Remote patient monitoring when the patient is CEO of a price transparency company

I’m a subscription junkie. And I’m not proud of it. Most of my subscriptions are routine and relatable, like when my wife and I watched two seasons of Yellowstone on Paramount, or Paramount+, and we never got around to cancelling (side note, what’s the difference between Paramount and Paramount+?).

Others are more egregious. I am the single worst offender on the ratio of “dollars paid to CorePower yoga’s virtual app” to “number of virtual yoga sessions completed.” I am an irrational, fast-moving, and aspirational consumer that is every subscription service’s easy mark.

This spring, I turned a new leaf. It was time to defeat the subscriptions that plague our household budgeting like death by a thousand cuts. I cancelled Paramount, all of them. I cancelled CorePower. I cancelled one app for learning piano and another for learning Portuguese. I gained power as an annuity slashing machine…until I came across a difficult subscription I’d forgotten about.

What to do about the heart monitoring implant in my chest wall? This one will prove a bit tricky.

How did I get here in the first place

I spent the summer of 2020 social distancing at short distances and running at long distances. In November, at age 31 and in the best shape I’d been since college, I got COVID. I tried to get back into jogging two weeks later and didn’t quite feel right. In fact, I could feel my heart skipping beats in a way I hadn’t felt before (except when I first met my wife—adorable!).

Half a year and several tests later (stress test, Cardiac MRI, and a few others), my doctor determined that I had developed a low risk but potentially dangerous arrhythmia that required medication and monitoring. In describing the unique severity of my arrhythmia, he actually said: “Imagine you saw someone suspicious walking towards you on the street. In all likelihood, they’ll walk right by. But there’s a chance they knife you and you die.” Thanks, doc—message received!

In the fall of 2021, this very same (and actually wonderful) doctor inserted a paperclip-sized Medtronic Linq II loop recorder subcutaneously into my chest wall. This device monitors cardiac activity and sends data by low energy Bluetooth from my heart to both my phone and a remote monitoring company for review. It’s as impressive and high tech as it sounds.

For how complex the technology is, the procedure was straightforward. As for cost? Turquoise Health data showed the median List Price for the Linq II in California is $27,000. Blue Shield ultimately reimbursed the provider (UCSD) $12,000 for the encounter. With a $1,000 deductible and 10% coinsurance, my patient liability was just over $2,000.

The beat goes on

Despite my improved symptoms, monitoring continues. Every month, my fancy paperclip that my wife named Loopy beams my cardiac data to my phone. My phone then beams this data to Vector Remote Care, a monitoring company based in Bend, Oregon. Finally, Vector beams a PDF file to my doctor to review.

This process, known as remote patient monitoring (RPM), is common across conditions like heart arrhythmias and metabolic disorders like diabetes. The industry has proliferated alongside advances in technology and the expansion of telehealth during COVID. Remote patient monitoring companies like Vector Remote Care can bill medical claims to insurance, and then to the patient, to be reimbursed. The experience feels somewhat disjointed for two reasons: first, because the patient doesn’t typically choose the RPM company. In my case, my cardiologist’s practice did. And second, because the patient never interacts directly with the RPM company.

These RPM costs are significant. I think it’s important to bring the total costs of care conversations to patients (even the price insensitive ones) at the time of care because they, like me, may not realize a new monthly bill comes due on the heels of Loopy’s insertion. There are also additional total cost considerations that could facilitate healthy discussions about alternative sites of care when quality and access are the same.

Breaking down the cost of Loopy

The average battery life of the Medtronic Linq II is 4.5 years, which translates to 54 months of remote patient monitoring bills. The total cost of a loop recorder implantation can be broken down into “implantation”, “monitoring period”, and optional “removal” period. Although these devices can be left in the body indefinitely after running out of juice, insurance also covers removal.

During the monitoring period, I receive two monthly bills (the list price has changed slightly over the years, so I present an average).

1. $147: Professional component of physician review of the Vector Remote Care report.
2. $110: Technical component from the monitoring company (Vector Remote Care reviewing data and generating a report).

With my Blue Shield of California low deductible plan that I had during my initial encounter, here is what the cost breakdown looked like over an assumed 54-month monitoring period:

Over a four and a half year period, Loopy’s $60 monthly “subscription” totals $3,240. For $60 a month, I can get AppleTV, Hulu, Disney+ and Netflix. I can sit on the couch like a vegetable and further exacerbate my cardiac issues.

Ultimately, I felt $60 a month was a reasonable cost for the periodic peace of mind that there were no “alertable events” going on in my heart.

And then, last June, our company insurance coverage switched from Blue Shield of California to Cigna, and the reimbursement behavior of my monthly monitoring shifted slightly. Though there was copay adjustment in my favor for the professional read fee, Vector Remote Care went out of network with my Cigna plan causing a monthly net cost increase from $60 to $110.

If all this math is making you tired, there’s one final consideration—those calculations don’t even get us to the point in time where I’ll need to consider Loopy’s removal either!*

Quick decisions, long term bills

I’ll admit, despite being a CEO of a healthcare price transparency company, I didn’t think about the ongoing costs of RPM at the time of Loopy’s implantation. I applied the same irrationality and near term thinking to this “subscription” as I did to many others. I had an immediate short-term focus on taking care of my health.

Of course, healthcare is different from my 19 different Paramount subscriptions. Especially heart health. At the time of the loop recorder insertion, I was likely price insensitive as I wanted to find out what was so profoundly aggravating my ticker. As the years go by and my symptoms have largely been treated, I can apply a more rational mindset to the Total Cost of Ownership of my loop recorder device. I can ask myself: To unsubscribe or stay?

I reached out to my cardiologist to discuss what to do about my loop recorder. The next appointment is 90 days away, or $330 in additional RPM fees. I’ll also pay a $75 specialist consult copay for my visit. Unless I take a crack at loop recorder removal with a butter knife in the meantime. Which, since my wife may read this, is of course hyperbolic and not under consideration.

As a tech-inclined millennial that chanced upon a heart condition relatively early in life, I feel like an early adopter of sorts. Savvy med tech companies have the opportunity to learn from patients like me as they plan for an onslaught of millennials aging into chronic conditions. There are a few learnings from my experience with Loopy, my Medtronic Linq II loop recorder, that I feel will be shared amongst my fellow millennials in time.

And yes, those learnings make me sound like an ungrateful technologist who can’t pause and appreciate the fact that a paperclip can beam my every heartbeat to a control center in Oregon for monitoring, but we’re here to blog and reflect, so the show must go on.

Lack of a direct relationship with the remote patient monitoring company

As a millennial consumer, I’m accustomed to every business I interact with trying to build a long term relationship with me. Bought a bagel? Join our bagel newsletter and earn points. Clicked on an ad for a new tent? Enjoy hearing about our camping company for the rest of your mortal life. This B2C consumer relationship exacerbates itself even more when a subscription is involved. I heard more from Dollar Shave Club for a few years than I did from my loving parents.

But Vector Remote Care, the company making over $3,000 from a relatively automated service managing cardiac monitoring data and notifying physicians of abnormalities? Not a peep. Perhaps this is because Vector’s main buyer is the cardiology practice and the patient as a consumer does not control which Remote Patient Monitoring (RPM) company gets selected to review the monitoring data.

I can imagine a future where, if I’m not satisfied with the service I receive from Vector, or I learn Vector is no longer in my network when my insurance plan changes, I can unsubscribe from Vector and use another RPM vendor. For now, though, it’s a purely transactional subscription: I only hear from Vector when a bill comes due.

High-tech device, low-tech deliverable

Despite the miracle of Loopy’s existence, I’m dissatisfied with the clunky, dated, end deliverable. Every month, I open MyChart and am greeted by a shorthand summary of the physician’s interpretation and a clunky PDF report from Vector Remote Care. There are way more interesting ways to productize the data that could be relevant to my patient experience, which we’ve seen from the consumer-grade continuous glucose monitors on the market today.

Plus, I know that subjectively, my arrhythmia tends to feel worse at night, worse after certain foods, and worse on low sleep. If I could pair my device data with my lifestyle data, I could learn a lot more about how to manage my symptoms. A one-dimensional monthly PDF doesn’t feel like the most compelling manifestation of the data for myself or my physician.

Lack of access to my data

I’m sure there are a myriad of complications involved with granting patients direct access to their own implantable cardiac monitoring data. For one, my electrophysiologist told me that it’s very common for healthy patients to experience bouts of abnormal episodes, which may cause an influx of concern and inquiries about what are ultimately non-events to an already undersupplied specialty. Additionally, the heart rhythm data that comes out of low energy Bluetooth is probably nuanced and computationally intensive to work with. I’m sure it doesn’t come out of Loopy looking like an Excel file.

But despite those complications, I speak for the aging millennials of the future when I say we won’t tolerate a lack of access to our device data. Especially in an age of advanced reasoning AI and “AI doctors” at our fingertips. I’m frustrated that, despite paying thousands of dollars, getting my chest sliced open by a (pleasant) cardiology fellow, and flying blind when an arrhythmic episode occurs until my monthly interpretation arrives, I can’t have direct access to my data.

What’s next for me, Loopy and the healthcare consumer?

Aging millennials will bring tech savviness, a penchant for consumerism, and an expectation for immediate gratification to the future of RPM. My predictions? New tools will emerge to help patients navigate healthcare decisions autonomously, and these tools will include price as a factor. They will be able to help the consumer budget for ongoing care down to unprecedented levels of precision.

We’ll see continued emergence of subscription models outside of traditional insurance (Function Health, One Medical, and the many direct primary care offerings come to mind). But we may also see the rise of alternative payment methodologies and empowered consumers under the purview of traditional coverage. This will take time. By then, Loopy may be long dead, but my inclination towards irrational subscriptions may live on.

*For those curious:

I called my cardiology practice to ask about removal of the loop recorder. One of the nurses on staff said the device is typically left implanted until the battery runs out, and after that, it's the patient's preference whether to leave the device in indefinitely.

If we assume that I have 18 months left of battery life, the $50/month cost increase adds $900 in costs of ownership, assuming that Cigna remains out of network with Vector Remote Care. This means I have an interesting set of options for managing this subscription:

Option 1: Leave Loopy in and remove it once the battery goes out

• Costs - $1,980 (monitoring)
• Costs - $1,160 (removal)

Option 2: Remove Loopy now and in turn, turn off monitoring

• Costs - $1,160 (removal)

Option 3: Call the office, turn off monitoring, and leave the device in.

• Costs - $0

Option 4: Same as option 3, except I MacGyver Loopy out with kitchen utensils like a scene from Squid Game:

• Costs - $0
• + Unknown cost of subsequent ER visit