By Justin Pasay, senior manager, Deloitte Consulting,

Remote Patient Monitoring (RPM) is a critical component of any comprehensive virtual-care strategy—particularly in chronic-care management—and could serve as an important tool as the health sector shifts from a focus on care to a focus on wellness. While device-based RPM solutions (e.g., connected heart-rate monitors), sophisticated apps, and wearable devices can be effective, they typically aren’t designed with the most vulnerable populations in mind. That could limit access for millions of Medicaid beneficiaries and people who qualify for both Medicare and Medicaid (i.e., dual-eligibles). 

In-home, device-based solutions can effectively capture patient health data outside of a traditional clinical setting. However, some Medicaid beneficiaries and duals might not be able to take full advantage of RPM technology due to barriers such as limited access to reliable Wi-Fi at home, an unstable living environment, and patient cost-sharing. Moreover, RPM devices are often designed to monitor a single chronic condition, such as diabetes. They typically do not address rising risks, multiple conditions, behavioral health issues or the drivers of health (also known as social determinants of health), which can be critical to serving this population. Many of these challenges also exist for app-based solutions and wearable devices, which could further complicate adoption due to gaps in digital literacy among beneficiaries.

Deloitte’s 2018 and 2020 Survey of US Health Care Consumers dispelled some misconceptions around Medicaid beneficiaries and their relationship with technology and digital health. Survey results revealed that Medicaid beneficiaries own smartphones at the same rate (86%) as the overall US population. Beneficiaries are also just as comfortable using technology to monitor health issues as people who have employer-based health coverage (30%), according to our survey results. In a recent blog on digital health tools for mobile devices, our colleagues Connie Richie and Bobby Powers outlined some key strategies for designing and building more inclusive digital products to advance health equity.

While there are similarities between Medicaid beneficiaries and the overall population, there are often critical differences in income level, formal education, disease prevalence, digital literacy, and social needs. These differences should be factored into RPM solutions to help ensure health equity and the most appropriate interventions.

Eight strategies for designing inclusive RPM products

Whether designing a suite of RPM products, or evaluating one with a partner, health organizations should ensure a focus on health equity and inclusivity. RPM products should account for some of the unique challenges that Medicaid and duals populations often face.

• Consider the drivers of health: In our recent article, we noted that the drivers of health (e.g., social, economic, and environmental factors) contribute to 80% of health outcomes. Deloitte's 2020 health care consumer survey found that Medicaid beneficiaries were most likely to say they faced challenges with having enough money for food (47%) and being able to pay for housing (51%). Health organizations should try to design RPM solutions that effectively capture these drivers of health.
• Consider medical and behavioral health conditions or risk factors that disproportionally impact Medicaid and duals populations: Our 2020 consumer survey found that 71% of Medicaid beneficiaries feel nervous or anxious, and 65% said they are sad or depressed. Low-income American adults also tend to have higher rates of heart disease, diabetes, stroke, and other chronic disorders compared to wealthier Americans. RPM offerings should be designed for a broader set of risk factors that can impact Medicaid and duals beneficiaries. The whole person’s health should be at the center.
• Evaluate interventions, care models, and programs: RPM technology, on its own, won’t move the needle on improving health equity and clinical outcomes. Along with monitoring patients, RPM programs should evaluate and intervene in issues that could negatively affect the health of high-risk patients. This includes designing the appropriate triage pathways, care models, community-based programs, and partnerships, and deploying trained, culturally competent staff. Such programs, for example, might be designed to offer food assistance, free smartphones, housing assistance, or community-based education programs. Health organizations should determine the most effective outreach strategy that encourages high-risk beneficiaries to adopt an RPM solution. This might include connecting patients to at-home care programs or in-person assessments to build trust, address barriers, and remove concerns about the solution.
• Minimize the financial impact on beneficiaries: In most states, adults qualify for Medicaid if their annual income is at or below 138% of the Federal Poverty Level.¹ This population often has little or no disposable income outside of basic, critical living necessities. Offering free solutions that hold beneficiaries harmless could help drive greater adoption of RPM solutions.
  
• Design solutions that work offline and with low bandwidth: Nearly one-third of Medicaid beneficiaries do not have access to internet at home.² Health care organizations should consider solutions that work without internet access (e.g., SMS based) or are designed to work offline and sync when internet is available.
  
• Help navigate gaps in digital literacy: Only about half of low-income Americans are digitally literate.³ Health organizations should create a simple, intuitive experience written at the appropriate reading level (e.g., 4th grade) and available in multiple languages. Not requiring users to create profiles, or online sign-ups, could also help increase adoption.
• Consider state-specific agendas: Health organizations should help ensure that RPM solutions are designed to address key state-specific objectives. Organizations that are willing to move the needle on health equity and drivers of health are likely to be most successful, as our colleagues Ben Jonash and Olga Karlinskaya indicated in their recent blog on winning and retaining Medicaid contracts.
  
• Drive Accountability: Health organizations should define quality, operational, clinical, and health-equity metrics as part of their RPM program. These metrics should be tied to partnership contracts and value-based care initiatives when appropriate. Moreover, data from the program should be continuously monitored to ensure any unintentional biases are addressed, particularly in solutions that use AI to evaluate and risk-stratify the population.
  

RPM Case Study⁴

Some organizations are beginning to focus on making RPM more inclusive and accessible for all patients. Deviceless, condition-specific RPM and engagement solutions offer potential avenues to address many of the barriers seen in Medicaid and duals populations.

For example, text messages and/or interactive voice response (IVR) phone calls can be used to capture patient-reported outcomes for a multitude of chronic, social, and co-existing conditions, including behavioral issues and the drivers of health. These technologies don’t require beneficiaries to download apps, enter passwords, or connect to Wi-Fi or data plans. No training is necessary, and little technical support is needed. 

STRIDE Community Health Center, the largest Federally Qualified Health Center (FQHC) in Colorado, recently implemented one such solution. STRIDE was moving to a value-based, proactive care model and faced many of the challenges that we have seen in other FQHCs and Medicaid managed care plans. These challenges include limited financial and staff resources and difficulties engaging vulnerable Medicaid and dual-eligible populations. STRIDE decided to align its clinical quality metrics with its value-based care initiatives. It selected two chronic conditions (diabetes and hypertension) that can have a significant impact on Medicaid beneficiaries and duals (see table, below):

Through automated outreach in English and Spanish, enrolled patients answered prompts that sent clinically relevant data to STRIDE’s vendor, CareSignal. At-risk individuals were automatically categorized, and alerts were sent to care Managers in real-time for intervention. Over the first nine months, diabetes patients with a baseline A1C of more than 9% showed a 2.02% decrease, on average. Patients who had hypertension exhibiting a baseline of more than 160 mmHG showed a 10 mmHg average SBP drop.

This case study helps to demonstrate that an RPM solution can be cost-effective, scalable, equitable and clinically actionable. 

Endnotes

1. Medicaid Income Eligibility Limits for Adults as a Percent of the Federal Poverty Level, Kaiser Family Foundation 01 January 1, 2021

2. How might internet connectivity affect health care access? Peterson-KFF Health System Tracker, December 14th, 2020

3. Why achieving health equity is so hard in the telehealth age, American Medical Association, October 21, 2020

4. Case study: How the largest FQHC in Colorado prepared for the shift from fee-for-service to value-based care, CareSignal

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