Telehealth in the United States: New Opportunities?

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It’s clear that patient–provider communications in the United States have not kept up with the rapid evolution in technology. Young kids are communicating with tablets and other devices that put current telehealth iterations to shame. But if we already have the technology, what is the holdup?

Current telehealth policy

One roadblock is that current rules governing telehealth in the United States state that it can only be administered in rural counties and health shortage areas in metropolitan fringes with the patient at a health facility (known as “originating sites”). Also, telehealth services may only be administered by a select group of practitioners and for a select number of medical procedures or services. Store-and-forward technologies (analogous to sending a picture via text message) are only permissible for demonstration projects in Alaska and Hawaii. Remote patient monitoring, a technology that enables patient monitoring of chronic conditions outside of conventional clinical settings, is not a covered telehealth service.

Why try to change it now?

According to the Centers for Medicare & Medicaid Services (CMS), more than 51 percent of patients with kidney disease have five or more comorbid conditions. Effective management of these comorbidities is especially important for patients with earlier stages of kidney disease, during which proper care from a nephrologist may slow progression toward renal failure, as well as prevent the advancement of costly comorbidities caused or worsened by the disease.

Besides improving patient outcomes, facilitating patient access to subspecialists through telehealth may contribute to long-term cost savings—particularly to the Medicare ESRD Program. Currently, approximately 25 percent of all Medicare dollars are spent on care for patients with kidney disease. When CMS reported on the top five most costly triads of chronic illness in 2012, CKD was included in four out of the five with an average cost of approximately $60,000 per capita.

New legislation and what it wants to change

On July 7, 2015, Reps. Mike Thompson (D-CA), Gregg Harper (R-MS), Diane Black (R-TN), and Peter Welch (D-VT) introduced the Medicare Telehealth Parity Act of 2015. This new legislation would allow a patient’s residence to serve as an originating site for home dialysis services, and permit them to conduct some monthly clinical assessments via telehealth. As of now, patients who dialyze at home have to travel to a hospital or facility-qualifying site to interface with an approved practitioner.

Providing reimbursement to physicians for caring for patients on dialysis via this telehealth legislation may enable more patients to consider home dialysis as an option, creating greater efficiency for both patients and physicians. Home dialysis—in the form of peritoneal dialysis or home hemodialysis—is an important treatment option that, for some patients, may offer significant clinical and quality of life advantages. Kidney transplant recipients and living kidney donors would also be well served with access to expanded telehealth options. Kidney donor follow-up consultations are mandated by both Medicare and the United Network for Organ Sharing, and typically comprise a simple well-patient visit for which donors must bear the costs of a day off work and travel. Were patient’s homes to be designated as an originating site, many of these consultations could easily be provided via telehealth. Clearly, this legislation has the prospect of helping patients with kidney disease of all stages.

Monitoring the system

Although there is wide consensus that telehealth has the potential to improve patient access, reduce hospitalizations, and reduce costs, these hypotheses remain unproven and therefore must be closely evaluated to ensure that the program achieves the intended goals and to ensure that patient safety and quality care remain the number one priority.

The ASN policy team will continue to monitor the progress of this and other kidney-related legislation in Congress and update the membership. Please stay tuned.

To learn more about ASN policy, please visit https://www.asn-online.org/policy/.