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Medicaid Becomes the First Third-Party Payer to Cover Passive Remote Monitoring for Home Care: Policy Analysis

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open access at: http://dx.doi.org/10.2196/jmir.9650 Background: Recent years have seen an influx of location-tracking, activity-monitoring sensors, and Web-cameras to remotely monitor the safety of older adults in their homes and to reduce reliance on in-person assistance. The state of research on these monitoring technologies leaves open crucial financial, social, and ethical cost-benefit questions, which have prevented widespread use. Medicaid is now the first large third-party payer in the United States to pay for these technologies, and their use is likely to increase as states transition to managed long-term services and supports (MLTSS). Objectives: This is the first study to examine how state Medicaid programs are treating passive remote monitoring technologies. This study identifies (1) which states allow location tracking, sensor systems, and cameras; (2) what policies are in place to track their use; (3) what implementation processes and program monitoring mechanisms are in place; and (4) what related insights Medicaid program stakeholders would like to learn from researchers. Methods: Interviews were conducted with 43 state, federal, and managed care organization (MCO) Medicaid program stakeholders about how these technologies are used in state waivers serving community-dwelling older adults in 15 states, and what policies are in place to regulate them. The interviews were analyzed by the research team using the framework analysis method for applied policy research. Results: Two-thirds of the states cover location tracking and activity-monitoring sensors and one-third cover cameras, but only 3 states have specific service categories that allow them to track when they are paying for any of these technologies, impeding regulation and understanding of their use at the state and federal level. Consideration of ethical and social risks is limited, and states struggle to understand which circumstances warrant use. They are further challenged by extreme resource restrictions and transitions to MLTSS by MCOs inexperienced in serving this growing “high-need, high-cost” population. Conclusions: Decisions about Medicaid reimbursement of technologies that have the potential to dramatically alter the way older adults receive supportive services are being made without research on their use, social and ethical implications, or outcomes. At a minimum, new service categories are needed to enable oversight. Participants prioritized 3 research aims to inform practice: (1) determine cost-effectiveness; (2) identify what type of information beneficiaries want to be generated and whom they want it to be shared with; and (3) understand how to support ethical decision making for beneficiaries with cognitive impairment. These findings provide direction for future research and reveal that greater interaction between policy makers and researchers in this field is needed.
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... The desire to predict and prevent health events through increased remote monitoring and analysis of behavioral biometrics is driven by health and long-term care cost containment and the widespread preference to manage chronic conditions at home. The need to be attentive to older adults' preferences for control and privacy enabled in technology design is pressing because of the strong momentum in many countries to rely on technologies in care provision, without fully considering how they could restrict rather than enhance autonomy, privacy, human connection, and other important needs and values [14,17,20,51,60,62 In addition to potentially restricting important needs and values, the ways that these emerging technologies instantiate control and privacy may impede adoption. Research has found that negative attitudes that older adults hold towards technology stem in part from concerns about technology interrupting home life, as well as privacy threats [15,101]. ...
... Policy makers, providers, and family caregivers are looking to technological solutions and investing in artificial intelligence (AI) and other technologies that monitor activity and safety of older adults, with a particular focus on Alzheimer's disease and related dementias (e.g., the AAL Joint Platform of the European Union and AGE-WELL Initiative in Canada) [25,69,91,127,129,138]. In the U.S., health care payment systems including Medicaid are now beginning to cover a range of technologies that have remote monitoring functions [17,28], foretelling significant growth as lack of third party reimbursement had impeded startups in the aging space [19,129]. ...
... It is important to put these in real-world context in which implementation of data intensive technology across care settings can be complicated and vary dramatically depending on specific care dynamics, as well as available resources, whether at the state (i.e., Medicaid) or household level. Policy lags behind use [17,18,124] and well-intentioned guidelines to support ethical and more empowering relationships to these technologies lack regulatory power and do not reach into private, familial practices. Codes of conduct and guidelines have been in place for over a decade and yet are still being called for and pointed to as a viable solution to potentially disempowering care practices [6,118]. ...
Conference Paper
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Studies find that older adults want control over how technologies are used in their care, but how it can be operationalized through design remains to be clarified. We present findings from a large survey (n=825) of a well-characterized U.S. online cohort that provides actionable evidence of the importance of designing for control over monitoring technologies. This uniquely large, age-diverse sample allows us to compare needs across age and other characteristics with insights about future users and current older adults (n=496 >64), including those concerned about their own memory loss (n=201). All five control options, which are not currently enabled, were very or extremely important to most people across age. Findings indicate that comfort with a range of care technologies is contingent on having privacy- and other control-enabling options. We discuss opportunities for design to meet these user needs that demand course correction through attentive, creative work.
... To reduce reliance on in-person assistance, states have begun paying for location tracking, sensors, and Web-cameras through Medicaid waiver programs, making Medicaid the first third-party payer to cover this category of technologies (Berridge, 2018). These passive remote monitoring devices collect and transmit information about an older adult that caregivers can monitor remotely. ...
... Fortunately, requests for these technologies in aging waivers are more often intended to supplement rather than replace human support, but concerns remain about the potential to contribute to isolation and override beneficiaries' concerns. This emerging policy trend in Medicaid waiver programs for older adults covers devices to track beneficiaries' locations, activity monitoring sensor systems, and Webcameras (Berridge, 2018). ...
... A significant policy problem is that most states do not have specific service categories that allow them to track when they are paying for a given technology, and therefore State Medicaid agencies and the Centers for Medicare and Medicaid Services (CMS) are unable to recognize which beneficiaries are using a given technology (Berridge, 2018). The ways that location tracking, sensors, and cameras are categorized in administrative tracking systems in practice are confusing and nontransparent. ...
Article
Implementation of passive remote monitoring is advancing faster than our knowledge base about appropriate and ethical use. For all the media and research attention these technologies are getting, there has been very little discussion about how they are positioned to be integrated into health plans, yet their integration is key to how they will be incorporated into social work practice. As coverage of passive remote monitoring technologies expands in Medicaid home and community-based services (HCBS), new policies that support informed decision-making, consenting processes, and regulations for ethical, appropriate use are urgently needed. Research translation often trails policy, but the rapid development and implementation of technologies that passively collect and transmit new information about older adults call for a more responsive approach. In this commentary, I describe passive remote monitoring technologies, their implementation in Medicaid HCBS, and ethical issues. I conclude with specific suggestions for policy and practice to start addressing these issues.
... Participants cautioned against generalizing ideas of how people prioritize implicated values, stressing the need to understand that this will vary by person. This work and others (Mulvenna et al. 2017;Berridge 2018;Wangmo et al. 2019;Berridge and Wetle 2019) suggest that we need to further investigate how to support personalized patient and family decision-making about these forms of technologies used in dementia care with attention to alignment with participants' cultural values . ...
... A recent policy analysis describes state Medicaid waiver programs' difficulty regulating geo-tracking, activity sensors, and web-cameras that some are allowing and paying for. Program managers report struggling to understand which circumstances warrant use of these devices and how to support ethical decision making for beneficiaries with cognitive impairment (Berridge 2018). Another ethics analysis of 23 policy documents from four Alzhiemer's Associations in four countries found that they prioritize benefits of technologies while inadequately discussing potential harms. ...
Article
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There is an urgent need to learn how to appropriately integrate technologies into dementia care. The aims of this Delphi study were to project which technologies will be most prevalent in dementia care in five years, articulate potential benefits and risks, and identify specific options to mitigate risks. Participants were also asked to identify technologies that are most likely to cause value tensions and thus most warrant a conversation with an older person with mild dementia when families are deciding about their use. Twenty-one interdisciplinary domain experts from academia and industry in aging and technology in the U.S. and Canada participated in a two-round online survey using the Delphi approach with an 84% response rate and no attrition between rounds. Rankings were analyzed using frequency counts and written-in responses were thematically analyzed. Twelve technology categories were identified along with a detailed list of risks and benefits for each. Suggestions to mitigate the most commonly raised risks are categorized as follows: intervene during design, make specific technical choices, build in choice and control, require data transparency, place restrictions on data use and ensure security, enable informed consent, and proactively educate users. This study provides information that is needed to navigate person-centered technology use in dementia care. The specific recommendations participants offered are relevant to designers, clinicians, researchers, ethicists, and policy makers and require proactive engagement from design through implementation.
... Researchers often highlight the core ethical problem of achieving informed consent with an individual living with dementia [14][15][16][17][18]. They have demonstrated the need for tools to support education, awareness, and decision-making about technologies used to support care [16,[19][20][21], including forward-looking consent processes before dementia undermines informed preference formation or expression [22]. This article reports on a novel self-administered intervention, Let's Talk Tech, to address this problem, which is modeled on advance care planning interventions. ...
Article
Background Monitoring technologies are used to collect a range of information, such as one’s location out of the home or movement within the home, and transmit that information to caregivers to support aging in place. Their surveilling nature, however, poses ethical dilemmas and can be experienced as intrusive to people living with Alzheimer disease (AD) and AD-related dementias. These challenges are compounded when older adults are not engaged in decision-making about how they are monitored. Dissemination of these technologies is outpacing our understanding of how to communicate their functions, risks, and benefits to families and older adults. To date, there are no tools to help families understand the functions of monitoring technologies or guide them in balancing their perceived need for ongoing surveillance and the older adult’s dignity and wishes. Objective We designed, developed, and piloted a communication and education tool in the form of a web application called Let’s Talk Tech to support family decision-making about diverse technologies used in dementia home care. The knowledge base about how to design online interventions for people living with mild dementia is still in development, and dyadic interventions used in dementia care remain rare. We describe the intervention’s motivation and development process, and the feasibility of using this self-administered web application intervention in a pilot sample of people living with mild AD and their family care partners. Methods We surveyed 29 mild AD dementia care dyads living together before and after they completed the web application intervention and interviewed each dyad about their experiences with it. We report postintervention measures of feasibility (recruitment, enrollment, and retention) and acceptability (satisfaction, quality, and usability). Descriptive statistics were calculated for survey items, and thematic analysis was used with interview transcripts to illuminate participants’ experiences and recommendations to improve the intervention. Results The study enrolled 33 people living with AD and their care partners, and 29 (88%) dyads completed the study (all but one were spousal dyads). Participants were asked to complete 4 technology modules, and all completed them. The majority of participants rated the tool as having the right length (>90%), having the right amount of information (>84%), being very clearly worded (>74%), and presenting information in a balanced way (>90%). Most felt the tool was easy to use and helpful, and would likely recommend it to others. Conclusions This study demonstrated that our intervention to educate and facilitate conversation and documentation of preferences is preliminarily feasible and acceptable to mild AD care dyads. Effectively involving older adults in these decisions and informing care partners of their preferences could enable families to avoid conflicts or risks associated with uninformed or disempowered use and to personalize use so both members of the dyad can experience benefits.
... A promising solution to many of these assessment challenges is remote in-home sensing or remote activity monitoring, which can provide objective and continuous monitoring and ecologically valid assessments (Gaugler et al., 2018;Thomas et al., 2020). Remote sensing systems have been designed for a variety of purposes, and are becoming widely accepted, even covered by Medicaid (Berridge, 2018). Passive remote monitoring systems for older adults' homes collect data in order to inform longitudinal research on activity and function, or response to treatment Block et al., 2016;Kabelac et al., 2019;Thomas et al., 2020), and can be adapted to inform care providers or other individuals supporting care about early warning signs of safety issues or health declines (Skubic et al., 2015;Wild et al., 2021). ...
Article
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Background and Objectives The Remote Assessment and Dynamic Response (READyR) Program was developed in order to address the current lack of early-stage dementia care planning programs that assess the care needs of persons with dementia. The goal was to create a program informed by care values and ongoing ecologically-valid data. The objectives of this study are to describe the development and design process of the READyR Program, and to evaluate the utility of the READyR Program for identifying dementia-related care needs. Research Design and Methods A prototype of the web-based READyR program tool was first created using digital activity data that was collected by previous studies using a platform of multimodal sensors installed in the homes of older adult couples with and without dementia. Digital activity data were then mapped onto potential care values (e.g., safety & autonomy) to create a values-based needs assessment that is tailored to the individual care dyad. Next, evaluation of the READyR Program by 11 professional dementia care coordinators and case managers (across three semi-structured focus groups) was used to explore the utility of READyR for assessing dementia-related needs. Qualitative description using conventional content analysis was used to iteratively code focus group data and to describe prevalent themes. Results Prevalent focus groups themes included barriers to (e.g., family relationship strain) and facilitators of (e.g., tailored assessments) the optimal process for assessing dementia-related care needs by care coordinators, as well as advantages to (e.g., providing new objective insights into function, and routines) and disadvantages of (e.g., bringing up new questions about care) incorporating the remote monitoring data into a values-based needs assessment. Discussion and Implications READyR has the potential to help family members, as well as care coordinators and providers, gain insight into the values-based care needs of persons with early-stage dementia.
... Theoretically this program could absorb 25% of medical consultation and tests manageable in output medical practice, can improve costs savings to 5% and reduce waiting lists. Based on telehealth efficiency, in many countries like US, there are already reimbursement models for telemonitoring platforms [13]. This study has certain limitations and should be interpreted with caution. ...
Article
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Background: Chronic diseases are expected to double their current incidence in people over 65, before by 2030. Cardiovascular diseases, such as ischemic heart disease and heart failure, are the most common cause of morbidity and mortality in developed countries and high blood pressure is the most prevalent risk factor. Telemedicine collects data, shares information and provides clinical care, education, public health and remote administrative services. Telehealth and specially connected health platforms, have the potential to improve the health care system, reduce costs and increase patient satisfaction. Methods: During 2018, 111 patients with high blood pressure (81 (73%) men and 30 (27%) women with an average age 58,4 years) were selected and followed for 12 months. All patients included in the telemonitoring program, received the Connected Health application on their smartphone and a bluetooth device to measure blood pressure. The application reinforces education about the disease, treatment compliance, blood pressure monitoring and in case of decompensation, generates alarms that trigger a response by the medical team with video consultation. Results: To analyse the difference in blood pressure (systolic and diastolic), we calculate the average of the first (when patients added to the program) and last 30 measurements after the 12-month follow-up. We observed a reduction of 5,7 mmHg (4%) in systolic and 4 mmHg (5%) in diastolic blood pressure (p <0.05). The use of the connected health platform avoided 3,2% of costs (Blood Pressure Holter and outpatient visits) in one year. The patient satisfaction analysed with the Net Promoting Score of the services implicated increased 2.2 points during the study period. Conclusion: A telemonitoring platform for patients with high blood pressure, based on health education, treatment compliance, blood pressure monitoring and early detection of decompensation, improves blood pressure figures, reduce costs and increase patient satisfaction.
... From a societal perspective, it is critical to share findings of effectiveness to inform families, older consumers, providers, and policymakers to offer important insights as to the limits of RAM in home-based dementia care contexts, as well as under what circumstances such technologies are potentially successful (Gitlin & Maslow, 2017). As Berridge (2018) notes in a recent policy analysis of Medicaid (which has recently emerged as the largest third-party payer of RAM technologies): "Decisions about Medicaid reimbursement of technologies that have the potential to dramatically alter the way older adults receive supportive services are being made without research on their use, social and ethical implications, or outcomes" (p. 1). ...
Article
Background and objectives: This study aimed to evaluate if and how remote activity monitoring (RAM) improves caregiver outcomes for family members providing care for persons living with Alzheimer's disease or a related dementia (ADRD). Research design and methods: We conducted an embedded experimental mixed methods study of 132 persons living with ADRD and their family caregivers (n = 64 randomly assigned to RAM treatment condition). In addition to baseline and 6-month quantitative survey data on context of care, primary objective stressors, resources, self-efficacy/competence, and distress collected from caregivers, 6-month RAM review checklists contained open-ended, qualitative information on perceived acceptability of the technology. Results: The RAM system did not exert statistically significant effects on caregiving outcomes over a 6-month period. However, qualitative analyses identified several potential moderators of RAM technology effectiveness that were subsequently tested in post-hoc repeated measures analyses of variance. Caregivers who utilized RAM technology and cared for relatives with: (a) less severe cognitive impairment; and (b) difficulty navigating around the home were more likely to indicate statistically significant increases in competence and self-efficacy, respectively. Discussion and implications: We found that the early months spent calibrating and modifying RAM are potentially challenging for families, which may prevent this technology from improving caregiving outcomes during initial months of use. Remote activity monitoring may work optimally for caregivers of persons living with ADRD in specific situations (e.g., earlier stages of dementia; wandering risk), which suggests the need for appropriate needs assessments that can better target such innovations.
Chapter
Wearable remote monitoring devices are increasingly being deployed to patients and utilized to extend patient data collection outside of conventional clinical encounters. The use of ambulatory monitoring devices in cardiology enables long-term, remote data collection for reliable diagnostics and continuous monitoring of cardiac disease. Despite the many advancements, there is still much work that needs to be done in terms of research to improve our understanding of actual outcomes and benefits of these tools. It is also critical to determine which patient populations are best suited to benefit from the use of these devices. This chapter provides a review of RPM devices in cardiology, and an overview of some key considerations in their use clinically with respect to safe, effective and efficient use of the data to impact patient care and outcomes.
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Full text available at: www.journals.cambridge.org/abstract_S0144686X15001269 Passive monitoring technology is beginning to be reimbursed by third-party payers in the United States of America. Given the low voluntary uptake of these technologies on the market, it is important to understand the concerns and perspectives of users, former users and non-users. In this paper, the range of ways older adults relate to passive monitoring in low-income independent-living residences is presented. This includes experiences of adoption, non-adoption, discontinuation and creative ‘misuse’. The analysis of interviews reveals three key insights. First, assumptions built into the technology about how older adults live present a problem for many users who experience unwanted disruptions and threats to their behavioural autonomy. Second, resident response is varied and challenges the dominant image of residents as passive subjects of a passive monitoring system. Third, the priorities of older adults (e.g. safety, autonomy, privacy, control, contact) are more diverse and multi-faceted than those of the housing organisation staff and family members (e.g. safety, efficiency) who drive the passive monitoring intervention. The tension between needs, desires and the daily lives of older adults and the technological solutions offered to them is made visible by their active responses, including resistance to them. This exposes the active and meaningful qualities of older adults’ decisions and practices.
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This study examines articulations of the relationship between privacy and passive monitoring by users and former users of a sensor-based remote monitoring system. A new conceptualization of privacy provides a framework for a constructive analysis of the study's findings with practical implications. Forty-nine in-depth semistructured interviews were conducted with elder residents, family members, and staff of 6 low-income independent living residence apartment buildings where the passive monitoring system had been offered for 6 years. Transcribed interviews were coded into the Dedoose software service and were analyzed using methods of grounded theory. Five diverse articulations of the relationship between privacy and passive monitoring emerged. The system produced new knowledge about residents and enabled staff to decide how much of that knowledge to disclose to residents. They chose not to disclose to residents their reason for following up on system-generated alerts for 2 reasons: concern that feelings of privacy invasion may arise and cause dissatisfaction with the technology, and the knowledge that many resident users did not comprehend the extent of its features and would be alarmed. This research reveals the importance and challenges of obtaining informed consent. It identifies where boundary intrusion can occur in the use of passive monitoring as well as how changes to technology design and practice could create opportunities for residents to manage their own boundaries according to their privacy needs. The diversity of approaches to privacy supports the need for "opportunity for boundary management" to be employed as both a design and practice principle. © The Author 2015. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.