JOURNAL OF THE INTERNATIONAL SOCIETY FOR TELEMEDICINE AND EHEALTH
Donnelly L, J Int Soc Telemed eHealth 2017;5:e6 1
TELEHEALTH IS A VIABLE ALTERNATIVE FOR THE TREATMENT AND ASSESSMENT OF HOME PERITONEAL DIALYSIS, STROKE AND CHRONIC CARE AND AS SUCH SHOULD BE REIMBURSABLE BY MEDICARE
Linda Donnelly RN
George Washington University, USA
Abstract
Telehealth has been shown as an effective method to improve access to care for rural patients who often travel long distances for their care. Medicare reimbursement however has been restricted to care provided through synchronous communication at a Medicare approved designated site. Proposed legislation that seeks to expand the use of this proven technology will offer respite to persons requiring chronic care, frequent home peritoneal dialysis as well as expedited assessment and treatment for those experiencing stroke signs and symptoms. In addition, to the improved quality of care, the cost savings associated with reduced readmissions for this population, makes it a viable option to be supported.
Keywords: telehealth; chronic care; renal dialysis;
stroke; reimbursement
Current Issue
Limited access to care in the United States is a widespread problem, especially in rural communities.
Fewer than ten percent of the nation’s doctors practise in rural areas making it necessary for many rural patients to travel a long distance for healthcare services.1 This increased burden to patients suffering from chronic conditions, which require more frequent monitoring, compounds the problem. To help alleviate some of these obstacles, Medicare now covers telehealth services provided in a rural Health Professional Shortage Area involving real time communication but its use can be broadened to further improve access to care.
Proposed Change
The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, introduced in February 2016, seeks to expand the
use of telehealth coverage under Medicare.2 The bill, sponsored by Senator Brian Schatz and Senator Roger Wicker, is looking to eliminate some of the limitations associated with originating sites and reimbursable codes which are currently restricting some remote patient access. In addition, it would allow for at-home dialysis monitoring for end stage renal failure, telestroke assessment and chronic patient monitoring for providers that are participating in the Medicare Access and CHIP Reauthorization Act (MACRA) programme which ties reimbursement to quality reporting. The projected savings associated with implementation of the CONNECT for Health Act are estimated at $1.8 billion over a ten year period.3 Current Practices
As defined by the federal Health Resources and Services Administration (HRSA), telehealth is “the use of electronic information and telecommunication technologies to support long distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the Internet, store-and forward imaging, streaming media and terrestrial and wireless communications”.4 Telehealth services that are currently eligible for re-imbursement must involve synchronous communication when the patient is present at an originating site such as a doctor’s office, rural health clinic, hospital, dialysis centre, skilled nursing facility or community mental health centre. Several additional requirements must be met such as the location of the originating site, having admitting privileges in the remote location and physician licensure recognised by the remote location’s state for reimbursement to be approved.5 Two exceptions of the synchronous communication regulation are noted for Alaska and Hawaii which are allowed “store and forward” technology, in which medical information is sent out to the practitioner for review at another time.6 Support for Change
JOURNAL OF THE INTERNATIONAL SOCIETY FOR TELEMEDICINE AND EHEALTH
Donnelly L, J Int Soc Telemed eHealth 2017;5:e6 2
The American Heart Association reported that in 2013, 6.5 million deaths were attributed to stroke, with 59%
of them occurring outside of an acute care hospital.7 The inclusion of telestroke as a covered treatment option would facilitate rapid identification and treatment of ischemic stroke, which occurs when a blood clot prevents blood flow to the brain. As per the American Stroke Association timely treatment may minimise the long term effects of stroke and prevent death.8 Clot dissolving medication can only be administered if the patient receives treatment within three hours of the start of symptoms. Implementing satellite stroke units in rural areas will allow neurologists at acute care settings to diagnose, direct interventions and monitor the patient’s care remotely. As an Italian study reporting outcomes for patients who received care by telehealth methods versus seeing a provider in person found they both received the same standard of care, telestroke would be a practical solution to improving access to care issues for many rural Americans seeking care for stroke.9
Peritoneal Dialysis is an effective treatment option for many end stage renal disease patients, however, monthly physician monitoring is required to evaluate effectiveness, adjust dialysate concentrations and diagnose/treat complications. Telehealth assessment will eliminate two thirds of the travel requirements to their physician’s office, improving the quality of life of these compromised patients. A two year study in Spain found that physician consultations were reduced from a mean of 33 minutes for “in office” to 22 minutes by telemonitoring. Both methods assessed catheter exit site and identified oedema equally. While the estimated cost of telemedicine was slightly higher, the mean hospital admission rate was significantly lower with telehealth patients admitted 2 days per year as opposed to 5.7 days for “in office” assessments.10
The National Vital Statistics Reports ranks the top ten causes of mortality with three chronic conditions noted as congestive heart failure- CHF (1st), chronic obstructive pulmonary disease- COPD (3rd) and diabetes mellitus- DM (7th).11 A two year analysis based on Medicare mortality data for CHF, COPD and DM compared mortality and admission rates between traditional care and a CMS sponsored program called Health Buddy Program (HBP) which integrated care with telehealth services. It was found that the mortality rate for the HBP patients was 15% lower and admissions 18% lower than the patients who received traditional care.12 A Taiwanese study on patient
satisfaction reported on interviews with patients who used telehealth for chronic disease care. Their responses addressed perceived support and security, enhanced disease self-management, concern with using the devices and worry about cost. Positive feedback highlighted convenience, immediate access, feeling safe and empowerment. Concerns were identified regarding device reliability and reasonable costs.13
How do the health providers feel about telehealth?
Shulver et al found positive responses from rural providers who welcomed utilising this technology to expand access and support patient’s needs. They felt telehealth was a safe alternative and provided equal or better services for the rural population. When asked about perceived safety risks, rural providers accepted risk, remodelling their treatment plans to manage and reduce them. One plan included having support staff present that was trained to intervene if needed, on the patient side of the encounter. Of concern were meeting regulatory mandates and the costs associated with implementing and maintaining a fully supported telehealth programme in rural communities.14
Time for Change
Today’s technology offers practicable solutions to facilitate some of healthcare access to care challenges and the proposed telehealth expansions are a viable way to bridge some of the gaps. Study results have shown that regardless of the medium, traditional office visits versus telehealth, standard of care was equal for peritoneal dialysis patients. Stroke assessment was found to be expedited for patients in rural areas and mortality and hospital admissions were reduced for patients with chronic care diagnosis of CHF, COPD and DM. While a survey found most physician respondents (approximately 90%) would utilise telehealth if compensated for their services, a current study scrutinising health insurance claims found that telehealth claims were reimbursed notably lower (approximately 40%) than traditional service methods.15 Our legislators need to recognise this alternate method for provider services, passing the CONNECT for Health act directing Medicare to reimburse telehealth virtual care at the same rate as an equal in-person visit. As costs were a common concern, financial government incentives, similar to those offered to promote the “adoption and meaningful use of interoperable health information technology and qualified electronic health records” can be offered to offset start-up and maintenance costs.16
JOURNAL OF THE INTERNATIONAL SOCIETY FOR TELEMEDICINE AND EHEALTH
Donnelly L, J Int Soc Telemed eHealth 2017;5:e6 3
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Correspondence to:
Linda Donnelly
George Washington University Washington DC
Email: ldonnelly@gwmail.gwu.edu
Conflict of interest. The author declares no conflicts of interest
References
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