Hybrid Telehealth Model Likely on the Horizon, Hurdles Remain

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When the pandemic hit more than 2 years ago, nephrologists and their patients had to pivot on a dime to adapt to telehealth technologies. Those technologies have proved popular with both nephrologists and patients. But now, clinicians face new challenges as they try to develop sustainable and equitable hybrid telehealth and in-person care models for the long term.

Provisions in the 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act enabled the Centers for Medicare & Medicaid Services to temporarily waive restrictions on where and how patients could receive telehealth (1). This policy change led to a rapid expansion of telehealth care. Before the changes, telehealth was allowed for patients on home therapies, such as home hemodialysis and peritoneal dialysis, through the Bipartisan Budget Act of 2018 (2). But there were restrictions on using telehealth for other kinds of kidney care. Medicare only covered telehealth visits in rural areas, and patients could not access telehealth visits from home. Audio visits were prohibited, and clinicians could only use Health Insurance Portability and Accountability Act-compliant video platforms. Clinicians were concerned the changes would expire with the end of the COVID-19 public health emergency. But in March 2022, Congress passed, and President Biden signed into law, a spending bill (3) that extended the provisions 5 months after the official end of the COVID-19 public health emergency.

“We commend the legislators for including critical telehealth extensions in this must-pass legislation, ensuring that patients do not fall off a ‘telehealth cliff’ immediately after the COVID-19 public health emergency ends,” wrote Kyle Zebley, vice president of public policy at the American Telemedicine Association (ATA), in a statement (4). But the ATA and organizations representing physicians, such as the American Medical Association (5), want legislators to make the policies permanent this year.

Temporary reprieve

Nephrologist Susie Lew, MD, professor of medicine in the Division of Renal Diseases and Hypertension at George Washington University in Washington, DC, said the extension for at least 5 months is wise. She noted there are still pockets of SARS-CoV-2 transmission throughout the country. The move, she said, would help reduce transmission of the virus in health care settings. It also reduces the burden on practices that might have to suddenly convert patients with scheduled telehealth visits into in-person visits on short notice.

But nephrologist Eric Wallace, the medical director of telehealth and director at the Home Dialysis Academy at The University of Alabama at Birmingham (UAB), said he was disappointed that Congress chose a temporary, short-term extension of the COVID-19-era telehealth rules. Instead, he hoped that Congress would pass the Telehealth Extension and Evaluation Act (6), a bill that would have extended the rules for 2 years and put in place programs to evaluate what telehealth can do well and what it cannot. Wallace said he did not think 5 months would be enough time to gather the evidence necessary to make the best policy decisions. He explained that the short timeframe makes it harder for clinicians to plan and test telehealth programs. It may also deter health institutions from investing in telehealth. “Many people are not willing to make a giant investment without some sort of permanency,” he said.

Wallace noted that clinicians and policymakers have already learned a lot about telehealth during the pandemic. For example, fears that it would lead to fraud and abuse or ramp up the cost of care have not materialized, he said. A recent review in the Clinical Journal of the American Society of Nephrology (7) about video-based telehealth care found that patients with kidney diseases were satisfied with telehealth care and felt it was comparable with in-person care. Both patients with chronic kidney disease and those undergoing dialysis said it improved their quality of life and reduced care costs. “There are things we know telehealth does very well,” Wallace said.

Broadband and barriers

Studies have also identified the need to reduce disparities in telehealth care access. For example, a survey (8) of 298 patients with kidney diseases at the University of Pennsylvania found that more older patients had reduced access to video telemedicine. Patients who are non-White and older were also more likely to need help accessing the internet.

Another recent study in JAMA Network Open (9) found increased COVID-19 mortality in communities that lack broadband access. Although the study could not prove a causal relationship, it added evidence of the importance of universal broadband access as a social determinant of health. Wallace and Lew agreed. “Broadband is becoming a surrogate marker for socioeconomics,” Wallace said, noting that broadband access is essential not just for accessing telehealth but also for education, commerce, and even purchasing medication. “It needs to be ubiquitous.”

Last year, the Infrastructure Investment and Jobs Act (10) included $65 billion to expand broadband access in the United States. But Lew said it is unlikely that broadband access will reach all US residents because of geographic or financial barriers. She noted that many cities have extensive broadband networks, but not everyone can afford to subscribe or pay for a device to access it. Both Lew and Wallace suggested that efforts to make internet access more affordable may help. For example, Lew suggested making mobile phones available to those in need. The Federal Communications Commission currently offers eligible low-income households a $30 discount on broadband and a one-time $100 discount on a laptop, tablet, or desktop computer through the Affordable Connectivity Program. The program offers a $75 discount for those living on qualifying Tribal lands.

Telehealth hubs could also help, both Lew and Wallace recommended. “One way to solve that issue is instead of bringing broadband to a patient's home, bring it to a location that patients have access to,” Lew said, for example, a business or other community gathering site. Wallace and his colleagues at UAB set up telehealth hubs at county health departments throughout the state.

Wallace also highlighted assisted telehealth during a presentation at Kidney Week 2021. Assisted telehealth sends a community health worker, equipped with satellite internet or another means of accessing the internet, to patients’ homes to help them during telehealth visits. “We need a multipronged approach,” he said.

Hybrid hope

Despite some of these challenges, both clinicians and patients are keen to continue with a hybrid in-person/telehealth model of kidney care. “A large majority of patients wish that telemedicine will continue in some form,” Lew said, based on preliminary data of patients from a survey she conducted.

Continuing access to telehealth care is particularly important for patients with rare diseases, noted Wallace, who co-directs the Fabry Disease Clinic at UAB. He explained that many patients do not have easy access to rare disease specialists and that some of his patients drive 4−8 hours or even cross state lines to see him. Many states have enacted rules during the pandemic to allow patients to receive care from licensed physicians practicing in another state.

Wallace also emphasized the importance of giving patients a choice in how they access care. He recommended that rulemaking is needed to protect patient choice, create guardrails against potential abuse of telehealth visits, and ensure that patients still receive appropriate care, such as vitals monitoring. Wallace cautioned that if policymakers pass telehealth rules that make using it difficult for patients and physicians, they may not use it. He warned that it could reduce preventive care and drive up the numbers of patients needing dialysis at enormous costs to the US health care system.

“There is a return on investment of giving patients a choice,” Wallace said. “Let's allow them to interact with the [health care] system how they want to but put some guardrails around it.”

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