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Statement of the eHealth Initiative
Subcommittee on Health
of the House Committee on Ways and Means
Eliminating Barriers to Chronic Care Management in
Medicare
February 25, 2003

Introduction

One of the greatest opportunities for improving care for Medicare beneficiaries is chronic disease management enabled by eHealth technologies. Effective chronic care requires systematic monitoring and management of patients by their health care providers before conditions become acute, painful and costly. The benefits of eHealth enabled chronic care have been established by leading health care institutions including the Department of Veterans Affairs, which recently published results from over two years of demonstration projects showing 63% reduction in hospital admissions and a significant improvement in the quality of life. Results were for patients enrolled in eHealth enabled disease management programs with major conditions that affect Medicare, including heart failure, diabetes, and respiratory disease.

Unfortunately, most chronic disease management services enabled by eHealth technology – such as in-home patient monitoring technologies and electronic clinical information tools for health care professionals – are not reimbursable under the current Medicare payment system, which generally pays for only face-to-face episodic care. As a result, providers have not adopted these technologies and the development of many quality
improvements enabled by these tools has been slowed.

Congress can remove a significant barrier to more effective chronic care management by updating the Medicare payment system so that 21st century care management solutions can be adopted and used to modernize the health care delivery system. This is a key priority of our organization, the eHealth Initiative (eHI), a non-profit entity with over 100 members representing many of the stakeholders in the health care industry, including hospitals, practicing clinician organization, payers, manufacturers, health care information technology suppliers and academic institutions. eHI’s mission is to drive improvement in the quality, safety and cost-effectiveness of health care through information technology.

Properly reimbursing chronic disease management services that are enabled by eHealth technology tools has many proven benefits including:

• Reducing emergency department and hospital costs by detecting patient problems before they become a crisis.

• Improving patient compliance by educating, motivating and monitoring patients, and by providing patients with timely and relevant information.

• Improving safety and quality by providing timely, relevant, and actionable information to healthcare professionals through quality assured processes that can be continuously improved.

• Increasing access to timely and appropriate care by replacing the current model of isolation and crisis with an efficient and cost-effective model of care based on in-home monitoring, communication and support.

• Providing continuity of care, particularly for the elderly, underserved, and chronically ill who need care the most, through integrated, interconnected monitoring and information systems, rather than fragmented and episodic care.

• Increasing accountability of disease management services as information technology solutions can standardize and streamline quality processes and reporting.

Overall, this translates into better health care for all Americans and holds promise for stemming the dramatically rising costs of medical care.

Remote Health Care Monitoring: An Illustrative Example
Recent legislative efforts to reimburse disease management services coupled with information technology were put forth in the 107th Congress. One example of an approach that could serve as a model for provider-based disease management services, if it were expanded to include a wider range of chronic care, is the Medicare Remote Monitoring Services Coverage Act (S. 1607, H.R. 3572) sponsored by Senators Jay Rockefeller (D-WV) and Olympia Snowe (R-MN) and Representatives Anna Eschoo (D-CA) and Richard Burr (R-NC). The approach in this bill was to use the existing Medicare physician fee schedule, but to redefine the notion of a patient encounter to include certain kinds of remote monitoring determined by the Secretary of Health and Human Services to provide comparable data. Congress should encourage and expand on creative approaches such as the Medicare Remote Monitoring Services Coverage Act and other similar legislation as a way to begin to reimburse health care providers for disease management services with proven benefits in terms of quality of care, access to appropriate care, and cost-effectiveness.

Remote health monitoring and management solutions designed specifically for elderly patients with chronic conditions have been successfully deployed at a wide range of healthcare institutions, including over 20 medical centers and clinics of the U.S. Department of Veterans Affairs. One example of this is Health Hero Network, a model of chronic care management and monitoring in use at the Department of Veterans Affairs,
Mercy Health System, Kaiser Permanente, and other leading healthcare providers. Health Hero Network uses a simple in-home device called Health Buddy that enables care providers to collect data based on clinical protocols and surveys while delivering personalized daily patient education and therapeutic regimen reinforcement. Patients with conditions such as heart failure, diabetes, respiratory disease, and other
conditions use Health Buddy to electronically answer personalized daily questions about disease symptoms, medication regimens, and knowledge, thereby becoming educated in their condition and learning to apply that knowledge toward improving self-care behaviors. Care coordinators and other authorized medical professionals access monitoring results and other patient information on secure websites that include an integrated set of patient enrollment, scheduling and monitoring tools that enable nurses to stay abreast of their patients’ day-to-day conditions and prevent critical situations by providing early intervention. Reports are generated for hospitals or other care centers, and for public administration or insurance payers.

Economic Benefits
For patients with complex chronic conditions, the models of chronic care enabled by eHealth technologies such as in-home health monitoring and management replace isolation and crisis with continuous communication and support. The benefits of reduced hospital admissions, improved quality of care, and increased access to timely and appropriate care are well established. Rather than treating disease complications after
conditions become acute, patients are maintained in a healthier state and disease exacerbations are prevented.

Published results from studies involving over 1000 patients with heart failure, diabetes, and chronic respiratory disease have quantified these results in economic terms:

791 elderly, high-risk, high-cost patients with hypertension, heart failure, COPD, and diabetes participated in a yearlong eHealth demonstration at the Veterans Health Affairs in which most patients were monitored daily using eHealth technologies. Compared to matched comparison group data, the community-based care coordination program reported 40% reduction in emergency room visits, 63% reduction in hospital admissions, 60% reduction in hospital bed days of care, 64% reduction in nursing home admissions, 88% reduction in nursing home bed days of care, and significant improvement in quality of life. These results translate into substantial cost savings, especially for care of patients with complex chronic conditions who account for the greatest portion of healthcare
spending. (Meyer, Kobb & Ryan, 2002).

In a one-year study in Texas of a home-based telemedicine program for a high-risk, underserved population with diabetes, 169 patients were studied using comparative cohort data. The program reported reduction in inpatient admissions reduced by 32% (p <0.07), reduction in emergency room encounters by 34% (p < 0.06), reduction in outpatient visits by 49% (p < 0.001). Improved self-care behaviors were evident by the percent of patients who took their medications more regularly increasing from 41% before the program to over 94% nine months after implementation of the program. (Cherry, Moffatt, Rodriquez & Dryden, 2002).

Additional results from other published studies have demonstrated substantial cost savings due to reduced hospital admissions (Cherry, Colliflower and Tsiperfal, 2000; Vacarro, Cherry, Harper & O’Connell, 2001).

Without in-home monitoring, patient encounters are not optimized by are either based on a schedule or a crisis. The in-home monitoring model of care bridges the gap between visits by providing a means for daily communication with the patient, encouraging patients to adhere to treatment regimens, and allowing patients and care providers to identify problems and intervene early. Early intervention can ultimately reduce the cost
of care while increasing the overall well-being and quality of life for the patient.

Care Accessibility Benefits
eHealth technologies for in-home health monitoring and management enable daily communication and support to patients with complex chronic conditions, which is a substantial increase in access to care for patients who need care the most. Before in-home monitoring, these patients had access to care only once their condition had become a crisis. In-home monitoring provided daily access to appropriate and timely care. In
addition, because of the eHealth solution employed, it is possible to serve many more patients with the same nursing staff. With telephone based monitoring, it was demonstrated that one nurse could provide weekly monitoring to not more than 100 patients, and this was a full time job. In the Mercy Health System Telemedicine Disease Management Program a single nurse monitors 425 patients with heart failure, diabetes, or
hypertension on a daily basis in just a few hours in the morning, greatly improving the access to chronic care services where they otherwise would have been cost prohibitive.

Quality of Care Benefits
eHealth solutions enable care providers to detect complications before they become acute and result in hospital admissions. The highest quality care is care that reduces painful and costly complications, but instead maintains patients in a healthier state.

Other factors that prove a higher quality of care are the measures of patient self-care behavior, medication compliance, and quality of life. In a high risk, indigent population with diabetes, the percent of patients who took their medications regularly increased from 34% before the program to over 94% twelve months after implementation of the program.2 In a pediatric asthma study, the odds of having any limitation in activity were
significantly lower (p<.03) for children randomized to the intervention group, they were less likely to report peak flow readings in the yellow or red zone (p<.01), and less likely to make urgent calls to the hospital (p<.05) (Guendelman, et. al., 2002).

In a post cardiac bypass surgery study at the University of Nebraska, patients who were monitored using eHealth technologies had higher scores on their quality of life measurement and complained of less fatigue and anxiety then the patients in the control group. In the Veterans Administration study, quality of life was assessed using the Medical Outcomes Study 36-item Short Form health survey designed for veterans (SF-
36V). At Lake City, six domain change scores and one composite change score were significantly different (p<0.05) from baseline to 6 months in the program. Of these significant differences, four were positive changes in quality of life. The positive changes were in physical functioning (p=0.005), role-physical (p=0.018), social functioning (p=0.013) and the physical composite score (p=0.014). At Fort Myers, 8 out of the 10
domain changes and composite scores changed in a positive direction, and of those four were statistically significant. The significant changes were in physical functioning (p=0.023), role-physical (p=0.024), vitality (p=0.000) and the physical composite score (p=0.008) (Cherry, Dryden, Kobb, Hilsen, & Nedd, in press).

A myriad of enabling eHealth technologies such as remote monitoring can aid in chronic disease management and have proven quality, safety and cost-effectiveness benefits.

Eliminating Barriers to Chronic Care Management in Medicare: What Can Be Done?

As medical and information technology evolves, new models of care that extend the point of care to the patient home and use of clinical information systems and tools to improve care management processes will become more prominent. The eHealth Initiative is providing leadership in a groundbreaking proof-of-concept project demonstrating a new model involving electronic, standards-based health care data transmission and exchange in 2003. Relevant to the hearing today, project data elements specifically include a subset of those that are necessary to measure the quality of care delivered for those with diabetes and cardiovascular disease, as well as those that will assist with public health
surveillance and response and those that will assist with improving patient safety. Participants include large hospitals, public health agencies, and other key stakeholders in the public sector with interests in improving the quality and safety of health care. The public and private sector must continue to work together on this and other initiatives to eliminate barriers to better care management.

Specific steps this Committee and Congress as a whole can take to achieve better chronic care management in the Medicare program include:

• Working on relevant legislative language that can be attached to vehicles likely to move in 2003 including Medicare prescription drug reform and medical safety and bills.

This language could encourage:

o Reimbursement of physician services in remote monitoring and care coordination that can be quality-assured and accountable through the use of information technology.

o Inclusion of disease management in metrics of quality of care and medical errors that are tied to existing reimbursement in Medicare or accreditation.

• Encourage movement of legislation to redefine the physician-patient encounter to include remote monitoring and management that underpins disease management, so that health care providers will be reimbursed for services that are now proven to boost quality of care and reduce hospital admissions.

• Provide funding for larger scale demonstration projects focused on models of care implemented by health care providers to better coordinate care for those with chronic diseases such as diabetes and congestive heart failure. The need for these demonstrations has been highlighted by both Department of Health and Human Services Secretary Tommy Thompson and Institute of Medicine experts.

• Engage in discussions with knowledgeable experts about the cost and savings model assumptions for disease management and enabling technology.

Conclusion
eHI and our members stand ready to lend our voice and private-sector expertise in the movement to create a more sustainable model of care that will effectively address the aging population, increased chronic care demand, systemic quality, cost and safety challenges and provider workload and resource scarcity issues. We believe that adequately reimbursed chronic disease management services enabled by eHealth technology that result in increased health care quality, safety and cost-effectiveness must be part of this new care paradigm. The benefits have been demonstrated by the Department of Veterans Affairs and other leading health care providers, and our members are ready to deploy solutions to modernize and improve chronic care for Medicare beneficiaries.

Endnotes

1. Mercy Health Center – Diabetes

Cherry, J.C., Moffatt, T.P., Rodriquez, C., & Dryden, K.V. (2002). Diabetes Disease Management Program for an Indigent Population Empowered by Telemedicine Technology. Diabetes Technology & Therapeutics; 4 (6): 783-791.

2. Veterans Administration – CHF, Diabetes, Hypertension and COPD

Meyer M, Kobb R, Ryan P. Virtually Healthy: Chronic Disease Management in the Home. Disease Management 2002; 5: 87-94.

3. Application of Technology at Catholic Healthcare West – CHF

Cherry, J.C., Colliflower, S.J. & Tsiperfal, A. (2000). Meeting the Challenges of Case Management with Remote Patient Monitoring Technology. Lippincott’s Case Management: 5 (5): 191-198.

4. UC Berkeley and Children’s Hospital Oakland – Pediatric Asthma

Guendelman, S., Meade, K., Benson, M., Chen, Y.Q. & Samuels, S. (2002). Improving Asthma Outcomes and Self-management Behaviors of Inner-city Children. Archives of Pediatric Adolescent Medicine; 156: 114-120.

5. PacifiCare – Heart Failure

Vaccaro, J., Cherry, J., Harper, A. & O’Connell, M. (2001) Utilization Reduction Cost Savings, and Return on Investment for the PacifiCare Chronic Heart Failure Program, “Taking Charge of Your Heart Health”. Disease Management; 4 (3): 1-10.