Home telemonitoring needs health reform, more research to become widespread

Several recent reports have predicted a rapid rise in the use of remote patient monitoring. So far, however, it appears that only a small minority of consumers are using these applications and that even fewer people have heard about them from their physicians. Moreover, the use of wellness and fitness apps on mobile devices--which does not require professional involvement--is taking precedence over monitoring of people with chronic diseases.

One reason is that most physicians are not yet organized or incentivized to participate in home or mobile telemonitoring. While healthcare systems and large physician groups employ an increasing number of doctors, the vast majority of physicians still work in small private practices. These practices are not set up for non-visit care management, nor can they afford the staff to keep tabs on telemonitoring data.

Equally important, most ambulatory-care physicians are being paid only for face-to-face office visits and procedures. Although a growing number of health plans are incentivizing practices to form patient-centered medical homes--which stress continuous, coordinated care--financially at-risk accountable care organizations are still in a nascent stage outside of California.

The Geisinger Health Plan recently reported that a pilot of home telemonitoring for patients with congestive heart failure (CHF), in conjunction with case management, reduced readmissions by 44 percent compared to a control group that received only case management. That success has emboldened Geisinger to expand the program to diabetes and hypertension. But other health plans won't necessarily rush to follow suit. Geisinger's care management program is aligned with the incentives of its physician group, which is part of its group-model HMO and thus profits from keeping costs down. In contrast, most health plans contract with physicians on a fee-for-service basis, so their disease management efforts are disconnected from the doctors' incentives.

Similarly, the Veterans' Health Administration (VHA) has invested heavily in home telemonitoring because the VHA discovered that it reduces hospital bed days by 25 percent and hospitals admissions by 19 percent. But the VHA is a single-payer system that owns its hospitals and employs its physicians (aside from private doctors who contract with the VHA), so it's able to benefit directly by lowering the costs of hospitalization.

Even if private plans did follow the Geisinger example and pay for home telemonitoring, the evidence of its efficacy is mixed. A randomized controlled study published in the New England Journal of Medicine in 2010 found that the use of home telemonitoring with CHF patients had no impact on their six-month mortality rates. Other evidence suggests that patient-centered medical homes, heart failure clinics and other interventions may be more effective than telemonitoring alone for CHF patients. So, while telemonitoring may be a useful adjunct to care management, it still is not clear whether its benefits justify its cost for this population. Even less research has been done on patients with other conditions.

In any case, none of this will slow down the rapid growth in the mHealth market, which already boasts more than 17,000 applications. Telecoms, mHealth software developers, and electronic health record vendors will continue to pile into this space because of the large-scale consumer adoption of mobile devices. But until physicians are organized and have an incentive to engage in remote patient monitoring, and until its value has been proved, the actual use of this technology in healthcare will remain limited. - Ken

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