Editor’s Note: The Centers for Medicare & Medicaid Services held a town hall Oct. 23 to discuss the proposed bundled payment rule for the End-Stage Renal Disease Program. The following was the prepared statement from Joe Turk, senior vice president, commercial operations for NxStage Medical Inc.
Good morning and thank you for this opportunity to comment on behalf of my colleagues and partners.
Since 2005 at NxStage Medical, we’ve been providing hemodialysis devices designed for the home that have at least partially enabled a modest rebirth of home hemodialysis in the United States.
In my comments, I’ll focus on access to home HD and how the proposed rule addresses home HD training. I’ll echo on some comments previously made, and hopefully expand on these as well.
In our review of the proposed rule, the agency’s desire to encourage home dialysis comes out loud and clear, and we applaud this. Many proposed policies are quite supportive of home HD, namely the treatment as the unit of payment, medical justification provisions for more frequent dialysis sessions, and the addressing issues with separately billable injectables in the home.
However, we have serious concerns about how home HD training is addressed in the proposed rule.
We feel that inclusion of training into the base bundle is inappropriate because of training’s investment significance and non-routine nature, and feel that home HD training should be handled with an adjustor.
So first, training represents a significant, essential investment by the dialysis provider.
Home patient training is a necessity, not an option. Training transforms a patient from a healthcare novice to an expert in his or her own care. Without resources and provider investment, patients cannot go home.
Our data representing thousands of patient experiences over multiple years show that home HD training requirements average 5 days per week for 3 to 4 weeks, representing 100 hours or more of 1:1 RN time per patient.
The Moran Company also analyzed Medicare cost report data for home HD training. This study found average costs of $394 per training session, approximately $250 more per session than the base composite rate. This amount is consistent with the reported labor requirements of training.
So, home HD training is far from a trivial expense for the provider. It also differs in scale and scope than that of PD. Home HD and peritoneal dialysis are very different animals, and I caution anyone from applying generalizations of what we know about PD to home HD. We cannot assume it directly applies.
Second, training is clearly a non-routine activity.
Only 15 percent of centers offer home HD therapy today. At even these centers, only a subset of their patients are trained each year. Training sessions represent only a tiny fraction of 1 percent of total treatments.
Paying for training in the bundle compensates clinics who are not even offering home modalities, while taking funds away from those that are.