Telehealth for Home Dialysis

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on December 20th, 2018.
Telehealth for Home Dialysis

Guess what? Patient complaints about having to go to a clinic monthly to see the doctor and dialysis staff have been heard! On February 9, 2018, President Donald Trump signed into law the Bipartisan Budget Act of 2018. A provision in this law may help more people have access to home dialysis by allowing home dialysis patients to choose to have some visits with their physician by “telehealth.”

What is telehealth?

According to CMS, telehealth is an interactive two-way audio and video telecommunications system that permits real-time communication. In the past, physicians could only see dialysis patients using telehealth if they were at certain ”originating sites,” such as skilled nursing facilities, hospitals, doctor’s offices, and only at hospital-based dialysis clinics and in-center dialysis clinics were excluded. This law changes all of that.

What does the law allow?

A home dialysis patient may choose to use his/her home as an “originating site” for telehealth. Starting on or after January 1, 2019, Original Medicare and Medicare Advantage plans will pay physicians whose home dialysis patients choose to see them by telehealth. It doesn’t matter whether a patient’s home is in an urban, suburban or rural area. However, a physician and home dialysis patient cannot use telehealth if they’re in the same location.

The law requires physicians to assess new home dialysis patients during face-to-face visits for the first three months of home dialysis. After that, the physician must see home patients at least quarterly. If patients choose to use telehealth for visits with their physician, they still need to get labs and should have access to other members of the interdisciplinary team.

How is telehealth reimbursed?

Medicare pays the same for telehealth or face-to-face visits. Dialysis clinics get no extra payment either way since they’re paid under Medicare’s bundled rate. For hospitals or others, there is no added facility charge for telehealth when the originating site is the home dialysis patient’s home. CPT codes are the same for face-to-face and telehealth visits:

  • 90963: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90964: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90965: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90966: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older

  • 90967: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age (effective for services furnished on and after January 1, 2017)

  • 90968: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 2-11 years of age (effective for services furnished on and after January 1, 2017)

  • 90969: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 12-19 years of age (effective for services furnished on and after January 1, 2017)

  • 90970: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 20 years of age and older (effective for services furnished on and after January 1, 2017)

Potential Telehealth Advantages for Patients Potential Telehealth Advantages for Physicians
Working patients don’t have to take off work as often. They don’t have to drive to multiple clinics to see home patients, saving time and gas.
Students or school children don’t have to miss school as often. They may be able to spend more quality time interacting with home patients.
Fewer trips to the dialysis clinic can save gas and wear and tear on a car. They can “see” a patient’s home set up for equipment and supplies.
Patients without cars do not have to find a ride or pay to get to the clinic as often. They may be more able to advise a patient on how to adjust his/her home dialysis to improve health and quality of life.
Patients can stay home in bad weather.
With a patient’s permission, families can be involved in a patient’s care plan and care.
Potential Disadvantages for Patients Potential Disadvantages for Physicians
Patients may fail to mention symptoms during a telehealth visit that a physician might identify in a face-to-face visit. Unless using more costly equipment, they can’t fully examine a patient’s access.
Patients may have technical issues with Internet connectivity or speed (even if they have Internet at home) They can’t touch a patient’s ankles to see if s/he has edema.
Patients who prefer face-to-face visits may feel pressured to use telehealth if their physician is not available otherwise. There is a cost to obtaining telehealth equipment and providing it to patients.
Telehealth visits could limit relationship building between patients and physicians.
They may feel pressured by clinics to use telehealth to save home dialysis staff time.

Conclusion:

Home dialysis patients will be able to choose to see their physician by telehealth starting on January 1, 2019. There may be advantages and disadvantages to the use of telehealth for patients and their physicians. Medicare doesn’t pay more for telehealth visits, so patients have no extra cost. However, providing telehealth equipment can be costly to physicians and lack of additional Medicare payment for telehealth visits may limit how many physicians offer home dialysis patients the option to choose to see their physician by telehealth.

References:

  • Bieber SD, Weiner DE. Telehealth and home dialysis: A new option for patients in the United States. Clin J Am Soc Nephrol 13: 1288–1290, 2018.

Comments

  • Peggy Bushey

    Jan 3, 4:14 PM

    I am grateful that CMS has come around to the idea of approving telehealth visits for our home dialysis patients. While this may not be the best option for complicated patients, I do see advantages for our stable patients. Living in a rural state, we have patients who have 2-hour drives to come in for a monthly visit, just to hear that everything is fine. With bad weather in the winter, they may decide not to come at all that month, which could lead to missed issues. I agree that patients should not feel pressured into using this option and that they should be educated around the questions/issues that will be discussed during the visit, so they can be prepared and make the best use of the time and technology.
    We have been utilizing telehealth with our in-center patients and find that it is well accepted. Patients are not at all shy about having a discussion with the doctor during that time. We are currently employing Nx2Me for our home hemodialysis patients, so every patient already has an iPad. One of the first things our patients asked when they received their iPads was if they could use it for the monthly clinic visit from home. So… I think the home-dialysis patient world is ready for this!

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    • Beth Witten

      Jan 3, 4:28 PM

      Thank you for your comment. I'm glad to hear that patients are open to using technology when they have it to be able to talk with their doctor and other team members. I think using telehealth also opens the door to having family members involved more in the patient's care, if the patient agrees to that. Family members can be great allies to the team in helping their loved one do well on dialysis.

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  • Michael Kraus

    Dec 21, 6:06 PM

    Thank you and this blog, it is a nice summary. I believe telehealth/telemedicine is extremely important to empowering the patient and increasing access to care. We have much work to do and need to continue to improve.

    The Bipartisan Balance Budget Act of 2018 promotes increased access to home dialysis and realizes the impact of telemedicine as part of the solution. Telehealth needs are not well defined and the technology needed is also not defined. CMS should intentionally minimize technology requirements and complexity to encourage adoption while technology and access to technology improves.

    It is important to note, that the use of telemedicine is a patient preference and a patient has the ability to opt out of telemedicine - it is the patient's decision to participate. Also, to participate in telehealth visits the patient is required to have monthly face to face visits for 3 months and then 1 face to face every 3 months ( slightly different than quarterly which could be a visit at month 1 and month 6).

    I do like your chart on benefits and disadvantages, but would like to point out the patient disadvantages mentioned could all be avoided or minimized. Patients may feel more comfortable in their home setting without the rush sometimes experienced in the clinic and hence, more prone to discussing all issues; If we minimize technology requirements we could even remove the need for high speed internet connections as a percentage of rural patients have limited access; and again the patient can elect not to participate in telemedicine. It is wrong to pressure participation and unlikely to be successful.

    The physical exam limitations of telemedicine today can be improved with proper education of patient self-exams of access and signs of volume overload, supplemented by the ability to forward photos as indicated.

    Again thank you for this important blog, we have much to learn but the future is exciting.

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    • Beth Witten

      Dec 23, 7:59 AM

      Thank you for your comment, especially for pointing out the once every 3 months visit vs. quarterly. I hadn't considered how that might be misinterpreted. Also, that you for pointing out how what some might consider negatives might not be negatives for others or can be overcome.

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