The document discusses emerging home health monitoring technologies that promise to enhance care for aging patients and reduce healthcare costs through remote patient monitoring. However, reimbursement from Medicare and other payers has not kept pace, posing financial challenges for healthcare providers looking to adopt these technologies. Some states have begun reimbursing for telehealth services, but widespread reimbursement will be necessary for these technologies to truly transform home healthcare. The future of home health monitoring depends on resolving the conflict between providers wanting to invest in new technologies and payers refusing to pay until technologies are proven effective.

1. CLINICAL MANAGEMENT
Will payinent issues spoil the booin?
HOME CARE HEATS HPNew monitoring devices promise to greatly enhance care
and control costs, but reimbursement isn't keeping pace
Clinical Managemeii! is a quarterly series
that looks al specific disease or treatment
areas Clinical Management amstowcsN-
ef trends m technology, stalling, financing
and ottier issues of concam to senior hos-
pital executives, Our nefl insiallment will
look 3t the pliarmacy.
BY JODIE SNYDER
T
he United States is in the midst of a demographic duel that could have serious conse-
quences for the nation's health care system. On the one side is an aging population—
by 2030 one in five Americans wHl be a "senior dtizen" and the demand for medical
services will intensify proportionately. On the other side is a shortage of health care profession-
als, already a critical problem and one that is likely to grow more acute.
But aD is not lost: While new and emerging technologies might not avert a crisis, ^ey coiJd
at least contain it, allowing older adilts, even tliose with multiple dirorvic illnesses, to remain in
their homes far later in life, while physidans, nurses and other health care staff monitor them
remotely without having to leave their hospitals, dinics or offices.
Advances are coming fast. Already, talking pillboxes and medidne cabinets remind patients
to take their medications. Motion sensors and video cameras installed in patients' homes record
their movements. Clothing is embedded with body sensors and mattresses monitor body tem-
perature, pulse rates and sleeping patterns. Patients can now have their weight, vital signs and
blood-sugar levels checked by providers miles away.
Telemedidne has always held out a lot ofpromise: improved care, increased access and low-
er costs. The question, as always, is how to pay for it.
Leaders in home health care and technology groups want the federal government to pick up
5 1 H & H N I J U L Y , 0 7 I w w w h h n m a f l . c o m P h o i o g ' a p l i j bv ImagBSiata

2. more of the tab, arguing that with aging baby
boomers and staff shortages, the time for new
tedinoiogy is now,
"Advancements in technology are going
to affect all those groups who provide health
care. Anyone who Is experiencing a shortage in
personnel will be impacted by this," says Richard
Brennan, deputy director of government rela-
tions for the National Association for Home
Qre & Hospice.
Tlie association is
polling members to find Ahnilt 74"/
out how many and
what kinds of home Of ttlG COUOtfy'S
tiofiiecofe
eyenciesofe
care services use home-
monitoring devices,
whidi technologies they
use and how usage
varies aaoss the coun-
try. Tlie report is expect-
ed to be finalized in
November, with prelim-
inary results in October.
The association hopes to use the data to
encourage the Centers for Medicare & Medic-
aid Services to offer more funding for telehealth
practices. Much of the current home care
providers' telehealth programs are funded
through federal grants, Brennan says.
"Many of our members are working on
tight budgets and are looking toward the feder-
al government for any kind ofHindir^," he says.
Demonstrating Value
A Urge teletiealtii demonstration project is CMS'
Care Management for High Cost Beneficiaries.
It was launched in 2005 to look at how home
health monitoring technology can help patients
witli chronic ;uid costly health conditions. Tlie
goal of the three-year program is to reduce the
costs of caring for 200.000 of Medicare's most
expensive patients by at least 5 percent.
Among the technologies being tested is
tlie Health Buddy Program, aeated by Health
Hero Network of Redwood City, Calif. The
Health Buddy unit, about the size of a lunch
box, has a computer screen and ports for
hookups to scales, glucose meters and blood-
pressure monitors. Patients are asked a series
ofdisease-specific questions. For diabetics, that
could mean inputting their blood sugar num-
bers or answering questions about their feet The
information is sent over a phone line toll-fi-ee to
a central site where a team monitors patients'
responses on a seaire Web site. Ifthere is a prob-
lem, the team can step in and guide tlie patient.
The Wenatchee Valley Medical Center in
Wasliington started its Health Buddy program
in February 2006. It currently monitors about
250 patients, but can handle 1,500. One of the
"bumps in tlie road" to greater participation was
getting patients tofitinto the Medicare criteria,
says Lori Smet, case manager and coordinator.
Some patients had more than one outstand-
ing health condition, such as diabetes and con-
gestive heart failure, and that made it difficult to
categorize them. Wenatchee worked with
Medicare to simplify dassification.
Health Buddy patients appreciate having
someone watch over tliem, Smet says. "Most of
the patients have really loved it. Many of those
who liave signed up are housebound with diffi-
culties getting to routine medical care; many
have diiidren out ofstate and that makes it hard-
er to get to the doctor for r^ular visits. It is anoth-
er pair ofeyes for tliem."
However, not all prospective patients are
eager to sign on. Wenatchee serves hundreds of
people in rural and remote eastern Washington
and some ofthem have specifically chosen tfiat
lifestyle, Smet says. "Tiiere are some people who
are isolated and they like it that way They don't
have to have a television or computer and they
aren't sure they want this."
The Wenatchee staff has been able to talk
most people into having the monitors installed
just to try them out. Only about 10 people have
opted out of being monitored.
Waiting for Medicare
Tlie question of how to pay for technology is a
classic conundrum: Providers can't afford to
invest in expensive devices for which they won't
be reimbursed; the government refuses to pay
for devices until it has proofthat they work.
Until that standoff is resolved, "the things
that are exdting are not affordable,'* says Pamela
Steding, chiefexecutive officer ofChristus Home-
How Bio is Home
Health Care?
• The U.S. home health care industry is made
up of more than 20,000 companies.
• Annual expenditures for home health care
are about tS5 billion.
• After changes in reimbursement as part of
the Balanced Budget Act of 1997, fBwer
hospitals have home health care compo-
nents. In 1998, about 30% of the country's
home care agencies were hospital-based;
in 2003, it was 24%.
• About a quarter of industry revenue is gen-
erated by nonprofit organizations, such as
hospltai-based agencies and visiting nurse
associations.
• The industry is highly fragmented: The 50
largest organizations hold less than 25%
of the market. A typical local agency has
80 employees and annual revenue of $3
million. Average annual revenue per employ-
ee is close to $50,000
• Home visits for general nursing care, includ-
ing limited physical examinations, physical
therapy and personal care, account for 75%
of industry revenue.
Sources Nfltional Associilion lor Home Cam &
Hosflice, 2007; fiesBafc(iAndMafk««.coffl, 2007
www.hhnmag.com I JU LY.07 | HSHN f7

3. CLINICAL MANAGEMENT
Remote
Intel's Health Research and Innova-
tion Group has developed a way for
people with Parkinson's disease to
conduct ongoing, in-home testing,
which will give a more accurate pic-
ture of how the patient is doing. The
device guides patients through six
motor and tremor assessment lests
that are traditionally performed in a
doctor's office and designed to track
disease progression. Intel researchers
hope that, v^'hen combined with tests
in a doctor's office, this ongoing in-
home monitoring will improve diag-
nosis and drug strategies. But will
Medicare reimburse for this new
technology? ^
Care in San Antonio, Texas,
Christus doesn't get additional reimburse-
ment for the 400 Honeywell monitoring units
that remotely dieck patients' weight, blood pres-
sure and blood sugar levels.
"No one pays us extra for those," Sleding
says. "Thafs the question: Who is going to pay
for the new gadgets? There is no question that
they provide better care. When a patient is start-
ing to have any symptoms, we are on it much
quicker, We can notify the physician and make
a change in the treatment plan."
Robert Waters, executive director of the
Home Care Technology Association ofAmeri-
ca, says the way Medicare reimbursement is
structured discourages providersfrominvesting
in new technology.
"It's mostly because ofhow Medicare pays
for things," he says. "They pay the providers out
ofseparate buckets—hospitals, providers, home
health—and they don't necessarily pay you for
what you do," he says.
Currently, CMS does notreimburseteleheahh
visits. Waters says. Instead, it defines a home health
visit as "an episode ofpersonal contact."
Medicare's shift toward pay for perfonnance
could result in better reimbursement when
providers demonstrate that home health saves
on costs and improves outcomes.
Kaiser Moanalua Medical Center in Hon-
olulu already has evidence ofthat. The hospital,
which has its own home care program, found
that patients participating in a telemonitoring
prc^ram required 92 percent fewer lab tests and
radiographies than those who remained in the
hospital for monitoring.
Help fram the States
Providers aren't pinning all their hopes for
home care progress on the feder-
al govemment.
Last year, Colorado's state leg-
islature required the state Medicaid
program to compensate providers for tele-
health visits. It is the first state to comprehen-
sively do so, says Ellen Caruso, exeaitive direc-
tor of the Home Care Association ofColorado.
Details are still being worked out. she says,
but the goal is to have payment based on the
sophistication of the technology and the acuity
of the patient. At one end of the tech scale are
medication monitors, which let staffers know
on a daily basis if patients' medication contain-
ers have been opened At the other end are video
displays that allow real-time long-distance com-
munication between patient and nurse.
Caruso says she has been contacted by oth-
er state home care associations that hope to
charge their Medicaid prograrr^.
The University of Kansas Medical Center
in Kansas City teamed up with the Kansas
Department on Aging and Windsor Place At-
Home Care. Coffeyville. Kan., for a program
beginning this summer that will monitor 50
patients for a year.
Without a state grant, it would have been
difficult to go ahead with the plan, says Monte
CofFman, Windsor Place's executive director.
Monitoring unite cost $4,000 to $5,000 per patient
and there are staffing costs on top of that.
Cerporate Connections
I'artiifis 1 leallli System, the umbrella organiza-
tion created by Brigham and Women's Hospi-
tal and Massachusetts Ceneral Hospital, is about
to begin a pilot telehealth project with a employ-
er for a blood-pressure monitoring system.
Private industry is also getting more
involved. Intel Corp. last year helped launch the
Continua Healtli Alliance, a consortium ofmore
than 20 electronics, medical device and health
care companies. Other members include Motoro-
la, Royal Philips Electronics, GE Healthcare and
Partners Health System.
That kind ofjoint effort will show that tele-
health is integral to easing the conflict between
greater demand and fewer providers, says Waters.
Ultimately, however, it may be patients who are
the strongest advocates for change.
"As consumers, especially the tech-sawy
baby boomers, learn about these technologies,
they will begin to demand them more and more.
lt is going to become a standard of care," he
says.—yodie Snyder is a writer in Phoenix. •
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