The Effects Of Telemedicine on Health Outcomes, Costs, and Perceptions of Care Delivery in In-Center Hemodialysis

Approximately 750,000 adults in the United States (US) have end-stage kidney disease (ESKD), where they require either dialysis or a kidney transplant in order to survive. Although in-center hemodialysis (HD) is the most common treatment for ESKD, it is associated with extremely high costs and poor health outcomes. Advances in communications technologies, combined with broad access to these technologies, have led many US policymakers and healthcare providers to champion telehealth as a way to improve access to care and to reduce costs in various healthcare settings, including the monitoring and treatment of patients with chronic disease. Until recently, regulatory barriers have effectively prohibited physicians from using telemedicine to deliver in-center HD care. This changed in March 2020, when emergency waivers issued in response to the COVID-19 pandemic allowed nephrology practitioners (nephrologists and advanced practitioner providers (APPs)) to deliver up to 4 encounters per month to HD patients via telemedicine. In the context of existing care gaps and inefficiencies associated with the current system of physician reimbursement for dialysis care, there are several ways in which telemedicine might improve dialysis care. Medicare's 3-tiered monthly capitated payment (MCP) system of reimbursing physicians for in-center HD care encourages nephrologists to see patients up to 4 times per month, often with little or no benefits resulting from frequent visits. Paradoxically, patients most likely to benefit from closer nephrology supervision (such as those recently discharged from the hospital) are, on average, less likely to be seen frequently. By reducing the amount of time nephrologists spend traveling to dialysis facilities to see patients frequently, telehealth could make it easier for practitioners to align their rounding schedules with the needs of their patients and could reduce costs associated with time spent traveling. Alternatively, if telehealth is used to replace interactions that are better conducted face-to-face (such as vascular access examinations or dry weight assessments) or to see patients frequently who don't require closer supervision, then the adoption of telehealth could impair health and increase costs. We propose 3 specific aims that will leverage the recent increase in the use of telehealth following the COVID-19 outbreak in order to assess the uptake of telemedicine for in-center maintenance HD care, to understand whether the use of telehealth for in-center HD practitioner care affects healthcare costs and patient health outcomes, and to describe patient and provider perspectives on telehealth in in-center HD. We propose a mixed-methods approach that includes secondary analyses of several large administrative dialysis databases which we will complement with semi-structured interviews of nephrology practitioners. When the current emergency waivers granting broad access to telehealth end, policy makers and the clinical community will need to determine the future role of telemedicine for in-center HD care. Our findings will inform these decisions by providing crucial information about the benefits and potential dangers of telemedicine in this setting.