Telehealth and Home Dialysis: Past, Present and Future

Telehealth and Home Dialysis

Long before the COVID pandemic, home dialysis patients had advocated for freedom from monthly in-person clinic visits. Benefits of home dialysis include greater flexibility for when and how dialysis is done, which allows more patients to work full-time jobs and travel. Having to go to a clinic during a home dialysis clinic’s operating hours—typically during most business’ work hours—or having to choose travel dates around in-person clinic visits stifled that freedom.

Finally after years of advocacy and letter writing by providers and patients to CMS and congress, on February 9, 2018, the Bipartisan Budget Act of 2018 became Public Law 115-123. This law requires any new home dialysis patient to have face-to-face visits with their doctor for a “clinical assessment” for the first 3 months of home dialysis. After that, if the patient chooses to have ESRD clinical assessments by telehealth, the patient only needs to have one face-to-face doctor’s visit per quarter, with the other two by telehealth from the patient’s home or other location.

The CARES Act since waived face-to-face visits for home dialysis patients who choose to use telehealth until September 30, 2025. Medicare pays no more for home dialysis patients who use telehealth for clinic visits. Dialysis clinics are paid a flat rate for in-center and home patients under the ESRD prospective payment system (PPS), and nephrology practitioners are paid a flat rate under the Medicare monthly capitation payment system whether patients are seen in-person or by telehealth. Telehealth visits may even save patients and providers time and effort while improving patients’ quality of life.

Telehealth Definitions

In 1997, the World Health Organization defined telehealth as ”the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of healthcare providers, all in the interests of advancing the health of individuals and their communities.” ¹

The U.S. Health Resources and Services Administration (HRSA) under the Department of Health & Human Services (DHSS) defines telehealth this way: “…the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, and public health and health administration. Technologies include videoconferencing, the internet, store- and-forward imaging, streaming media, and landline and wireless communications. ²

A Telehealth Timeline

Who knew that telehealth and telemedicine had such a long history?

• As far back as 500 BC Romans and Greeks communicated warnings about plagues by means of fire and light.

• In the 1940s and 1950s, doctors sent X-ray images by telephone.

• In the 1960s, NASA monitored animal health and wellbeing in space, Nebraska psychiatrists provided counseling to patients using the TV, and the Miami fire department and the University of Miami worked together to send rescue victims’ ECGs to Jackson Memorial Hospital.

• In the 1970s the first telemedicine conferences were held and published, and the Indian Health Service and NASA collaborated to send Arizona Native Americans’ ECGs and X-rays by microwave to the Public Health Service hospital.

• In 1983, the birth of the Internet led to establishing standards of communications.

• In the 1990s, Dr. Jay Sanders, founder of the American Telemedicine Association (ATA) and consultant for NASA, created Georgia’s telemedicine system, a telemedicine program for prisons, and telemedicine in homecare that he called the Electronic House Call. The nonprofit ATA was established to grow telemedicine and provide patients greater access to healthcare.

• In 1994, Dr. Rashid Bashshur co-founded the Telemedicine Journal and later sent Congress three telemedicine reports.

• In 2009, the American Recovery and Reinvestment Act (ARRA) was passed, which led CMS in 2010 to define the “meaningful use” of electronic health records as “the use of certified EHR technology in a meaningful manner, such as prescribing medication and improving quality of care.”

• In 2016, HRSA was funded to use telehealth to expand access to healthcare in rural areas. ³

Public Education About Telehealth

A government website provides public education about telehealth and how it allows an individual to visit with, send messages to, and track and send health data to their doctor or other healthcare provider using a computer, tablet, or smart phone. According to the site:

“Having a telehealth visit is just like a regular visit, but you are in one place and your health care provider is in another. While you may need to see your health care provider in person sometimes, telehealth has many benefits:

• It keeps you and others from getting sick by being close to each other.

• You can see your health care provider anywhere: home, work, or even your car.

• It saves time because you don’t need to travel, take time off, or find someone to watch your kids.

• You may get an appointment faster.

• You have more choices. You can have a visit with a health care provider who may be far from you.

Telehealth may not be right for everyone or every health care condition. Always talk to your health care provider if you have questions or concerns.”⁴

Telehealth and Medicare

Medicare paid for telehealth services starting in 2010, but limited patients who could receive telehealth services under Medicare to those living in rural areas who went to a specific kind of facility. Communication could be only by two-way audio-visual technology with certain types of providers who were located at a distant site. These barriers limited telehealth use under Medicare.

Legislation for Telehealth During and After the COVID Public Health Emergency

In March of 2020 when COVID was declared a public health emergency, President Trump issued an executive order that eliminated many of the pre-pandemic barriers, making telehealth available to anyone anywhere. These laws included telehealth provisions:

• 2020

  • The president declared the COVID pandemic a public health emergency (PHE) and allowed Medicare to waive many pre-pandemic barriers to telehealth use.

  • Congress passed and the president signed the Coronavirus Preparedness and Response Supplemental Appropriations Act allowing Medicare to cover telehealth from a qualifying provider and waiving geographic requirements for originating sites.

  • Later Congress passed and the president signed the Coronavirus Aid, Relief, and Economic Security (CARES) Act waiving periodic in-person visits for home dialysis patients who chose to use telehealth for monthly clinical assessments.

• 2021

  • Congress passed and the president signed the Consolidated Appropriations Act of 2021 allowing Medicare to permanently pay qualified mental health providers for telehealth services to evaluate, diagnose and treat mental health conditions by phone. (This law also established Medicare Part B-ID that covers immunosuppressive drugs only for those without health coverage who lose Medicare 3 years post-transplant. Patients pay a premium, a Part B annual deductible, and 20% coinsurance.)

  • CMS issued the 2022 Physician Fee Schedule Final Rule that expanded some telehealth services and extended Medicare coverage until the end of the PHE or December 2023. The PFS said that would allow time for CMS and stakeholders to decide if telehealth services should be covered by Medicare permanently.

• 2022

  • Congress passed and the president signed the Consolidated Appropriations Act of 2022 extending coverage of telehealth services for 151 days (5 months) after the PHE ends.

• 2023

  • Congress passed and the president signed the Consolidated Appropriations Act of 2023 extending telehealth services by qualified providers, Federally Qualified Health Centers and Rural Health Clinics under Medicare to December 31, 2024.

• 2024

  • Congress passed and the president signed the American Relief Act of 2025 that extended telehealth provisions through March 31, 2025.

• 2025

  • Congress passed and the president signed the Full-Year Continuing Appropriations and Extensions Act, 2025 (the “Continuing Resolution of 2025”) on March 15, 2025. It extended all the telehealth waivers through September 30, 2025.

The Future of Telehealth for Home Dialysis

No one can predict what will happen after September 30, 2025 as far as the pre-pandemic requirement for home dialysis patients to have face-to-face doctor visits for 3 months and then one face-to face doctor’s visit/quarter with the other two visits by telehealth. And no one knows whether Medicare will continue to cover any telehealth services after that date. Anyone who appreciates being able to use telehealth for physician visits should contact* their Senators and Congressperson and urge them to:

• Support making Medicare telehealth coverage permanent for at least the “qualified providers” listed in the most recent law.

• Allow coverage no matter where a patient is located (urban, suburban, or rural) located.

• Allow patients’ visits with providers to be by any two-way communication, including audio-only.

Doing all these things would go a long way to break down barriers to telehealth services to Medicare beneficiaries. H.R.1407 – Permanent Telehealth from Home Act would remove geographic requirements and make Medicare coverage of telehealth permanent. Making Medicare telehealth coverage permanent would be a win for all.

*Tips for Contacting Your Representatives

It may seem intimidating to contact elected officials, but they are just people like you who may even be your neighbor. Their job is to represent all of their constituents. And most important of all, your advocacy efforts may help not only you and/or your home dialysis patients, but every Medicare beneficiary in the U.S.

Whether you call or write, elected officials keep records of constituents’ contacts. Make it easy for them by starting your message or letter with the topic. Be respectful. Personalize your message with benefits of telehealth and/or burdens of not having it. Be specific about what you want your elected official to do, e.g.:

• Support making telehealth permanent

• Eliminate geographic requirements

• Allow any Medicare provider to use telehealth

• Allow communication using any 2-way technology including oral-only.

• Ask your Congressperson to cosponsor H.R. 1407 with an amendment to include all Medicare providers and any 2-way communication, including oral-only.

• Ask your U.S. Senators to introduce a bill that includes the provisions above.

• Thank your elected official for supporting this important issue.

Tips for Phone calls:

• Include your name, address and phone number.

• You may talk with a staff member or have to leave a message.

Tips for Letters:

• Include your name, address and phone number and signature.

• Address a letter to The Honorable (first and last name).

• Keep your message short (if written, 1 page or less).