Remote Patient Monitoring and Sustainable Rural Healthcare Delivery

Introduction

Rural communities across the United States (U.S.) face persistent challenges accessing essential healthcare services, and as reported in the U.S. Census Bureau’s 2020 Census, 66.3 million, or one in five Americans, live in a rural area.[1] These individuals, including 10 million Medicare beneficiaries, often face challenges in accessing healthcare as well as keeping connected to the broader healthcare system.[2]

For areas with reliable access to broadband and cellular service, the growing use of digital health technologies has created new opportunities to transform healthcare delivery. One of these, remote patient monitoring (RPM), allows patients to collect and electronically transmit health information from home to their healthcare provider, who can monitor health and outcomes from a distance.

Medicare’s recent coverage decisions for RPM have supported the integration of RPM within a holistic care delivery approach. Given the advantages of continuous monitoring for ongoing care needs, RPM offers an opportunity for improving access and healthcare delivery as health systems consider alternative models of care that can extend beyond traditional clinical settings.

Rural Health and Access to Care

Rural health needs are increasing. Not only does 14 percent of the American population, or 46 million people, reside in rural counties as of 2023, but recently, rural communities have also been experiencing year-over-year growth for the population aged 65 or older.[3] These demographic shifts, combined with more intense healthcare needs, are increasing demand for healthcare services while placing additional pressure on the rural healthcare workforce’s availability to meet those changing needs.

Rural populations have care needs that differ from their urban counterparts. Rural Americans, 80 percent of whom are medically underserved, experience a higher burden of chronic disease, including diabetes, chronic obstructive pulmonary disease (COPD), and heart disease, and often face multiple chronic conditions simultaneously.[4] Among Medicare beneficiaries living in the most rural areas, almost one-third experience five or more chronic health conditions.[5] These conditions often require ongoing monitoring, disease management, and coordination across multiple healthcare providers.[6]

Rural residents are also more likely to rely on public sources of health insurance, including Medicare and Medicaid, compared to urban residents.[7] Uninsurance is more common among working-age adults in rural communities. 3 These factors create financial and workforce pressures that affect provider capacity to maintain services for their communities, particularly for a growing Medicare population.

Access barriers in rural areas make it difficult to address healthcare needs and play a significant role in shaping healthcare delivery. Rural populations may have to travel significant distances to receive specialty and complex care, even when primary care is available within their communities. Longer travel distances and limited transportation options make accessing services and maintaining continuity of care more difficult.

Another critical issue is the availability of a sustainable rural healthcare workforce. A growing gap is emerging in which current workforce capacity is struggling to keep up with growing care needs. Only about 12 percent of physicians practice in rural communities, which also experience shortages of other providers such as nurse practitioners, dentists, and social workers.[8] Additionally, rural hospitals and hospital services are disappearing, with over 200 hospitals in rural areas having closed between 2005 and 2025 and 400 more facing significant financial hardship.[9] Finally, providers often operate within a challenging financial environment, shaped in part by payer mix, lower patient volumes, and reimbursement rates.

The Opportunity for Remote Patient Monitoring

RPM allows patients and providers to monitor health metrics (e.g., blood pressure, weight, or blood glucose levels) from home using connected medical devices that electronically transmit information to their healthcare providers. Medicare coverage and reimbursement requirements define RPM as including three components: (1) the initial setup and patient education on use of the device; (2) the supply of an internet-connected device, including the collection and transmission of at least two readings every 30 days; and (3) treatment management, where healthcare providers review the information and interact with the patient as part of their care.[10]

Using RPM, providers incorporate monitoring of Medicare beneficiary health outside of in-person encounters, which may support earlier identification of changes that require follow-up or intervention. Rather than relying solely on information collected during sporadic and periodic in-person visits, RPM provides health information over time, which allows providers to track changes and support the ongoing management of chronic conditions. For rural Medicare beneficiaries, who may face longer travel distances or limited access to healthcare providers, RPM provides an additional way to remain connected to care between visits.

Current Policy Landscape

The Centers for Medicare & Medicaid Services (CMS) established a separate Medicare payment for RPM services in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (PFS) final rule, where beginning January 1, 2019, physicians and clinicians could bill Medicare under evaluation and management (E/M) codes for RPM services provided to beneficiaries with whom they have an established relationship. Over the years, CMS has expanded and refined its RPM payment and program requirements, including providing additional codes and allowing more flexibility in providing RPM services. For example, in the CY 2021 PFS final rule, CMS added clarification highlighting that certain RPM services could be provided by auxiliary personnel, including third-party contracted employees, under the supervision of the billing practitioner.⁸

However, in the CY 2027 PFS proposed rule, CMS incorporates proposals designed to limit RPM. In one proposal, CMS would require a separately billable, in-person or telehealth initiating E/M visit prior to RPM service initiation, creating an additional step for RPM enrollment. During this visit, the billing practitioner must assess the patient’s needs and clinical appropriateness of RPM, obtain consent, and address the monitoring services. If finalized, the proposal would require practices to adjust scheduling and staff workflows.

In another proposal, CMS would effectively reverse its 2021 clarification that had allowed third-party contractor clinical staff involvement. Beginning in January 2027, CMS proposes that clinical staff who provide RPM services must be directly employed by the billing practitioner or practice and subject to general supervision and applicable “incident to” requirements. If finalized, this change would require practices that currently rely on contracted staff for RPM services to end their contractual relationships and directly employ clinical staff to receive Medicare RPM payment.

Congressional Interest

At the beginning of October, a bipartisan group of House members sent a letter to CMS Administrator Mehmet Oz, MD, urging him to roll back the proposed RPM changes as these proposed regulatory changes are seen likely to significantly reduce access to RPM services for Medicare beneficiaries, particularly those in rural areas. It is anticipated the final rule will address these concerns as well as the comments CMS received in response to the proposed rule from stakeholders across the healthcare and technology industries.

Implications for Rural Healthcare Delivery

Although reimbursement is critical for supporting RPM care delivery, implementation depends on how these services fit within existing rural technology infrastructure and healthcare delivery models. The limitations proposed in the CY 2027 PFS proposed rule may have significant consequences for rural providers, including an impact on workforce, workflow, and organizational structure in addition to administrative burden, connectivity, and access considerations.

The Proposed Direct-Employment Requirement and Initiating Visit

The proposed direct-employment requirement could strengthen integration between the clinical staff providing RPM services and the billing practitioner, particularly within larger health systems that have the resources to augment the clinical staff necessary to provide RPM services in-house. Staff are needed to enroll and educate patients, monitor incoming information, determine when follow-up is needed, communicate with patients, document services, and coordinate subsequent care.

However, for smaller rural practices with less capacity, this proposal will likely create operational and financial challenges. The Remote Monitoring Leadership Council noted that smaller and rural providers may lack the patient volume, workforce, or financial resources to directly employ staff dedicated to RPM services. According to a National Association of Rural Health Clinics survey, nearly 70% of rural health clinics that reported offering RPM relied on partners to make RPM services available[11]—demonstrating that rural providers often rely on regional partnerships and shared-service models to provide services.

Additionally, CMS proposes requiring a separate face-to-face initiating visit before RPM services can officially begin. This paired with the direct-employment requirement could threaten remote care availability for rural Medicare beneficiaries as rural providers may not be able to provide their patients with these tools.

Technology and Connectivity

Infrastructure challenges may further strain and compound existing capacity constraints in certain communities. In 2025, KFF Health News reported that 3 million Americans live in more than 200 counties that lack access to reliable high-speed internet as well as sufficient access to primary care and behavioral health services.[12] To provide RPM services, organizations require access to appropriate devices and reliable supply chains, sufficient connectivity for data transmission, integration with clinical systems, technical support, and processes for educating staff and patients on how to use the technology. Once information reaches the practice, there must also be a clear pathway to review and respond when follow-up is needed. Gaps at any point in this process, from device access and connectivity to clinical response, may limit the potential benefits of RPM.

Looking Ahead

While RPM presents an opportunity to extend healthcare beyond traditional clinical settings and strengthen patient-provider connections outside of in-person visits, the proposed policy, if finalized, could change how healthcare is delivered, particularly in rural areas. As Medicare policy continues to evolve, it is important to understand how implementation of these programs differs across rural healthcare settings and patient populations.

We anticipate that the CY PFS 2027 final rule, expected in November, will solidify RPM requirements. Depending on the final Medicare payment policy incorporated into the rule, the industry could see large scale and potentially disruptive changes to how remote care is provided, particularly in rural areas.

Applied Policy will update this story following the release of the final rule.

Research assistance for this project was provided by Erica Stephens, MPH.

[1] 2020 Census Urban Areas Facts

[2] Key Facts About Medicare Beneficiaries in Rural Areas, KFF

[3] Rural America at a Glance, 2025 edition. (Report No. EIB-295). U.S. Department of Agriculture, Economic Research Service.

[4] Rural Health Needs in America: Challenges & Solutions

[5] Key Facts About Medicare Beneficiaries in Rural Areas, KFF

[6] Chronic Disease in Rural America Overview – Rural Health Information Hub

[7] Health_Insurance_Coverage.pdf

[8] Addressing Rural Health Inequities in Medicare | CMS

[9] Rural Health Needs in America: Challenges & Solutions

[10] Remote Patient Monitoring | CMS