas/Populations are areas or populations desig-nated by HRSA as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. HPSA’s are generally fully reimbursed for health care services by Medicare, and may be reimbursed by Private Insurers (varies based on carrier and the state in which carrier re-sides). Every year, Bills are introduced in Congress to expand Federal reimbursement for telehealth and remote monitoring services. Medicaid is more expansive on reim-bursement for remote care through mobile technology of any of the payers. Medicaid’s rules vary from state to state. Medicaid not only reimburses health care provided in HPSA’s but may reimburse for all health care services (regardless of location). According to the Center for Telehealth & e-Health Law (CTEL), 39 states have some type of reimbursement for services provided via Telehealth.14 The vast majority of this coverage is for limited geographical areas, is lim-ited to Medicaid patients, and provided for severely limited indications. As referenced in the mHIMSS Roadmap the VA has shown success related to remote care through mobile technology and ROI:15 “In the U.S., no organization has shown a more powerful commitment to mHealth adoption than the VA. The second largest government department after the Department of Defense, the VA manages a $100B budget, with 300,000 employees. Half of the budget and nearly all the employ-ees are part of the Veterans Health Administra-tion (VHA), which delivers health benefits and services to 8.3 million patients per year, with 5.3 million unique patients per year, through 152 medical centers and 1,400 community clinics. As an early and rapid adopter of mHealth, the VHA represents half of the 300,000 chronic disease re-mote monitoring patients in the U.S. It has awarded contracts for $1.4B to mHealth technolo-gy vendors for devices and services, and it has published the most comprehensive studies on the costs and benefits of deploying mHealth and re-mote patient monitoring across multiple chronic disease, geographies, and socio-demographics.” Numerous mHealth studies of the VA exist that continue to show the entities stance on cost avoidance through telehealth. One example includes Troop Health Initiatives (THI), Service-Disabled Veteran-Owned Small Business (SDVOSB) which is a technology provider and trainer for mHealth.16