Comment to CMS on Remote Patient Monitoring

To whom it may concern,

I am a practicing nephrologist and have spent my career caring for patients with complex chronic conditions, particularly those with kidney disease, diabetes, and hypertension. I currently serve as the managing partner of one of the largest Nephrology medical groups in Los Angeles.

My interest in remote monitoring began well before Remote Patient Monitoring codes existed.

After completing my training, I approached a local health plan with a simple idea: if we could monitor patients’ vital signs at home, particularly their blood pressure and weight, we could identify acute decompensations earlier, intervene quickly, delay disease progression, and reduce high-cost events. At that time, the concept was foreign and quickly rejected.

Years later, when CMS created reimbursement pathways for Remote Patient Monitoring, I strongly supported implementing these programs within our own offices and dialysis centers to maximize clinical benefit. What I quickly learned, however, was that operating a high-quality RPM program was far more complex than simply purchasing a blood pressure monitor and receiving readings.

Initially, we partnered with a vendor that provided software and connected devices, while our practice remained responsible for the other tasks: hiring staff, training them in new technologies, supervising the program, monitoring patient engagement, reviewing workflows, documenting care, and ensuring that services were performed correctly and compliantly.

It became clear very quickly that RPM is an operationally intensive service, distinct from what our practice was designed to do, and that it requires new areas of expertise and training.

For a successful RPM program, a medical practice must take on additional tasks that require time, operational expertise, and technical training. These include patient enrollment, device deployment, technical support, ongoing outreach, clinical documentation, escalation protocols for abnormal readings, care-plan creation, and billing requirements. Practices must also ensure that the people performing this work are appropriately trained and have enough dedicated time to do it consistently.

That experience ultimately led me to create TOCA Health.

The goal was not simply to build another software company. The goal was to create an organization that could function as a true extension of the physician’s office.

We developed a model in which we provide the technology, connected devices, and dedicated care management team required to operate these programs on behalf of medical practices. Today, we support more than 20 physician practices in our local community, all within approximately 50 miles of our office.

Our model remains intentionally hands-on.

We regularly visit our partner practices. We deliver monitors, patient education materials, consent forms, and contact information for the care team. We work directly with office staff and providers. When patients experience symptoms or have concerning readings, our care managers communicate with the practice. We reinforce upcoming appointments and provider-directed interventions and help patients understand the plan of care established by their physician. This has allowed our partners to enroll their patients without administrative burden and to see the benefit of improved outcomes and a lower total cost of care.

As a practicing physician, I also see the benefits firsthand.

I routinely review my patients’ home blood pressure readings before and during visits. Having longitudinal information from the patient’s home environment creates a much more informed clinical encounter than relying on a single blood pressure measurement taken in the office.

My patients also frequently tell me how much they value the ongoing conversations with their care managers. They appreciate having someone checking on them between visits, helping them understand their readings, reinforcing their treatment plan, and communicating concerns back to our office. This occurs because TOCA Health has dedicated resources, managed outside the complexity of a busy medical office, that allow for complete and consistent outreach.

At the same time, medical assistants in the office can focus on the responsibilities that truly require their presence inside the practice, including rooming patients, processing prior authorizations, reconciling medications, coordinating appointments, and supporting the physicians during clinic.

This is why I am concerned that proposed changes that significantly reduce the ability of qualified third-party organizations to support RPM services could move chronic care in the wrong direction.

Chronic diseases are not episodic. Hypertension, kidney disease, heart failure, diabetes, and other chronic conditions do not become relevant only when a patient walks into a physician’s office. They require ongoing monitoring, education, follow-up, and intervention between visits.

A dedicated team that performs this work every day can provide an important layer of support for both patients and physicians.

I fully support CMS’s goal of eliminating fraud, waste, and abuse within Remote Patient Monitoring and other care management programs. Bad actors undermine these services and damage trust in programs that can provide meaningful clinical value.

However, eliminating or significantly restricting the role of legitimate third-party organizations is not the appropriate solution.

As with other reimbursable healthcare services, accountability should come through appropriate standards, documentation requirements, oversight, and audits. CMS should distinguish between organizations that operate responsibly and organizations that exploit these programs.

Transferring the operational burden entirely back to physician practices may have unintended consequences. Many practices do not have the staffing, technology, expertise, or infrastructure required to operate these programs effectively on their own. Faced with those requirements, some physicians may simply choose not to offer RPM at all, or may substantially limit enrollment.

The result would not necessarily be less waste. It may simply mean fewer patients receiving proactive chronic disease management.

The original promise of Remote Patient Monitoring was to use technology and ongoing care to identify problems earlier, reduce avoidable hospitalizations and readmissions, and improve the management of chronic disease. Those goals remain critically important as the number of Americans living with chronic conditions continues to grow.

Before making substantial changes to how these programs may be delivered, I strongly encourage CMS to evaluate real-world data from physicians, patients, medical practices, and responsible RPM organizations.

Examine hospitalization rates. Examine blood pressure control. Examine medication adherence. Examine patient engagement. Examine physician experience. Examine total cost of care.

Most importantly, speak with the patients using these programs every day.

From my perspective as both a practicing nephrologist and the founder of an organization that supports these programs, RPM works best when the physician remains responsible for clinical decision-making while a trained, accountable care team provides the operational infrastructure necessary to monitor and engage patients consistently.

We should strengthen that model, establish appropriate safeguards around it, and hold organizations accountable when they fail to meet those standards.

We should not dismantle an infrastructure that allows physicians to provide more proactive care to patients who need it most.

Respectfully,