When a rural family in West Virginia has to drive hours for a pediatric follow-up, access is not an abstract policy issue. It is a care delivery problem with operational, financial, and clinical consequences. That is why understanding the pillars of the RHTP funding in the state of West Virginia and the benefits of the Dr. Miltie N9+ matters for providers, administrators, and care transformation leaders working to extend services beyond the traditional exam room.

For organizations serving mountain communities, school-based populations, safety-net settings, and pediatric patients with special healthcare needs, the real question is not whether virtual care belongs in the model. It is whether the technology being deployed can support clinically relevant care, align with funding priorities, and fit the realities of reimbursement, staffing, and patient engagement.

What RHTP funding priorities mean in practice

Rural health transformation funding is typically designed to move care closer to the patient while improving sustainability for the provider organization. In West Virginia, that often means supporting strategies that reduce access barriers, strengthen local clinical capacity, improve care coordination, and use technology in ways that produce measurable impact.

The most durable funding proposals usually rest on a few core pillars. First is access. Funders want to see how an organization will reach patients who face transportation barriers, specialist shortages, or long wait times. Second is infrastructure. It is not enough to say virtual care will be offered. Organizations need workflows, devices, training, data capture, and clinical processes that can actually support adoption.

Third is outcomes. Rural transformation initiatives increasingly expect evidence that new programs can improve follow-up, support chronic disease management, reduce unnecessary transfers, and strengthen continuity of care. Fourth is financial viability. Programs that depend entirely on short-term grant dollars often struggle after launch. A stronger model considers reimbursement pathways, staffing efficiency, and scalable deployment from the start.

For West Virginia providers, there is also a practical fifth pillar that often shapes success even when it is not stated that way: fit for community-based care. Technology that works in a tertiary hospital may not work in a school, a community clinic, a rural health center, or a patient home. The setting matters, especially when pediatric care, behavioral needs, caregiver participation, and broadband limitations are part of the equation.

The pillars of the RHTP funding in the state of West Virginia

If a healthcare organization is evaluating the pillars of the RHTP funding in the state of West Virginia, it helps to think less about the label and more about what reviewers and operators need to see.

Access expansion must be tangible

Access is often the headline goal, but vague promises are easy to dismiss. A stronger approach shows exactly how care will be extended to rural patients, pediatric populations, underserved communities, and patients who struggle to travel. That could include virtual primary care touchpoints, clinician-directed remote assessments, remote patient monitoring, or school- and community-based exam capabilities.

This is where hardware and workflow design matter. Video alone may help with basic check-ins, but it cannot always support a more complete clinical encounter. If the goal is to reduce deferred care and improve decision-making, providers need tools that can bring more of the physical exam into distributed settings.

Care coordination has to extend beyond the visit

Transformation funding is rarely just about adding another appointment channel. It is about creating continuity. That means supporting communication between clinicians, caregivers, community sites, and follow-up teams. For pediatric and special needs populations, continuity is especially important because caregiver involvement, routine, and lower-stress environments often affect whether care plans are followed.

A program that captures data but does not connect it to care management, chronic care monitoring, or team-based follow-up may fall short. RHTP-aligned models are stronger when they support an ongoing circle of care rather than isolated telehealth transactions.

Workforce efficiency is part of rural access

West Virginia organizations know that access problems are often workforce problems. Rural sites may not have enough specialists, enough pediatric expertise, or enough staff time to move patients through fragmented processes. Funding-backed models need to help clinicians work at the top of license, support distributed teams, and reduce avoidable patient transfers or duplicate visits.

That does not mean technology replaces local care teams. It means technology should make those teams more effective. The right deployment can help a nurse, medical assistant, school-based health professional, or community clinic team facilitate a higher-value remote encounter under clinician direction.

Sustainability depends on reimbursement-aware implementation

One of the most common failure points in innovation programs is the gap between pilot success and operational sustainability. A device may work clinically, but if implementation ignores billing, documentation, staff training, and program ownership, the model becomes difficult to maintain.

For that reason, funding priorities increasingly favor solutions that can support remote patient monitoring, chronic care management, virtual assessments, and other care models that fit within existing or emerging reimbursement structures. It depends on payer mix, service lines, and patient population, but the principle is consistent: transformation should not end when grant dollars do.

The benefits of the Dr. Miltie N9+

The benefits of the Dr. Miltie N9+ become clearer when viewed through the lens of these funding pillars. For healthcare organizations building rural and pediatric virtual care capacity, the value is not just that the platform enables remote encounters. It is that it helps make those encounters more clinically useful, more operationally practical, and more aligned with long-term care transformation goals.

It supports clinician-directed virtual physical exams

A major limitation in many telehealth programs is the gap between conversation and examination. The Dr. Miltie N9+ is built to help clinicians conduct more informed remote assessments by capturing clinically relevant patient data and extending parts of the physical exam beyond brick-and-mortar settings.

That matters in rural West Virginia because every avoided delay has ripple effects. Better remote assessment can support triage decisions, follow-up care, monitoring, and specialist collaboration without requiring every patient to travel to a distant facility.

It is well suited for pediatric and special needs care

Pediatric care has different operational demands than adult virtual care. Children may engage better in familiar environments. Caregivers often need to be active participants. Autistic children and pediatric patients with special healthcare needs may benefit from lower-stress encounters that reduce sensory disruption, travel fatigue, and waiting room overload.

A connected-care approach can help bring pediatric services closer to where children already are, including homes, schools, pediatric practices, and community clinics. That is not just a convenience benefit. For many families, it can improve adherence, reduce missed follow-ups, and support earlier intervention.

It helps rural and safety-net providers extend reach

Critical access hospitals, federally qualified health centers, rural health clinics, and community health centers often need technology that can work across distributed environments. The N9+ is not simply a point solution for one department. It supports a broader strategy for extending care delivery into places where patients live, learn, and receive community-based services.

That flexibility is especially relevant when organizations are trying to meet funding objectives tied to underserved populations. A system that can support both clinical relevance and deployment flexibility is more useful than a narrow virtual visit platform.

It aligns better with scalable care models

The strongest technology investments are the ones that can move from pilot to program. A connected platform that supports virtual exams, remote monitoring, care coordination, workflow customization, and reimbursement-aware deployment gives leadership teams more room to scale thoughtfully.

This does not remove every implementation challenge. Broadband variation, staff readiness, change management, and local clinical protocols still matter. But it improves the odds that a rural health initiative can become part of regular operations rather than remain an isolated innovation effort.

Where strategy and technology need to meet

No funding framework, in West Virginia or anywhere else, should be treated as a simple equipment purchase opportunity. The better question is whether the proposed model strengthens access, supports local teams, improves patient experience, and creates a realistic path to sustainable care delivery.

That is why organizations should evaluate more than features. They should look at whether a solution can support pediatric workflows, caregiver participation, distributed clinical environments, documentation needs, and reimbursement planning. They should also ask whether the technology helps them serve the patients who are hardest to reach, not just the patients easiest to enroll.

For many healthcare leaders, the real opportunity is not telehealth by itself. It is building a more complete virtual care capability that supports rural transformation, community-based care, and better continuity across the patient journey. When that capability includes clinically relevant assessment tools and a model designed for pediatric, rural, and underserved populations, it becomes much more valuable.

West Virginia providers do not need more technology for technology’s sake. They need practical, clinically credible systems that help move care closer to patients while protecting staff capacity and supporting measurable outcomes. That is the lens worth keeping as funding opportunities are evaluated and care models take shape.

The post West Virginia RHTP Funding and Dr. Miltie N9+ appeared first on Dr. Miltie.

A child with complex medical needs does not stop needing clinical attention at 5 p.m. Families know that. So do providers trying to reduce avoidable ED visits, missed follow-ups, and the strain that comes with repeated travel for care. Pediatric home 24/7 care has become a practical model for organizations that need to extend clinical reach while keeping children in familiar, lower-stress environments.

For pediatric patients, especially those with chronic conditions, autism, developmental differences, or medical fragility, home is often the setting where symptoms, routines, and caregiver observations are most visible. That makes the home more than a place of recovery. It can be a meaningful site of care delivery, assessment, monitoring, and intervention when the right clinical and technology infrastructure is in place.

What pediatric home 24/7 care means in practice

Pediatric home 24/7 care is not one single service line. In practice, it usually refers to an around-the-clock support model that combines in-home caregiving, ongoing clinical oversight, remote patient monitoring, after-hours escalation pathways, and scheduled or on-demand virtual assessment. Depending on the child’s diagnosis and acuity, the model may include skilled nursing, chronic care management, medication oversight, symptom tracking, and care coordination across multiple specialists.

That distinction matters. Some organizations hear the phrase and think only of private-duty nursing in the home. Others assume it means telehealth alone. Neither view is complete. The strongest pediatric home care models combine human caregiving with clinician-directed workflows, actionable patient data, and clear communication between caregivers, nurses, primary care, and specialty teams.

For health systems and community-based providers, the question is less whether children need continuous support and more how to deliver it in a way that is clinically sound, operationally realistic, and financially sustainable.

Why pediatric home 24/7 care is gaining traction

The growth of pediatric home 24/7 care reflects both family need and system pressure. Pediatric capacity remains uneven, subspecialty access is limited in many regions, and transportation barriers continue to disrupt continuity of care. For rural providers, federally qualified health centers, critical access hospitals, and pediatric programs serving underserved communities, these barriers are not occasional. They are structural.

Home-based pediatric care can reduce some of that friction. Families spend less time traveling. Children who struggle with sensory overload or disruption of routine may tolerate care better at home than in busy clinics or hospital settings. Caregivers can participate more fully because they are present where the child actually lives, sleeps, eats, and receives day-to-day support.

From an operational standpoint, organizations also gain a better window into real-world status. A virtual physical exam supported by connected devices can help a clinician evaluate symptoms between visits, check response to treatment, and decide whether a child needs escalation, an in-person appointment, or continued home management. That kind of triage is especially valuable when staffing is tight and pediatric specialists are stretched across large geographies.

The clinical case for care beyond the clinic

Children with asthma, neurologic conditions, congenital disorders, feeding challenges, respiratory support needs, or post-acute recovery needs often require ongoing observation that does not align neatly with episodic office visits. The home setting can fill that gap, but only if clinical quality is preserved.

This is where many programs succeed or fail. If home care is treated as disconnected check-ins with limited exam capability, clinicians may not trust the information enough to act on it. If, however, the model includes clinically relevant data capture, structured assessment, and caregiver-supported workflows, providers can make more informed decisions without bringing every child back into a facility.

For pediatric patients with special healthcare needs, this matters even more. Signs of deterioration may be subtle. Caregivers may notice changes in breathing, sleep, appetite, mood, tolerance, or behavior before a measurable crisis occurs. A well-designed home care model does not replace that caregiver insight. It gives it clinical structure.

Building pediatric home 24/7 care around the circle of caregivers

A child receiving continuous home-based support is rarely cared for by one person alone. Parents, grandparents, school nurses, therapists, primary care teams, specialists, home health staff, and case managers may all play a role. Without coordination, that network becomes fragmented very quickly.

Pediatric home 24/7 care works best when it is organized around a defined circle of caregivers and clinicians, each with a clear role in observation, escalation, documentation, and follow-up. That may sound simple, but in practice it requires workflow design. Who is reviewing alerts overnight? What vital signs or symptom trends trigger outreach? When should caregivers use a virtual exam pathway rather than wait for the next appointment? What documentation supports reimbursement and continuity?

These are not minor administrative details. They determine whether home-based pediatric care becomes a scalable service model or a series of improvised workarounds.

For that reason, technology selection should be tied to care model design. The right platform is not just video-enabled. It should support virtual physical exams, remote patient monitoring, caregiver engagement, configurable pathways of care, and documentation that fits regulated clinical environments. For organizations expanding pediatric access, that is often the difference between offering virtual touchpoints and delivering true connected care.

Where virtual exams fit into pediatric home 24/7 care

Not every pediatric issue can be managed remotely, and providers should be cautious about overselling what home-based care can do. A child in acute distress still needs rapid in-person escalation. Some diagnostics still require facility-based resources. And some families need hands-on support that technology alone cannot provide.

Still, there is a wide middle ground where remote assessment adds real value. Virtual exams can support respiratory checks, skin assessments, follow-up after discharge, chronic condition surveillance, medication response review, and caregiver-guided evaluation of symptoms that might otherwise result in unnecessary travel or delayed intervention.

For autistic children and pediatric patients with sensory sensitivities, the home environment can also improve exam tolerance. Familiar surroundings may reduce anxiety and behavioral stress, which can lead to a more accurate assessment and better caregiver participation. That does not eliminate clinical complexity, but it can remove barriers that often interfere with care delivery.

One example is a child recently discharged after a respiratory event. If the family has after-hours concerns, a connected home-based exam and monitoring workflow may allow a clinician to assess status, review relevant measurements, and determine whether the child can remain safely at home with follow-up or needs escalation. The benefit is not convenience alone. It is better decision support at the point where decisions are actually being made.

Operational realities healthcare leaders should plan for

Organizations considering pediatric home 24/7 care need a realistic view of implementation. Success depends on more than purchasing devices or launching a telehealth service line. Clinical leadership, operations, IT, compliance, and reimbursement teams need alignment from the start.

Licensure, HIPAA compliance, documentation standards, staffing models, caregiver training, alert thresholds, and escalation protocols all affect performance. So does payer strategy. In some cases, reimbursement pathways for remote patient monitoring, chronic care management, or virtual services can support sustainability. In others, the economics depend on reducing readmissions, improving follow-up adherence, supporting value-based arrangements, or extending specialist reach into underserved areas.

There is also an equity consideration. Not every home has the same connectivity, caregiver availability, or comfort with digital tools. Programs that assume ideal conditions will miss the very populations that often benefit most. Pediatric home models need flexible deployment, simple user experience, and support structures that work for families under real-world pressure.

This is one reason institution-facing platforms matter. A technology partner should be able to support workflow customization, training, and rollout across pediatric practices, rural clinics, school-linked programs, and community settings. Dr. Miltie’s approach reflects this broader view, treating connected pediatric care as an operational model rather than a standalone device deployment.

Pediatric home 24/7 care is not all-or-nothing

Some organizations hesitate because the phrase sounds large and resource-intensive. In reality, pediatric home 24/7 care can be built in phases. A program might begin with high-risk pediatric follow-up after discharge, then expand into chronic disease monitoring, after-hours virtual assessment, or support for children with special healthcare needs.

That phased approach often makes sense. It allows teams to validate workflows, define clinical criteria, and understand where remote exams and monitoring create the most value. It also helps leaders separate cases that truly require full around-the-clock skilled support from those that benefit from a lighter, technology-enabled model.

The key is not to frame home-based pediatric care as a replacement for clinic or hospital care. It is an extension of clinical reach. When designed well, it strengthens continuity, supports caregivers, and gives providers a better way to stay connected between visits.

For children whose health needs do not fit neatly inside office hours, that kind of continuity can change the quality of care in very practical ways.

The post How Pediatric Home 24/7 Care Really Works appeared first on Dr. Miltie.

Dive Brief:

• The U.S. Food and Drug Administration is asking for public input on the transition to at-home care and how it can support enabling technologies.
• As part of its push to advance health equity, the FDA has posed a series of home-care questions to the medtech industry, including a query about how it can support the development of devices for use in non-clinical care settings.
• Other questions cover how digital health technologies can support home-based healthcare, the device design attributes that facilitate use outside of clinical settings and methods for generating data to inform regulatory reviews.

Dive Insight:

The development of remote patient-monitoring devices and other connected medical technologies has made it possible to treat more patients at home. In theory, home care can help reduce costs and risks associated with spending time in healthcare facilities and lessen burdens on patients. The COVID-19 pandemic accelerated uptake and validation of telehealth and remote monitoring, setting the stage for wider use of the technologies.

In its request for comment, the FDA’s Center for Devices and Radiological Health said it is committed to “facilitating access to medical devices designed to be safe and effective when used outside of traditional clinical settings, for example, medical devices intended for use in the home.” The questions posed by the FDA cover the information it may need to deliver on that promise. 

Some of the questions are broad, covering the factors that “effectively institute patient care that includes home-based care” and the medical procedures that are ideal for transitioning to the home. Other questions focus on what the FDA can do. The agency wants to know how it can facilitate access to medical technologies when people are unable or unwilling to access care in clinical settings.

Officials said the interest in allowing people to access care wherever they are is consistent with the FDA’s goal of advancing health equity. One question asks what digital health technology design attributes “could better facilitate their use by diverse patient populations outside of a clinical setting” and what other factors can improve acceptance in older adults and non-English speakers. 

The FDA is accepting comments until the end of August.

The post FDA Seeks Feedback on Technologies That can Enable Healthcare at Home appeared first on Dr. Miltie.

Tuesday, June 27, 2023

Trending in Telehealth is a new series from the McDermott digital health team in which we highlight state legislative and regulatory developments that impact the healthcare providers, telehealth and digital health companies, pharmacists, and technology companies that deliver and facilitate the delivery of virtual care.

Trending in the past week:

• Telehealth pilot programs
• Mental health

A CLOSER LOOK

Finalized Legislation & Rulemaking

• Connecticut enacted HB 6768, which permits physicians, advanced practice registered nurses and physician assistants to certify a qualifying patient’s use of medical marijuana and provide follow-up care using telehealth if they comply with other statutory certification and recordkeeping requirements.
• Florida enacted HB 5101, which requires each school district to implement a school-based mental health assistance program that provides behavioral health services in-person and supplemented by telehealth.
• Florida enacted SB 2500, which provides additional funding for telehealth services under the Minority Maternity Care program.
• Illinois enacted SB 1298, amending the Home and Community-Based Services Waiver Program for Adults with Developmental Disabilities to permit medical and emergency telehealth services for persons with intellectual and developmental disabilities.
• Louisiana enacted SB 186, adopting the Occupational Therapy Licensure Compact.
• Louisiana enacted SB 66, which amends the state insurance code by replacing the term “telemedicine” with “telehealth,” for consistency throughout the code. The amendment does not require a provider to have an in-person examination with the patient prior to using telehealth but does require that a referral be made to an in-state healthcare provider or in-state follow-up care be arranged if necessary. The amendment also permits the use of interactive audio without video if, after access and review of the patient’s medical records, the healthcare provider determines that the provider is able to meet the same standard of care as if the services were provided in-person.
• Louisiana enacted HB 41, which requires health plans to provide equivalent coverage and payments for telehealth occupational therapy services as for in-person services, unless the plan and the provider agree otherwise.
• Louisiana enacted HB 181, which allows coroners to use telehealth when conducting an examination for an emergency mental health commitment.
• Texas enacted HB 2727, which amends the requirements for the home telemonitoring program under Medicaid, including reimbursement requirements.
• Texas enacted HB 617, which establishes a pilot project to provide emergency medical services instruction and emergency prehospital care instruction through a telemedicine medical service or telehealth service provided by regional trauma resource centers to healthcare providers in rural trauma facilities and emergency medical services providers in rural areas.
• Texas enacted SB 1146, increasing access to telehealth services for inmates. The law requires the Department of Criminal Justice, in conjunction with The University of Texas Medical Branch at Galveston and the Texas Tech University Health Sciences Center, to establish procedures to expand access to telemedicine medical services, telehealth services and onsite medical care for inmates, including onsite mobile care units that provide diagnostic imaging, physical therapy and other appropriate mobile health services.

Legislation & Rulemaking Activity in Proposal Phase

Highlights:

• Maine progressed LD 757 in the second chamber to expand telemonitoring in the MaineCare program. The rules would allow a provider to offer telemonitoring services if medically necessary given the patient’s health status, and would allow providers to determine the frequency of telemonitoring services to achieve care plan goals for the patient.
• Rhode Island progressed SB 965 in the second chamber. The bill would amend the Telemedicine Coverage Act and define a patient-provider relationship as a relationship where the healthcare professional agrees to undertake diagnosis and treatment of the patient and the patient agrees to be treated.
• Rhode Island progressed HB 6489 in the second chamber to establish telepractice standards for audiology and speech language therapy and pathology professionals.

Why it matters:

• States continue to progress and pass legislation establishing telehealth pilot programs across multiple departments. As noted in past posts, pilot programs are important steps to determine the best uses of telehealth and increase access to healthcare in vulnerable populations.
• States continue to progress and pass legislation expanding the use of telehealth and telemedicine for mental health.

The post Trending in Telehealth: June 13 – 21, 2023 appeared first on Dr. Miltie.

On May 19, 2023, Novitas Solutions and First Coast Options sent an email to certain interested parties, with whom they had engaged following the multijurisdictional contractor advisory committee (CAC) meeting explaining that they have decided to not pursue at this time a local coverage determination for remote physiological monitoring (RPM) and remote therapeutic monitoring (RTM).

What does this communication mean for RPM/RTM service providers?

In the short term, the status quo remains (i.e., there is no proposed local coverage determination) for Novitas and First Coast. This communication is specific to Novitas and First Coast, and does not prevent the other Medicare Administrative Contractors (MACs) from developing local coverage determinations for their jurisdictions. Novitas and First Coast may change their mind at any time and decide to draft a proposed local coverage determination for RPM and/or RTM services.  Further, if any of the MACs decide to issue a draft LCD, they are not obligated to hold another CAC meeting or to notify stakeholders in advance.

Accordingly, healthcare providers and digital health companies should continue their focus on compiling the evidence to support the clinical utility of their services. This action (or inaction) by Novitas and First Coast should not be misinterpreted as a justification for easing off evidence generation and collection.

SUMMARY

A recent multijurisdictional CAC meeting held by six of the seven MACs gave stakeholders an initial opportunity to provide feedback on the strength of clinical evidence to support Medicare coverage for RPM and RTM services for non-implantable medical devices. We previewed how this meeting may influence the development of Medicare local coverage determinations in a recent article.

Twenty-four subject matter experts (SMEs), both physicians and other stakeholders, including digital health company medical leaders and clinicians with extensive experience with remote monitoring programs participated in the CAC meeting. The questions posed during the CAC meeting included requests for examples of SME experience with remote monitoring technologies and opinions on the amount of high-quality evidence to support their use for various diagnoses and conditions.

Despite certain questions posed during the CAC meeting that demonstrated a skepticism for remote monitoring services outside certain use cases, the SMEs voiced overwhelming support for continued coverage of remote monitoring services and several SMEs expressed concern about the potential proposal of one or more local coverage determinations (each, a LCD). Several participants noted that literature and data not referenced in the meeting materials, together with pending research studies, could provide support for continued coverage of remote monitoring services for a variety of clinical uses.

IN DEPTH

BACKGROUND

Remote Monitoring Background

In recent years, the Centers for Medicare & Medicaid Services expanded payment for remote monitoring services, which generally use digital technologies (medical devices, together with software) to collect medical and other forms of health data from patients in one location and electronically transmit the information to the patient’s healthcare provider in a different location for assessment and care management. The data collected is electronically transmitted to health professionals for review and can be used in patient management. In some cases, the technologies can either trigger direct patient engagement or facilitate that communication.

RPM services involve monitoring physiological conditions (e.g., weight, blood pressure, blood sugar) through medical devices, which transmit data obtained from patients automatically to healthcare providers for assessment and recommendations. In contrast to RPM services, RTM services involve the use of medical devices to monitor a patient’s health or response to treatment using non-physiological data. RTM can be used to monitor medication adherence, response to therapy, musculoskeletal activity and respiratory activity. Unlike RPM, devices for RTM are not limited to transmitting data automatically obtained from patients but can also transmit data self-reported by patients.

Medicare Coverage Policies and Role of CACs

In determining whether to develop an LCD for particular services, MACs may, but are not required to, hold a CAC meeting as an opportunity for healthcare providers to provide feedback (i.e., evidence) that the MAC contract medical directors can consider when contemplating the potential development of future coverage policies. CACs provide a forum for communications between the MACs and the healthcare industry more broadly. CACs are advisory only, however, and the final decision on whether to proceed with a draft LCD remains at the discretion of the MAC. If a MAC decides to draft an LCD, it will be published on the Medicare Coverage Database and on the MAC’s websites. After the publication, the public will have at least 45 days to provide written comments, as well as an opportunity to deliver comments verbally during an “open meeting” before the LCD is finalized. A MAC will then consider the submitted evidence and comments before taking final action on the draft LCD. This final action must be taken within 365 days of the draft LCD being published, and it can be finalized, revised or withdrawn. MACs are required to respond to submitted comments in a comment/response document published alongside any final LCD. Once a MAC publishes a final LCD, there must be a minimum 45-day notice period prior to the policy becoming effective.

IN DEPTH

Key Takeaways

The recent CAC meeting focused on the clinical use of remote monitoring technologies and the quantity and extent of clinical literature supporting the use of RPM and RTM across specialties. The stated purpose of the CAC meeting was to examine the quality and strength of the clinical evidence supporting remote monitoring technologies, discuss the relevance of the evidence to the Medicare population, and obtain opinions from a variety of clinical backgrounds. The CAC meeting involved the MAC medical directors and certain SMEs on remote monitoring services.

The SMEs overwhelmingly supported the use of remote monitoring technologies and services across a wide variety of specialties. The SMEs advocated for continued Medicare coverage of this type of treatment and highlighted a variety of success stories. The SMEs were asked questions on their clinical use, and also on the evidence to support use, as detailed below.

Clinical Use of Remote Monitoring

The SMEs provided background on their clinical practice and reasoning for using RPM or RTM technologies. SMEs that utilize remote monitoring technologies were asked to discuss how they identify potential patients, how long patients are monitored, and what patient diagnoses are suitable for RPM or RTM services. The SMEs represented specialties including cardiology, physical therapy, internal medicine, podiatry, pediatrics, geriatrics, urology, anesthesiology, interventional pain management and orthopedics.

The majority (if not all) of the SMEs had extensive experience with either RPM or RTM, with many clinicians leveraging both technologies. The SMEs discussed at length the benefits of having data regularly collected by remote technologies and the value of being able to engage patients both sooner and more regularly when compared to in-person care. SMEs highlighted more regular contact with patients and access to data on patients’ clinical status in particular as beneficial with respect to chronic conditions and patients who may receive less regular in-person care because of limited access to regular care. As one expert from Mount Sinai remarked, having access to data from high-risk patients allows for higher intensity care in a cost-effective manner.

Another area where there was broad agreement related to the need to accommodate variation in the length of monitoring for patients. The SMEs stated that the duration of remote monitoring was dependent on the patient’s condition and the treating practitioner’s particular evaluation. Ranges between four weeks and up to six months were offered, depending on the patient and the ongoing utility of remote monitoring, although other participants noted that remote monitoring can be of use for longer periods of time for patients with chronic conditions or for patients receiving RTM as part of a physical therapy plan of care.

Remote Physiologic Monitoring Use Cases

RPM was discussed across the majority of specialties, with specific discussions on the advantages of filling in data points for patients that are not seen often. The most frequently mentioned clinical uses of RPM services included the following:

• Patients diagnosed with the below conditions where consistent monitoring can aid in medical decision making:
  • Diabetes
  • Neuropathy
  • Musculoskeletal traumatic arthropathy
  • Vascular disease
  • Hypertension
  • Chronic heart failure
• Patients with more than one hospital stay in one year
• Patients who utilize healthcare resources or visit emergency departments frequently
• Patients who have had an escalation of their condition in the last 24 months
• Patients who are geographically disadvantaged to seek in-person care
• Patients with obstructive sleep apnea who use CPAP machines
• Patients with chronic obstructive pulmonary disease (COPD) exacerbation
• Chronic heart failure patients, specifically in relation to reducing hospital readmissions.

Remote Therapeutic Monitoring Use Cases

Similarly, RTM was widely discussed. The clinical use cases noted to have particular advantages included medication adherence and physical therapy monitoring. The clinical use cases for RTM included the following:

• Ensuring patients are adherent with therapy plans of care and are following therapist directions with respect to physical therapy exercises
• Medication adherence monitoring, specifically for identifying and monitoring the development of substance use disorders for chronic pain patients
• Providing ongoing monitoring to patients recovering from total knee replacements and to reduce the number of in-person physical therapy visits
• Monitoring the use of inhalers for patients with asthma and COPD.

Evidence-Supported Outcomes

The SMEs were asked to provide opinions on the amount and quality of literature supporting the use of RPM and RTM. The SMEs felt existing literature supported the use of RPM and RTM over established standards of care in several areas, including elevating patient engagement, improving patient care and reducing overall healthcare utilization. Several SMEs highlighted ongoing studies in the following areas:

• The value of RPM for hypertension and hyperlipidemia patients
• The correlation between the use of remote monitoring and improvements in health equity
• Use of remote monitoring in orthopedics and musculoskeletal treatment
• Improvements over the standard of care for treatment of patients with diabetic ulcers.

During the meeting, participants were asked whether there is high-quality evidence to support the use of remote monitoring for patient diagnoses other than chronic heart failure, hypertension, COPD, hemoglobin A1c (blood glucose monitoring for diabetes), back/knee pain and musculoskeletal conditions. Based on this question, the CAC may believe that the clinical evidence is stronger for these conditions, and views the evidence as less robust with respect to other conditions or use cases. Due to the number of SMEs participating in the meeting (and the extensive responses to certain questions provided by the SMEs), the MAC medical directors did not weigh in or provide additional insight as to how they are viewing the clinical support for various conditions or use cases.

Several individuals raised concern about the MACs implementing coverage policies before currently pending studies have been published, stating that these programs need time to finish and develop. Some commenters suggested that the timing of the availability of these codes—either shortly before (in the case of RPM) or shortly after (in the case of RTM) the start of the public health emergency—hindered efforts to collect data effectively on many of the remote monitoring services. Other commenters raised concern about implementing restrictive coverage policies before RPM services in particular have a chance to demonstrate value through published studies for use cases other than the conditions noted above. There were specific concerns over the implementation of LCDs by MACs that negatively impact coverage and payment for remote monitoring services more broadly, particularly in the Medicaid population.

Practical Impact

As discussed above, the CAC meeting is one of the first steps before an LCD may be proposed. If a MAC (or MACs) do propose an LCD, potential coverage limitations may relate to the particular conditions for which remote monitoring services are viewed as reasonable and necessary and the duration of remote monitoring that may be provided. Although the CAC meeting did not include meaningful discussion on the types of devices furnished to Medicare beneficiaries in connection with remote monitoring services, an eventual LCD could also potentially implement limitations on the types of devices for which remote monitoring services are considered reasonable and necessary.

Digital health companies that furnish these services (or help providers furnish these services) and have access to persuasive literature or have concerns about potential limitations in an eventual LCD should strongly consider submitting feedback and literature for consideration. The most persuasive literature or information will include evidence on what specific medical devices are used and which patient diagnoses are supported by clinical data, and how the use of RPM or RTM services impacts patient management and improves patient outcomes (for example, lowers the likelihood of side effects post-surgery, reduces the incidence of chronic condition exacerbation, or reduces recurrent hospitalizations or office visits). Healthcare providers with evidence to support the clinical utility of RPM and RTM services should similarly focus on compiling such evidence. This evidence will be crucial for establishing that the use of particular devices for certain diagnoses provides clinical benefit to the patient.

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The threat of a physician shortage is nothing new but seems to have picked up steam in the last few years. In fact, new figures from the Association of Medical Colleges (AAMC) anticipate a shortage of up to 120,000 physicians by the year 2030. This is a particular challenge in rural areas, where the ratio of patients to physicians is around 769 to 1.

As discouraging as these statistics may seem, there is still hope. The fact is that, despite a widening ratio of patients to doctors, there remains a severe lack of optimization in healthcare organizations across the country. Far too many appointments currently go unfilled or are missed by patients on a daily basis.

When physicians operate at full capacity, with fewer no-shows and cancellations, there’s a much better balance between healthcare demand and physician supply. Addressing this imbalance would be the equivalent of adding thousands of physicians into the healthcare system overnight.

To begin, we must build a system that benefits all involved in healthcare delivery-from physicians to patients to staff. The good news is this solution is already available. Several strategies facilitated by technology are helping provide access to hidden capacity in our current health system:

Digital care coordination

Digital care coordination, or technology with the ability to intuitively guide patients to and immediately schedule them with the right care, is key to filling any open or unused appointment slots and reducing no-show rates, both of which increase physician capacity. With direct access to physicians’ calendars, call center agents, patients, and referring agencies can see all available appointment slots in real time for any given day. This increases the chances that those open slots will be filled on an ongoing basis, ensuring that physicians’ daily schedules are full.

Physician practices note that no-shows are one of their biggest challenges. Across specialties, no-show rates hover between 5 percent and 10 percent on average although we have seen them as high as 30 percent or more. Implementing online self-scheduling with automated reminders can help physicians regain these lost appointment times and reduce no-show rates.

Lead time, or the time between scheduling and a care visit, is also one of the strongest determinants of patient no-shows. Reducing this time can reap positive results that not only improve care outcomes, but better utilize existing capacity. Our data show that 20 percent of patients can get same- or next-day appointments when self-scheduling is available, and more than 50 percent can see their physician within a week.

But digital care coordination isn’t just about self-scheduling. When used by call centers, referring agencies, or discharge staff, it can enable real-time referrals that close gaps in care. For example, with one of our clients we’ve seen lead times for referrals from primary care physicians to specialists decrease by nine days on average when referrals were booked digitally.

Actionable analytics

Actionable analytics are a vital factor in optimizing physician capacity. With analytics, physicians can track patient behavior, better understand patient needs, and optimize their calendars accordingly. This ensures a more orderly day and a better anticipated schedule with appointment availability that aligns with demand. Viewing patient show rates in aggregate and over time helps physicians guard against no-shows, while real-time capacity metrics can identify opportunities to increase utilization.

Digital health and long-distance medicine

In light of the physician shortage, virtual care tools can be particularly helpful for providing care to patients in remote rural areas. Such tools further close gaps in care by connecting rural primary care physicians and their patients with specialists that may normally only be accessible by visiting a larger, urban hospital.

By balancing the demand for specialty care with those who are capable of providing it, but may not be geographically accessible, virtual care technology is helping patients in need receive expert care while filling existing capacity in the calendars of available specialists.

Technology is helping to transform access to care for millions of Americans and can be an effective tool in addressing the physician shortage. With digital care coordination, analytics, and innovations such as telemedicine, we can bring a more proactive approach to healthcare and solve some of our industry’s greatest challenges.

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Like many people, I was introduced to telehealth during the pandemic. I met with my psychiatrist virtually, settling onto my couch instead of hers for our sessions. But those appointments required only a conversation. It made sense that psychotherapy easily made a switch to the online world.

What’s more surprising is how often telehealth now is being used in other medical areas, such as in cancer care. Although chemotherapy and immunotherapy are typically done in person, follow-up visits and medication and symptom management can be done virtually, says Leah Rosengaus, director of digital health at Stanford Health Care in California, where 44 percent of oncology visits are virtual. For patients with cancer receiving routine treatment, that equals a lot less hassle. And for a patient with a poor prognosis, it might be even more meaningful. “The biggest gift [we can] give them is time,” Rosengaus says.

Telehealth programs made up less than 1 percent of all health care in the U.S. until March 2020, when, of course, everything changed. The pandemic restricted personal contact, and telehealth surged. (At Stanford, it went from less than 2 percent to more than 70 percent of visits in just a few weeks.) State and federal regulators relaxed rules that required doctors to see patients personally before offering care, and insurers began to cover virtual visits. Now the use of technology such as video chats, secure messaging, and even old-school phone calls to allow clinicians and patients to communicate appears to be here to stay. It has settled at 10 to 30 percent of patient appointments in many large hospital systems.

In general, the quality of telehealth care seems high. Nearly 87 percent of the time, Mayo Clinic researchers reported in JAMA Network Open last fall, an initial virtual diagnosis agreed with a later diagnosis made in person. Oncology and psychiatry proved especially accurate; ear, nose and throat and dermatology appointments—which rely more on physical examinations—were somewhat less so. A 2022 study of more than 500,000 patients found equal or better outcomes for telehealth across 13 of 16 primary care measures, such as management of diabetes and following through on flu shot appointments, when compared with in-person visits.

The quality-of-care results seem highest in the specialties that use telehealth most. Endocrinologists, for instance, like it because their patients get lab work done separately and then discuss results with doctors virtually; surgeons are using it to confer with patients before and after procedures.

Patient satisfaction with these visits is good, according to reports from large health-care systems. People say they like the convenience of virtual care—there is no travel, no parking, no child or pet care to arrange. Sanford Health, which serves a widespread rural population from its base in Sioux Falls, S.D., estimates its patients who used virtual care were spared two and a half million miles of driving in 2022.

In some cases, technology is providing clinicians with better insights into those they care for. Jeremy Cauwels, chief physician at Sanford, says an endocrinologist in his organization now carves out several hours a week for video visits with diabetes patients after discovering how much information about diet and habits he could glean from observing them at home.

People vary in how much of their home life they are willing to show, of course. Whereas some patients would never turn a camera on in the living room, others cheerfully display the insides of their medicine cabinets or refrigerators. “We’re getting a window into the patient’s lived environment that we never had before,” Rosengaus says. “That harkens back to the days of doctors and house calls.”

Virtual visits do not work for everything and everyone. In the large 2022 telehealth study, in-office patients were more likely to receive and adhere to some medications, such as statins for cardiovascular disease. Starting “a lifelong medication” is a big decision that may be best suited to an in-person discussion, the authors suggest. Another study found that patients who followed up an emergency hospital visit via telehealth rather than in person were more likely to be readmitted to the hospital.

Clearly, medical providers must fine-tune the best use of this technology. The rest of us will keep finding our comfort level (I draw the line at showing my medicine cabinet). The goal, proponents say, is not simply to increase telehealth use but to optimize it and create a good form of hybrid care they call “clicks and mortar.”

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As medicine continues its digital shift, new billing codes are being added next year for specialties like remote therapeutic monitoring and digital ophthalmology.

“The [Current Procedural Terminology] code set does move at the pace of medicine, and it continues to evolve and keep pace with all of the changes,” said Leslie Prellwitz, the American Medical Association’s director of CPT content management and development, in a Dec. 5 AMA article.

New digital health codes for 2023 include:

Remote therapeutic monitoring (time per month):

• 98980: for the first 20 minutes of treatment management services.
• 98981: for each additional 20-minute period of treatment management services.

Digital ophthalmology:

• 0704T–0706T: for remote treatment of amblyopia using an eye-tracking device and to cover device supply, technical support, interpretation and report.

Examination by pathologists remotely or in conjunction with the use of artificial intelligence algorithms:

• 0751T–0763T: for digitization of glass microscope slides, enabling remote examination by the pathologist and/or in conjunction with the use of AI algorithms.

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Physician adoption of digital health tools continues to grow, as does the infrastructure facilitating appropriate payment for their use. The Current Procedural Terminology (CPT®) code set, often called “the language of medicine,” is expanding to meet the demand.

“The CPT code set does move at the pace of medicine, and it continues to evolve and keep pace with all of the changes,” said Leslie Prellwitz, the AMA’s director of CPT content management and development.

“When you look at digital medicine, the areas with significant physician interest, confidence, utility and patient care also have significant CPT code representation,” Prellwitz said during a recent AMA webinar on telehealth, other digital health tools, and CPT coding.

The webinar built on the most recent findings of an AMA physician survey (PDF) that indicates adoption of digital tools has grown significantly among all physicians regardless of gender, specialty or age. Improved clinical outcomes and work efficiency are identified as the key drivers of adoption.

Supporting telehealth is an essential component of the AMA Recovery Plan for America’s Physicians.  Telehealth is critical to the future of health care, which is why the AMA continues to lead the charge to aggressively expand telehealth policy, research and resources to ensure physician practice sustainability and fair payment.

Massive shift on telehealth

“Adoption of remote-care tools such as televisits or telehealth and remote monitoring have seen the most movement,” said Meg Barron, the AMA’s vice president of digital health innovations.

“This isn’t a huge surprise, given the spike in usage during the pandemic,” Barron added. “But when you think about this, the use of telehealth has tripled since 2019, which is a massive shift.”

Digital health encompasses a broad scope of tools, going beyond telemedicine and remote monitoring wearables, apps and more. The digital health tools that garner the most enthusiasm among physicians are televisits (57%) followed by remote-monitoring devices (53%).

In terms of ensuring proper payment, the CPT code set classifies the latter applications as either tools for remote physiologic monitoring (RPM) or remote therapeutic monitoring (RPT).

RPM CPT codes were created in 2019 and cover device setup, educating patients in the use of the devices, device supply and the management of patient treatment.

The RPM codes are intended to be used in the monitoring of a patient’s physiologic parameters such as weight, blood pressure, pulse oximetry or respiratory flow rate.

The RTM CPT codes were launched this year and are also used for device supply, device setup and patient education in their use, plus patient adherence and response to therapy.

“Therapeutic monitoring is really being able to look at the impacts of a particular treatment regimen,” Prellwitz said.

While much expansion is expected, current RTM codes focus on musculoskeletal system status, respiratory system status, cognitive behavioral therapy, therapy adherence and therapy response, and the review and monitoring of data related to a therapeutic response,

Related codes include:

• 98975 to report the initial setup, patient education and use of the equipment.
• 98976 and 98977 to report a device supply with scheduled recordings or program alert transmission to monitor the respiratory or musculoskeletal system, each 30 days.

Use of digital therapeutics is low (11%), but a greater share of physicians (40%) reported plans to incorporate the technology in the next year than they did for any other new digital health tool.

“Despite the growth in RPM, it’s still actually the least utilized of the solutions that we asked about,” Barron said. “That just speaks to the market-share opportunity that we have on hand—and the role that technology can play to help address chronic disease.”

The ability for digital health tools to help reduce stress and burnout has also gained importance as a major driver of adoption, she added.

New digital health codes for 2023

Another CPT code category launched this year involves remote therapeutic monitoring treatment-management services. Codes for these services are reported for time spent per month:

• 98980 reports the first 20 minutes of treatment management services.
• 98981 reports each additional 20-minute period of treatment management services.

Last year, the CPT Editorial Panel, authorized by the AMA Board of Trustees to revise, update and modify CPT codes, descriptors, rules and guidelines, adopted a taxonomy to describe health services or procedures delivered via augmented intelligence (AI)—often called “artificial intelligence.” The document’s guidance, contained in Appendix S to the CPT code set, took effect in January.

Codes being added in 2023 for digital ophthalmology services include:

• 0704T–0706T for remote treatment of amblyopia using an eye-tracking device and cover device supply, technical support, interpretation and report.

CPT codes enabling remote examination by pathologists or in conjunction with the use of AI algorithms are also being added in 2023.

• 0751T–0763T cover digitization of glass microscope slides, enabling remote examination by the pathologist and/or in conjunction with the use of artificial intelligence (AI) algorithms. .

“There’s a whole series of codes in that section,” Prellwitz said. “That’s very new and you don’t see that type of advancement all the time at that scale.”

A special section for CPT education has been created for the AMA Ed Hub™, an online learning platform containing CME and education, including a module series covering an overview of CPT coding basics and other topics. The CPT Network is also available for authoritative CPT coding guidance.

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With the goal of filling in gaps related to virtual healthcare, the American Medical Association (AMA) and Manatt Health released a Blueprint for Optimizing Digitally Enabled Care, which describes six pillars that can help optimize digital health practices.

According to the AMA, there is untapped potential associated with digitally enabled care. The organization noted that investments, technology adoption, and patient needs play a significant role in how digitally enabled care evolves and how it can be used to improve access and care quality.

“When equitably designed and thoughtfully integrated, digital health tools can effectively augment and enhance care,” said AMA President Jack Resneck Jr., MD, in a press release. “Yet often, digital health products exist in silos and risk additional fragmentation, higher costs, and diminished care experiences. Optimizing the full potential of digitally enabled care requires a collaborative effort and the blueprint offered by the AMA outlines opportunities for physicians and other stakeholders to move in partnership toward improving the health of the nation.”

Dig Deeper

• AMA Survey Charts Explosive Growth of Telehealth Services in 2020
• AMA Adds Digital Literacy to its Telehealth Adoption Gameplan
• AMA Launches Telehealth Immersion Program to Promote Sustainability

The AMA’s blueprint highlights six areas stakeholders should focus on when optimizing digitally enabled care.

The six areas relate to building care models for patients and clinicians, designing with a health equity lens, basing care on the relationship between patients and providers, improving payment channels to incentivize high-value care, eliminating fragmentation through technology, and scaling evidence-based models quickly.

Building for patients and clinicians refers to creating care models based on the needs of patients, providers, and other involved stakeholders. Designing with an equity lens relates to eliminating bias and launching efforts to reach marginalized communities. The recommendation to recenter care on the relationship between the patient and provider is based on the impact of this relationship on early detection and treatment of conditions.

Improving payment models can support the development of financially stable innovations, in the long run, using technology to reduce fragmentation can lead to improved coordination, and scaling evidence-based models quickly can lead to higher accuracy when determining its effectiveness, according to the report.

After establishing these six foundational pillars, the AMA also defined healthcare stakeholder opportunities.

The blueprint recommends that physicians add digital workflow tools to make care more efficient and direct more attention to technology design and implementation. It also notes that health plans evaluate the effectiveness of digital care models, improve payment equity, and simplify administrative burdens.

Further, the blueprint urges employers to create on-site virtual care environments, incentivize relationships with primary care providers (PCPs), and require information sharing with employees’ PCPs.

Policymakers can also help advance digital health processes by extending telehealth flexibilities, directing more attention to research funding, and improving interoperability.

Meanwhile, health technology companies can play a role by considering patient and provider input and easing provider workflows, and venture capital and private equity funds can plan investments in companies that embrace integration and direct more investments in companies focused on vulnerable populations, the report stated.

Similarly, in February, the AMA released a report that described recommendations for healthcare stakeholders as they work to strengthen behavioral health integration (BHI). In the report, the AMA detailed three goals that apply to advancing BHI efficiently.

The goals are defining opportunities and limitations associated with digital care methods, determining the best channels for combining BHI and telehealth, and representing the value related to the AMA’s Return on Health framework.

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