DaVita Medical Insights
How the COVID-19 Pandemic Has Affected Kidney Care
According to Leslie Wong, MD, chief medical officer for the Nephrology Care Alliance (NCA) and practicing nephrologist at the Cleveland Clinic, during the pandemic, “…It's really incumbent upon us to stay united as health care providers. Remain positive, not just for each other, but for our patients, and make sure that we also help and celebrate when things go right.” Listen to this podcast, in which Sarah Carpenter interviews Dr. Wong on how COVID-19 has affected health care, in general, and kidney care, in particular. Dr. Wong discusses the impact of COVID-19 on clinician use of telehealth, the need to move care upstream to patients with chronic kidney disease (CKD), the adoption of value-based care models, the roles of patient education and predictive analytics in managing kidney care, and the communities of patients, families, caregivers, and nurses and other health care professionals. He also provides information on how NCA can help nephrologists address some of these challenges.
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Sarah Carpenter (00:45): Hello, everyone. Welcome to the DaVita Medical Insights podcast. My name is Sarah Carpenter. I'm a teammate with Nephrology Care Alliance and I'm joined on the phone today with Dr. Leslie Wong, the Chief Medical officer for Nephrology Care Alliance. Hi, Leslie. Thanks for joining.
Dr. Leslie Wong (01:00): Yeah, absolutely. Sarah, happy to be here.
Sarah Carpenter (01:02): So I have a few questions for you. The first is, what has been your focus during the pandemic?
Dr. Leslie Wong (01:08): Yeah, so while I am a chief medical officer for Nephrology Care Alliance, I'm actually, still a practicing Nephrologist at Cleveland clinic, so I kind of have a few different roles there. So it's been a very busy time as a physician leader. And in terms of interacting and orchestrating with teammates at DaVita, but also seeing my own patients and seeing the challenges that they've gone through as well as my colleagues at the hospital.
Sarah Carpenter (01:42): Yeah. Thank you for sharing that there has been an emphasis on telehealth throughout COVID-19. How can clinicians better leverage telehealth to engage with patients?
Dr. Leslie Wong (01:52): I think it's valuable to kind of step back and just think about how the pandemic kind of affected health care in general. I think especially in March and in April, when we really experienced the surge in the Northeast and really started seeing come to grips with how COVID was hitting the United States. I think that things that we thought could never happen or impossible, all of a sudden reality. And one of, again, the important things I think that everyone remembers and still it really preoccupies us today is how do you limit exposure to the virus? Not only for patients, but for health care workers. So I think the pandemic was really unique, at least in my medical career where, we're used to treating people with disease.
Dr. Leslie Wong (02:48): We're not actually in the habit of thinking of how something that we're treating could actually affect us and actually harm us. And I know I've been really struck by all the testimonials, stories and collages of health care professionals, doctors, nurses, EMT, et cetera, they've actually succumb to COVID.
Dr. Leslie Wong (03:09): So I think that, that's an important kind of background to acknowledge as we think about telehealth. So with this, really important need to limit exposure and transmission of the virus, the government enacted, these broad waivers across, various aspects of health care. But importantly that allowed clinicians in different categories of health care to be able to deliver and being reimbursed for telehealth services. So, again, not only to prevent transmission from an infection control standpoint, but also the reality is that, as people, even physicians were under quarantine. Or unable to use public transportation, but still with the need to have their medical conditions look after to speak with a health professional, telehealth is a technology that, that enables is really, really critical.
Dr. Leslie Wong (04:16): So, being able to actually do that was and still is a tremendous benefit for our patients.
Sarah Carpenter (04:23): Yeah. That's great. And what measures did Nephrology Care Alliance or NCA take to help with it?
Dr. Leslie Wong (04:30): Yeah. So, One of the things that's important to understand is that prior to the pandemic, in order to participate in telehealth, there were very strict regulations and rightfully so. Privacy making sure that the data transmission was secure so that, people's information wasn't compromised. All those things were in place, but because of the extenuating circumstances with the pandemic, you really saw a kind of a broad relaxation of these guidelines. So it was actually permissible to use things like FaceTime and these kind of non-traditional platforms to deliver telehealth. Which actually would in some instances made it easy, but also, brought up a lot of other concerns and certainly larger health systems like Cleveland Clinic and other hospital systems already had telehealth systems in place, but had never had or utilized in the manner that this pandemic brought.
Dr. Leslie Wong (05:35): So all of a sudden you had a lot more demand and then a lot more interests and then a lot more confusion about like, well, what's the right platform to use? What's the safest platform to use the most secure? And what's the most reliable? You can imagine a physician's office, a practice, just thinking about, well, listen, how... First of all, I don't have access to my patients. I'm now just processing all of these new telehealth waivers. I see the benefit of getting to patients, but it doesn't matter what I have. If they're not able to log in to my telehealth platform or they don't have say an iPhone, they can't use FaceTime. What do we do? So what we realized early on with... And where we thought NCA could really make a difference is that the Nephrologists were very much overwhelmed, not just with, processing information about the pandemic. But just all the different changes that accompany that.
Dr. Leslie Wong (06:43): And so trying to actually figure out what is a telehealth platform to choose? What works? What are the features? I mean, these are things that there weren't enough hours of the day to do. We saw many Nephrologists that were just basically taking up either the first solution that came to them, or we're kind of inundated with a lot of advertisements. And had a lot of, different options that they didn't really understand it. And really felt like uncomfortable, committing to. So, I think the big thing that NCA did was that we recognized the need and we really pivoted the entire team to do a very broad, extensive search. And again, using a lot of the resources that we had within DaVita, kind of tapping on social strategy and other folks that look at that segment of this technology in the health care field, really try to identify and narrow down the field for our members.
Dr. Leslie Wong (07:51): So I think over the course of about two weeks, we were able to meet with review, research, a limited number of telehealth vendors. And we were really struck and impressed by a company called Mend, they really had a... Not only a physician friendly interface, but also very patient friendly one as well. So we were able to negotiate a kind of a special rate and plan for a Nephrology practices so that they could quickly implement and sign up for a telehealth platform. And it start immediately taking care of their patients. And I think the big value for our members is that they could trust that not only they were signing up for something with no kind of, no strings, but really that we done our due diligence and research for them. Because really it was about how do we position them to start taking care of their patients as soon as possible.
Sarah Carpenter (09:09): That's great. It sounds like a lot of work went into that. And so I think it's a really a value add. Speaking of patient care, how has COVID-19 brought forth the need for upstream care for patients with CKD?
Dr. Leslie Wong (09:23): Well, unfortunately I think it's really highlighted some of the negative aspects of keeping people in isolation and away from the hospital. So, obviously we don't want the patients to be admitted to the hospital. We don't want them moving around visiting family unless it's absolutely necessary. And indeed, in many health care systems of hospitals, there were mandates that any elective surgeries, procedures, those things, those were not actually permitted for safety reasons. And furthermore, a lot of preventative health care interventions, vaccinations, cancer screening, those things were not considered essential.
Dr. Leslie Wong (10:15): So patients were actually kind of discouraged. Or those things were not being scheduled. I think what really came to life was that, there wasn't a need for patients with chronic conditions, not only kidney disease, but heart disease, lung disease, diabetes know conditions that before the pandemic really required, close and regular follow up with physicians. And nurse practitioners in order for patients to remain healthy. Those visits also went down. And so what you saw was that it wasn't just the surgeries and procedures. It was the outpatient visits that really, really kind of almost went away. And some of those of course were things that could potentially in the short term be put off. But other things are really necessary care. And, I experienced that patients, even though they knew they needed to come in. They were actually scared because they didn't want to go to the doctor's office because that's where sick people were.
Dr. Leslie Wong (11:22): They didn't want to go to the hospital because they were afraid of contracting COVID there. So I think what you saw from a health system perspective, is that the actual amount of energy and resources that we were spending on COVID went up tremendously, but everything else went down. And while that actually, on the surface looks like it's good that you're spending less resources on health care. I think universally, we think that, that's actually bad or that was bad because people aren't getting the kind of preventative care that they need.
Dr. Leslie Wong (12:00): Again, as we discussed earlier, telehealth was a way that some of that need was met and we mitigate it to that risk. And in fact, at places like Cleveland Clinic and others, I mean the amount and volume of telehealth went up astronomically or exponential, I should say, compared to prior to the pandemic. But still, probably wasn't the same as before. I think as the situation changed, at least locally, where I practice, the in-person volumes quickly ramped up once kind of restrictions were lifted and locked hours and stuff became relaxed.
Dr. Leslie Wong (12:45): But I don't know, if we absolutely know the end effect of that. So it's certainly something that is top of mind for many physicians, like the biologist who take care of patients with chronic conditions. And I should add that, one of the things that we think, and we know when we talked with our Nephrology Care Alliance physician leaders, we have a very highly engaged advisory board. And other physicians that we often speak to for input. And what they said was that the one thing that's really critical for managing and taking care of people with kidney disease is education. And had a discussion about how COVID is affected education for our children. But COVID really had a negative and dampening effect on disease education. Because, at the end of... That's like the first thing that goes because people don't think it's essential. And again, short of telehealth or the right type of equipment and connection from the patient it's really hard to do over the telephone.
Dr. Leslie Wong (13:52): So I think those are things that we are very conscious of right now. I don't know if we know the effects yet because they're still in some degree ongoing.
Sarah Carpenter (14:00): How do you think COVID-19, had an effect on conversations of value based care and that continued conversation of adoption and changing?
Dr. Leslie Wong (14:08): Yeah, that's a very timely question Sarah. So one of the things that we do at Nephrology Care Alliance is, we're trying to help Nephrologists succeed with value based care, whether it's with government programs. Or with private health plans. And I think before COVID, kind of following the advancing American kidney health executive order in July, of 2019, it's kind of unprecedented excitement and conversations in the kidney community about the new government models. And speaking of what's called kidney care choices. So they're basically two programs, they're administered by CMS, that's centers for Medicare and Medicaid services.
Dr. Leslie Wong (15:08): And specifically by something called CMMI, which is a center for Medicare and Medicaid innovation. And basically what the kidney care choices model are a weekly, the government sponsored innovation model for transforming kidney disease. So looking not only at the care of patients that are on dialysis, but importantly, moving up the screen to the care of patients with late stage chronic kidney disease. So we call stage four or five. So these are people that have kidney disease from hypertension, diabetes, and other causes, but they're not yet on dialysis. So it's kind of a really critical period where nephrologists can intervene. And as I mentioned, provide education that allows, kind of a shared decision making process. So, and we think that--And we actually have data, plenty of data, not just in the US but internationally that it's, that those interventions are done early enough during the.. In chronic kidney disease, patients are more apt to be transplanted. They're more apt to choose a home dialysis options and more apt to choose conservative measures and palliative care when that's appropriate.
Dr. Leslie Wong (16:28): So I think that those models generate a lot of excitement, but what happened though, was around February or March, when the pandemic really started to come to the United States, there was... Everything was kind of put on hold, right? So, really the talk on the government side was about the emergency waivers, and all the different changes and including telehealth, but also other things in terms of how were we were kind of forced to change our daily kind of routines. And prioritize things differently. So I think there was a great deal of uncertainty if value based care, what the status was going to be. But know now is that as things have kind of... They haven't, again, we're not out of the woods by any means with, some of the resurgence in different areas in the country. But CMMI, did release finally kind of a delayed timetable, but basically they pushed the models back several months, but they were actually ongoing.
Dr. Leslie Wong (17:44): So I think in terms of what NCAA is doing, how we're trying to enable value based care, it's kind of like the reset button has been pushed. So we're really actively engaging with a lot of the nephrology practices, nephrologists and other stakeholders, at a national level in terms of how they can participate, how they can succeed. And how to kind of navigate all the question marks that come with kind of large scale transformation and change.
Sarah Carpenter (18:19): So I think one tool that can be really important with value based care is predictive analytics. How do you see predictive analytics playing a role in managing kidney care, especially during COVID-19?
Dr. Leslie Wong (18:32): Well, I think the role of predictive analytics technology and data has never been clearer. That is... I think, on one side, if we go back just to talking about the new kidney choices models, there are some things in terms of program requirements, which really kind of obligate Nephrologists to see their patients at maybe a higher frequency.
Dr. Leslie Wong (19:06): And then, what had been done in the past. So you definitely need the right kind of data systems, so they can track your patients and make sure that they're coming in. But I think more importantly at a time when, seeing a patient face to face, isn't something that you can take for granted any longer. Making sure that you get the right patients in at the right time has never been more important. So the predictive analytics allows us to use lab data, demographic data, that is the patient's age, some other demographic information to help us kind of predict the risk of an event like transitioning to dialysis. Now, that seems like intuitive, that you would want to use some type of model like that, but across the United States, that's not kind of the standard of care. Even though we have the ability to calculate it and calculate those numbers.
Dr. Leslie Wong (20:09): And oftentimes it's because those formulas and equations are things that even if they're available on your phone or on your desktop, they're not built into the workflow of the electronic medical record. So, things like that NCA offers like our CKD insights, a population health platform, this is built in. So it really enables physicians to more kind of readily identify patients that they take care of that are at a higher risk for transitioning to kidney failure. And I think that's important because not all patients are the same. So even patients that have, for example, the same lab values, depending on, for example, how much protein is in their urine. Depending on some other factors, which we can again, get from these models, they may actually be at a higher or lower risk. So, again, obviously the patients that's at a higher risk, you want to see more frequently. You want to perhaps be more aggressive in terms of your interventions.
Dr. Leslie Wong (21:21): And, you want to really kind of be more intensive in terms of education and meeting their needs. Someone who's left kind of apt to progress still has to be followed. And, but maybe can be a little bit of a lower priority. And that's not to minimize the importance of seeing them. But again, patients will tell you, doc, I don't want to have to come in to see you one more time than I have to, right. So, and again, especially with all the conditions today, making sure that offering those patients telehealth. Or say, Hey, listen, we can get your lab work. You don't have to come in. But we're still keeping a very close eye on you.
Dr. Leslie Wong (22:02): I think that's a very reassuring message for patients.
Sarah Carpenter (22:05): Thank you, dr. Wong for joining today and for being a leader on the NCA team during this COVID-19 pandemic. This pandemic has impacted a lot of people. We want to acknowledge the patients and families who have been touched by COVID-19 and what they've been through.
Dr. Leslie Wong (22:20): Yeah, absolutely. Sarah, I think we should… And I think it's actually really important that we do that. Not just the people that have been affected and survive the virus. Families, caregivers, our nurses, other health care professionals that have been so courageous and selfless in giving their time and their hearts in terms of caring for others. It's been really tough. I think for communities, particularly for the health care community, we've seen actually paradoxically people being laid off in health care because of some of the asymmetry in terms of where we're putting our resources.
Dr. Leslie Wong (22:58): But I think it's really incumbent upon us to stay united as health care providers. Remain positive, not just for each other, but for our patients. And make sure that we also help and celebrate when things go right. Because we're still really deep in this, but there will be an end at some point. And important that we're there in charge and giving support for people that need it.
Sarah Carpenter (23:26): Listeners, thank you for tuning in be sure to check out other DaVita medical insights episodes for more kidney care educational podcasts. You can also find additional kidney care thought leadership and industry news following @DaVitaDoc on Twitter.