Almost 25 years after the Texas Telemedicine Project, one of the first major telemedicine initiatives, we are still trying to determine where and how telemedicine fits into modern nephrology.
Increased access to care is just one of many potential advantages of telemedicine. However, at a time of increasing healthcare costs, policymakers and payers ask, “What is the added value?” Furthermore, debates about acceptable means of providing telemedicine care rage on. Legal battles waged between providers of telemedicine and state medical boards have provided further hesitancy on the part of physicians to incorporate telemedicine into their daily practice. Many of the concerns surrounding telemedicine could take another 25 years of study to answer. However, for many patients, telemedicine is not needed for mere convenience or easy access to treatment for sore throats. It is needed to extend substandard access to subspecialty care, as well as expanded treatment options, and it is needed now.
Telemedicine has been primarily used to bridge geographic disparities in access to care, and has been focused mainly on provision of care in rural areas. Approximately 25% of the US population lives in areas considered rural, and rural location has been associated with increased incidence of end stage renal disease (ESRD). Thus telemedicine provides a means to improve access to care where the need is greatest. Luckily, the rural patient is considered the most appropriate recipient of telemedicine visits. In large part, Medicare and Medicaid already cover telemedicine for standard outpatient visits for this population, as do many other private insurers in states with existing telemedicine parity laws. Telemedicine for this population not only serves to increase access to subspecialty care, but also increases the comfort levels of rural primary care physicians who are otherwise practicing in medical deserts with little to no subspecialty support.
While standard outpatient subspecialty visits are covered, coverage of home dialysis follow-up visits is another story. Prior to January 2016, there was no coverage of any telemedicine visits for the home dialysis population. The 90963-90966 outpatient home dialysis codes appeared in January of 2016 as a covered telemedicine code for Medicare. Unfortunately, this coverage excludes home hemodialysis patients (or even peritoneal dialysis patients) with a vascular access as it is stipulated that an in-person face-to-face visit must be provided to examine any vascular access. Still, acceptance of the 90963-90966 codes by the Centers for Medicare & Medicaid Services (CMS) represents a large step for telemedicine in the provision of rural peritoneal dialysis.
Rural patients are the natural focus of telemedicine services, but should rural areas be the only focus of telemedicine? For many patients living remotely from care but in a metropolitan area, the answer is no. Certain super-subspecialized care might only be achieved in tertiary referral centers or university settings. Patients who might fall into this category include those with rare diseases, pediatric nephrology patients, and transplant recipients. These patients currently have no option for telemedicine. Furthermore, for the elderly and those with limited mobility of all ages living in metropolitan areas, telemedicine might limit non-emergent ambulance transport to and from clinic visits and improve the ability of these patients to make appointments that might thwart frequent hospitalizations. This feature of telemedicine is even more applicable for the home dialysis patient population with limited mobility. Unfortunately, owing to CMS’s geographic restrictions on telemedicine, patients such as these do not have access to telemedicine services. Thus a large barrier for many applications of telemedicine lies in the removal of the rural restrictions on telemedicine services.