By Eric Wicklund, mHealth Intelligence | July 11, 2019

President Donald Trump’s executive order targeting new methods for detecting and treating kidney disease could expand the opportunities for those using telehealth and mHealth.

The executive order, signed on July 10, aims to change how the nation’s healthcare system treats end-stage renal disease, and how providers are reimbursed for that care. As such, it opens the door to, among other things, home-based dialysis programs that use remote patient monitoring technology for care management and transplant programs that use telehealth to improve organ procurement and post-operative recovery.

The goal, officials say, is to incentivize the healthcare industry to improve outcomes, rather than simply paying them for services rendered.

“There may be no better example than kidney care of how government domination of healthcare can sideline patients, discourage innovation from providers, distort payment incentives, and focus only on paying for treating sickness, rather than preventing disease and supporting health,” Health and Human Services Secretary Alex Azar said in a press release.

“For decades, across all of American healthcare, and kidney care in particular, the focus has been on paying for procedures, rather than paying for good outcomes,” he pointed out. “We need to flip that around: We’re going to start paying providers for better health outcomes, rather than procedures, and we’re going to pay for health, rather than simply paying once people are already sick.”

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Among the initiatives outlined in the executive order is a mandatory payment model known as ESRD Treatment Choices, which, according to Azar, “will give about half of all dialysis providers new incentives to encourage dialysis in the home.”

That could very well include telemedicine platforms that help providers keep track of their patients at home, such as in RPM programs that relay vital signs and other data from the home to the care provider and allow for on-demand communication and care management.

Roughly 30 million Americans, or 15 percent of the adult population, are affected by chronic kidney disease. Of that number, more than 660,000 have kidney failure, and almost 470,000 are on dialysis. More than 193,000, meanwhile, have a functioning kidney transplant, which requires them to follow a very strict daily medication regimen.

According to the National Kidney Foundation, telemedicine offers a promising alternativeto in-person care, most often delivered in a doctor’s office or dialysis clinic. Clinicians can remotely monitor a patient’s blood pressure and other vital signs, as well as offering resources for medication adherence and diet plans.

More importantly, nephrologists and nephrology nurses can coordinate care online with a patient’s primary care provider (a model now being used by the Indian Health Service) and interact at home with patients undergoing hemodialysis and peritoneal dialysis, offering on-demand care between regularly scheduled office visits.

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One such program was launched in 2016, the result of a partnership between the University of Alabama at Birmingham School of Medicine and the Alabama Department of Public Health. The program places telemedicine carts in rural health clinics, along with Bluetooth-enabled stethoscopes, to enable nephrologists to conduct virtual visits with patients on dialysis.

“(W)hat these dialysis visits mean for Alabama is what I’m most excited about,” Eric Wallace, MD, an assistant professor of medicine at UAB and one of the nephrologists providing telehealth services,” said in a 2016 story prepared by UAB. “If I can provide a fully comprehensive telehealth visit for a home dialysis patient — which is one of the most complicated visits to do — then I can do this for any patient and virtually any disease. It means that the subspecialty and super subspecialty care that may only be available in a university setting, such as rare diseases, can now be extended to every corner of Alabama, thus increasing the quality of care of patients in Alabama. The gaps in care and education that telehealth can bridge are tremendous and incredibly needed in Alabama.”

“There are so many patients in our state who have little to no access to subspecialty care like nephrology and have limited access to home dialysis care, and that’s the reason we are doing this,” said Wallace, who estimates a quarter of his patients have to drive an hour or more to see him. “As soon as telehealth carts are deployed, UAB physicians could get to any county in the state. My goal is to have some traditional clinics where I’m in my clinic office, and then connect to ‘be in’ several county health departments seeing other patients with telehealth. You could be in multiple places within a normal half day of clinic.”

While Trump’s executive order suggests the potential for connected health, some in the industry were concerned that it didn’t come right out and make digital health a priority.

“I would have liked to see greater emphasis placed on how technology can enable this, and specifically the ways RPM and telehealth care play a central role in the stated objectives of this initiative,” Drew Schiller, CEO of digital health company Validic, told mhealthIntelligence in an e-mail. “Technology today is sophisticated enough to manage patients remotely. With smartphones and health devices being utilized at mass alongside advancements in interoperability and data science, we have the tools to monitor patients. We have the demonstrated ROI that these programs can reduce hospitalizations, disease progression, and the development of co-morbidities. At the end of the day, physicians want to stay in their workflows and patients want to stay in their homes. Data flowing from the patients’ home into the clinicians’ workflow allows for better real time, proactive management of conditions.”

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“Value-based care is here,” he added. “We’re actively moving from a system that is ‘paying for sickness and procedures’ towards one that is ’paying for health and outcomes.’ This is empowering for patients and providers alike, because financial incentives are beginning to align with the shift. As we push forward to align incentives and payment model, it’s become clear that organizations need deeper guidance from (the Centers for Medicare & Medicaid Services) on implementing these new models.

Healthcare providers using telehealth in home dialysis programs got a bit of good news in last year’s federal budget, which included elements of the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act. Included in the budget bill was language adding the patient’s home to the list of freestanding dialysis facilities that a nephrologist could use telehealth to visit, and for which he or she could be reimbursed through CMS.

Congress is also trying to tackle the issue.

In May, US Senators Benjamin Cardin (D-MD) and Roy Blunt (R-MO) reintroduced The Chronic Kidney Disease Improvement in Research and Treatment Act of 2019 (S. 1676), which aims to, among other things, improve care management for kidney disease treatment through the use of telemedicine.

“New technologies are changing outcomes for chronic kidney disease patients, but those treatments are out of reach physically and financially for too many in this country. We can do better and, in the process, save lives and improve quality of life for millions,” Cardin said in a press release.

Finally, health systems like UAB and Vanderbilt are using telehealth to improve the kidney transplant process, both before and after the transplant.

At Vanderbilt University Medical Center, specialists are using telemedicine technology to connect with a clinic in Jackson, some two hours distant, to screen candidates for kidney transplants and help conduct monthly checkups.

“We will see patients who have been referred to us for kidney transplant in an effort to save them at least one trip to Vanderbilt,” Rachel Forbes, MD, an assistant professor of surgery and surgical director of the living donor transplant program at Vanderbilt, said in a press release. “We are hoping this will be a valuable tool for those patients who have a distance to travel.”

“This option will allow patients real-time assessments without the burden of travel,” she added. “We will have documents from their referring physician and information provided during the intake process. We can get a thorough history and a very good sense of any issues and determine further testing that will be required for evaluation.”

UAB, meanwhile, has expanded its connected care program for home dialysis patients to include transplant recipients.

“Being able to see the patients via telehealth not only saves them time, but also reduces the stress of having to make plans to travel for their annual appointments,” Clifton Kew, MD, medical director of the Kidney and Pancreas Transplant Program in Birmingham, said in a news release issued by UAB. “II hope this will make it easier for patients to keep their appointments so we can make sure their health is continuing to improve.”

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