Home dial­y­sis grows de­spite cost and lo­gis­ti­cal hur­dles

Modern Healthcare - - KIDNEY CARE REFORM - By Steven Ross John­son

Robert Richard­son, 46, dis­cov­ered eight years ago that his kid­ney func­tion had de­te­ri­o­rated to the point where he needed dial­y­sis. It re­sulted from glom­eril nephri­tis, a chronic con­di­tion he’s had since age 5.

“The doc­tors caught some­thing on a phys­i­cal, and they had me see a nephrol­o­gist,” Richard­son said. “The nephrol­o­gist told me my kid­ney func­tion was down around 15%.”

By fall of that year, Richard­son, newly mar­ried and work­ing as a teacher and a tour guide in Savannah, Ga., was per­form­ing peri­toneal dial­y­sis sev­eral times a day at home. The pro­ce­dure re­moves tox­ins from his blood by filling his ab­dom­i­nal cav­ity with a spe­cial so­lu­tion. After three-and-a-half years us­ing that treat­ment, Richard­son said it left him feel­ing tired. He switched to home hemodial­y­sis, in which each night he con­nects to a ma­chine that fil­ters his blood while he sleeps.

Richard­son is one of a grow­ing num­ber of U.S. pa­tients hav­ing dial­y­sis at home. Re­search shows that pa­tients on home hemodial­y­sis or home peri­toneal dial­y­sis who di­a­lyze five to six times a week have bet­ter health out­comes than those who visit an out­pa­tient cen­ter three times a week be­cause home- based pa­tients fil­ter their blood more fre­quently. But ex­perts say Medi­care pay­ment poli­cies, cost is­sues for providers and pa­tients, pa­tient de­mo­graph­ics and physi­cian com­fort lev­els have got­ten in the way of broader use.

A New Eng­land Jour­nal of Medicine study pub­lished in 2010 com­par­ing the health out­comes of pa­tients re­ceiv­ing hemodial­y­sis in a cen­ter three times a week ver­sus six times a week found that those re­ceiv­ing more fre­quent dial­y­sis had a bet­ter qual­ity of life, in­clud­ing im­proved con­trol over hyper­ten­sion and ane­mia and fewer days in the hos­pi­tal.

“Once you get some­one home, they feel bet­ter at home than they do with in-cen­ter dial­y­sis,” said Dr. Leslie Spry, a spokesman for the Na­tional Kid­ney Foun­da­tion and med­i­cal di­rec­tor of the Ne­brask­abased Dial­y­sis Cen­ter of Lin­coln. Over the past five years, Spry said he

has seen a rise in the use of home dial­y­sis. “Most peo­ple who are in in-cen­ter dial­y­sis will tell you that they are usu­ally very much in­ca­pac­i­tated after go­ing in for their treat­ment.” Home dial­y­sis users tend to re­cover in about 30 min­utes, he said.

But Dr. Ra­jnish Mehro­tra, a pro­fes­sor of medicine at the Univer­sity of Wash­ing­ton, said providers face fi­nan­cial dis­in­cen­tives that pre­vent many from of­fer­ing home-based ser­vices. “Most pa­tients do not have ac­cess to home dial­y­sis be­cause ei­ther their in­surance, mostly Medi­care, is not go­ing to pay enough to cover the costs, or (the pa­tients) lack suf­fi­cient so­cio-eco­nomic re­sources to be on it,” he said.

Some ex­perts say more end-stage re­nal dis­ease pa­tients would be served by home dial­y­sis if more clin­i­cians rec­om­mended it. Though the num­ber of pa­tients us­ing peri­toneal dial­y­sis has in­creased by about 40% over the past five years, a 2011 study pub­lished in the Amer­i­can Jour­nal of Kid­ney Dis­eases found that up to half of dial­y­sis pa­tients choose home treat­ment.

“Most pro­grams that train nephrol­o­gists don’t have enough peo­ple who are on home dial­y­sis,” Mehro­tra said. “As a re­sult, the nephrol­o­gists are not com­fort­able of­fer­ing home hemodial­y­sis, which in turn it feeds into the cy­cle of it not be­ing of­fered enough.” For providers, there are big up­front ex­penses as­so­ci­ated with hav­ing nurses train pa­tients on dial­y­sis. Train­ing for each pa­tient can take up to six weeks. Also, providers have to pro­vide on­go­ing home-based support. In most cases, clin­i­cians must have at least one face-to-face visit a month with home pa­tients to qual­ify for Medi­care’s monthly cap­i­ta­tion pay­ment.

Spry said for in-cen­ter dial­y­sis, he can train a tech­ni­cian su­per­vised by a nurse to serve three or four pa­tients at a time. In con­trast, with home dial­y­sis, his cen­ter has to pay a nurse $25 to $50 an hour to work with a pa­tient one-on-one daily for at least three weeks.

For pa­tients, the en­ergy cost of run­ning a dial­y­sis ma­chine at home can be a sig­nif­i­cant bar­rier. Also, many ESRD pa­tients live alone and are un­able to per­form the pro­ce­dure them­selves be­cause of phys­i­cal or cog­ni­tive lim­i­ta­tions. Medi­care no longer cov­ers the cost for home health nurses to visit pa­tients’ homes to help with dial­y­sis.

Still, hemodial­y­sis is more in­tru­sive. It re­quires pa­tients to set aside three to five hours for treat­ment plus travel to and from the cen­ter three times a week.

One year of hemodial­y­sis can cost up to $72,000, while a year of peri­toneal dial­y­sis costs about $53,000, ac­cord­ing to in­for­ma­tion from the U.S. Re­nal Data Sys­tem.

De­spite cost and lo­gis­ti­cal chal­lenges, the use of home dial­y­sis, par­tic­u­larly peri­toneal dial­y­sis, is grow­ing. Large dial­y­sis providers such as Fre­se­nius Med­i­cal Care and DaVita Kid­ney Care are mov­ing to in­crease the share of their pa­tients who re­ceive home treat­ment. Large providers are bet­ter-po­si­tioned to bear the up­front costs as­so­ci­ated with home dial­y­sis, know­ing that serv­ing th­ese pa­tients at home even­tu­ally will re­duce costs.

Keith Lester, vice pres­i­dent of home ther­apy ser­vices for Fre­se­nius, the largest U.S. dial­y­sis provider, said his company has in­creased the per­cent­age of its pa­tients re­ceiv­ing home dial­y­sis from 6% in 2008 to 11% by 2014.

For DaVita, peri­toneal and home-based hemodial­y­sis rep­re­sented 16% of the company’s to­tal rev­enue in 2013, ac­cord­ing to the company’s an­nual re­port.

That’s still far be­low the level of home dial­y­sis in the U.S. decades ago. In 1972, 40% of dial­y­sis in the U.S. was per­formed in a home set­ting, ac­cord­ing to the U.S. Re­nal Data Sys­tem. By 1980, the rate had plum­meted to less than 5%.

U.S. be­hind other coun­tries

Home dial­y­sis is used sig­nif­i­cantly less in the U.S. than in some other coun­tries. Only about 8% of the more than 400,000 dial­y­sis pa­tients in the U.S. are on home dial­y­sis. In con­trast, eight other coun­tries— Aus­tralia, Canada, Den­mark, Fin­land, Ice­land, Mex­ico, the Nether­lands and New Zealand —have home dial­y­sis rates at or above 20%, ac­cord­ing to a 2011 ar­ti­cle pub­lished in the Clin­i­cal Kid­ney Jour­nal.

Ex­perts say the de­cline in home dial­y­sis in the U.S. was re­lated to the in­tro­duc­tion of the Medi­care End Stage Re­nal Dis­ease Pro­gram in 1973, which paid for dial­y­sis for nearly all Americans with ESRD. That pro­gram cre­ated a strong fi­nan­cial in­cen­tive for providers to max­i­mize the num­ber of pa­tients who could re­ceive dial­y­sis treat­ment. So they shifted to out­pa­tient dial­y­sis cen­ters.

The grow­ing in­ter­est in home dial­y­sis comes as pro­jec­tions in­di­cate in­creased de­mand for dial­y­sis care in the com­ing years. More than 20 mil­lion adults have some form of chronic kid­ney dis­ease, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Preven­tion. By 2025, that num­ber is ex­pected to rise by 50%. The preva­lence of Americans treated for ESRD grew by nearly 600% be­tween 1980 and 2009, from 290 cases per mil­lion to 1,738, ac­cord­ing to the Na­tional In­sti­tute of Di­a­betes and Di­ges­tive and Kid­ney Dis­eases.

In re­cent years, the CMS has tried to get providers to put more pa­tients on home dial­y­sis by re­vis­ing its pay­ment sys­tem. It has waived a 90-day wait­ing pe­riod for re­im­burse­ment for home-dial­y­sis pa­tients that is re­quired for in-cen­ter pa­tients. In the agency’s rule on ESRD pay­ments is­sued last Novem­ber, the CMS in­creased the rate for train­ing pa­tients to per­form home dial­y­sis by 50%, from $33 a ses­sion to $50.

Medi­care pays 80% of costs as­so­ci­ated with dial­y­sis care for ser­vices ei­ther at home or at a dial­y­sis cen­ter. For home dial­y­sis, the fed­eral gov­ern­ment pays for train­ing, dial­y­sis equip­ment and sup­plies, in­clud­ing drugs and doc­tors’ ser­vices.

Mehro­tra said he was en­cour­aged by the CMS’ ef­fort to in­cen­tivize more home dial­y­sis use, and he pre­dicted that up to 25% of dial­y­sis pa­tients would even­tu­ally re­ceive treat­ment at home.

Richard­son, the Savannah pa­tient, en­dorses the home ap­proach. “I had got­ten so used to think­ing that I can’t do things be­cause I’m sick,” he said. “You get your life back.”

Robert Richard­son uses home hemodial­y­sis, in which each night he con­nects to a ma­chine that fil­ters his blood while he sleeps.

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