A Research-Based Analysis of State Medicaid Policies on GPS, Sensor and Camera Use in Home and Community Based Settings to Replace and Supplement Staff

Background and Purpose: Medicaid participants receive Long-Term Services and Supports through state waiver programs to enable them to remain living in the community. Technologies that include GPS, motion sensors, and audio and video monitors are now allowable in some state Medicaid HCSB 1915 waiver programs if they reduce or replace the amount of personal care provided. The primary barrier to widespread uptake of these monitoring technologies has been lack of reimbursement by third party payers due to inadequate evidence of clinical and financial benefit. Recent changes to Medicaid policy have implications for other third party payers and are likely to lead to rapid proliferation across settings. The objective of this research is to assess state Medicaid HCBS waiver policies regarding allowable devices, authorization, and restrictions, and place them in the context of research that examined actual practices of remote monitoring use by social workers in low-income independent living.

Methods: This presentation describes a policy analysis that was informed by 49 in-depth interviews with social workers, family members and residents of six non-profit independent living residences where sensor-based activity monitoring had been offered on a subsidized basis for six years. The qualitative research captured actual procedures of use with older adults, as well as decision making about adoption and discontinuation. For the qualitative study, one third of the older adult residents were Medicaid beneficiaries and the others had incomes between $29,000 and $36,120. Over half were born outside the U.S. and all residents had multiple chronic conditions. The policy analysis focuses on the policy and consent forms piloted in 2015 by the first state to formally expand its remote monitoring services. It is informed by discussions with decision makers at the federal and state level in aging and disability services, as well as national HCBS advisory groups.  

Results:  The qualitative study revealed extremely low adoption rates (2%) and high rates of discontinuation (20% in 12 months) of the voluntary sensor-based passive monitoring system. Coercive techniques were used to pressure adoption and informed consent was difficult to achieve. All study participants who had sensor systems reported not wanting a camera in their apartments, including those with high level home aide support. Within state Medicaid HCBS 1915 waiver policies, passive monitoring is covered under a range of procedure categories, which has made it difficult for states and CMS to know when passive monitoring is being used. Current guidelines for remote monitoring are not empirically-based and consent forms are often not required for “less invasive” remote monitoring such as the activity monitoring sensor system this qualitative research describes.   

Conclusions: This study of actual practice reveals the ways in which current state Medicaid policies are inadequate to regulate the ethically fraught deployment of remote monitoring technologies. Two specific recommendations to strengthen states’ abilities to enable least restrictive housing without significant reductions in quality, participant autonomy, and access to non-technological supports will be discussed: the need to align passive monitoring technology use with the preferences of end users, and the need to track its use.