Telehealth seeks its place in nephrology
Click Here to Manage Email Alerts
As the deadline looms for Congress to make telehealth flexibilities permanent, nephrology is trying to determine what role it plays in patient care post-COVID-19.
Prior to the pandemic, telehealth accounted for a fraction of the health care delivered in the United States. Although the need for telehealth for many patients pre-dated the COVID-19 pandemic, the Medicare regulations to deliver these services were formidable. Primarily, the patient had to be in a medical facility, deemed the originating site, and the site had to be in a rural area.
No telehealth services could be delivered into the home or in urban areas, until the Omnibus Act of 2018 passed by Congress allowed for two new services: stroke care and home dialysis.
Need for telehealth
Despite these restrictions, those of us who had recognized the necessity of telehealth, largely through seeing the impact it made on our patient’s lives, pressed on. COVID-19 removed the most significant barriers including the geographic restriction, allowing for the originating site to be a patient’s home, allowing for audio-only coverage and paying for telehealth services at parity with in-person services. This led to a dramatic increase in telehealth, which peaked the first quarter after the public health emergency for COVID-19 was declared.
However, since that time, there has been a steady decline in the use of telehealth and a looming deadline for Congress to act, leaving some to question: Why keep telehealth and, if we keep it, should we pay the same for its delivery?
Rural vs. urban
I began working with telehealth for the home dialysis and rare disease population 5 years before anyone had even heard the word “COVID.” Why? Because my patients needed it and asked for it, and many of them see the benefit (see Table). There was a need for telehealth before the pandemic. There is a need now. There will be an increasing need in the future and not just in rural communities.
Flexibilities
One of the flexibilities that is before Congress is that of geographic restriction. Prior to the pandemic, patients had to be in rural areas to allow telehealth. This restriction presupposes that every urban area has access to every needed subspecialty.
But that is not true. One prime example in nephrology is that of taking care of transplant patients. Prior to the pandemic, my clinic at the University of Alabama (UAB) provided transplant nephrology care via telehealth. UAB is the only transplant center in the state. Unfortunately, for patients who lived in an urban area 4 hours away, telehealth was not an option in their city despite not having access to transplant care.
The way around it was to have the patient drive to the nearest rural medical facility to get care. This was still closer than driving to Birmingham but still made no sense.
Home vs. clinic
Should telehealth continue in the patient’s home? Telehealth provided in the clinic had some advantages. Primarily, there was access to a nursing staff, reliable computers and the potential for peripherals such as tele-stethoscopes. The major drawbacks, however, were operational hurdles and scalability.
To deliver telehealth services to a clinic location, there either needs to be a contractual arrangement with the originating site for the patient or the physician or the institution in which the physician works needs to own the originating site. Examples of this include the Veteran’s Administration (VA), where veterans have access to multiple ambulatory locations with access to telehealth. However, outside of the VA and other large health systems with a wide geographic range of outpatient brick and mortar, these arrangements and networks must be built. Furthermore, there is added burden when there are two separate scheduling systems and electronic medical records that must be navigated.
The home as an originating site has multiple advantages, the primary one being the ability to scale given the new widespread access to videoconferencing devices we now always find in our pockets. The disadvantage was the inconsistent access to vital signs and the need to obtain labs at outside facilities when needed. Disallowing the home an originating site given the complexities in establishing widespread brick-and-mortar telehealth networks will likely be a death knell for the use of telehealth and will adversely affect access to care for those in need.
Parity vs. less pay
Should telehealth be paid at parity? In the recent MedPAC report, it was suggested that alternative ways to pay for telehealth should be evaluated given that telehealth reduces the expense of providing the service. However, is that true? Most of the telehealth is being offered in what I call the hybrid clinic, whereby a clinician has multiple in-person visits and then a handful of telehealth visits. These are clinicians who are using telehealth to help those in need. In this model, the clinician still must pay for the brick-and-mortar facility. There is still a need for patient intake and medication reconciliation. Literally nothing about the overhead changes in the hybrid clinic.
Future
If we keep the current flexibilities in place, what can we expect in the future for telehealth? To understand a little better about the trajectory, the Gartner Hype Cycle is a graphical representation referring to the predicted phases in the adoption of any technological advancement. Although telehealth predated the COVID-19 pandemic, the pandemic itself was a technological trigger that led to a huge increase in telehealth usage. In the first quarter after the pandemic, telehealth found itself in the peak of inflated expectations, where there were unrealistic expectations of what problems telehealth could and could not solve. After the peak, there was and has been an expected decline in the use of telehealth. However, the decline has steadied and now accounts for about 10% of all evaluation/management visits at most institutions, which is still a dramatic increase from the pre-COVID era. This phase is called the trough of disillusionment and is where we find ourselves currently.
What is predicted to follow is the slope of enlightenment, where the use of telehealth will continue to increase during the next 10 years, until it plateaus.
As telehealth permanency develops, an industry in home diagnostics will develop around it, allowing for more diagnoses to be made and to be managed at home. Regulators will begin to align to make sense for health care delivery using telehealth and a shift to value-based care will continue to move chronic care management to the home.
- For more information:
- Eric L. Wallace, MD, FASN, is a professor of medicine in the division of nephrology in the department of medicine at the University of Alabama and is medical director of eMedicine. He also serves as co-director of the home dialysis program and director of the Rare Genetic Kidney Disease Clinic. He is a member of the Editorial Advisory Board for Healio | Nephrology News & Issues. He can be reached at elwallace@uabmc.edu.
Collapse
Read more about
Click Here to Manage Email Alerts