Home dialysis is at a crossroads. More people are aware of home dialysis than ever before, whether it is home hemodialysis or peritoneal dialysis. However, big changes in dialysis payment have left many dialysis clinics scrambling to figure out how to adapt to this brave new world of bundling and other market forces, let alone how to grow their home dialysis practice. To help make sense of all this, Renal Business Today posed three questions to the following thought leaders in the renal community.
- James Sloand, MD, FACP, Senior Medical Director, North America, Baxter International Inc.'s Renal Division
- Wayne A. Evancoe, CEO/Renal Administrator, Hortense and Louis Rubin Dialysis Center Inc.
- Joyce F. Jackson, President and CEO, Northwest Kidney Centers
- Allen R. Nissenson, MD, FACP, Chief Medical Officer, Davita
- Cedric Tuck-Sherman, Vice President of Marketing, DaVita At Home
- Scott Esposito, Vice President, Home Hemodialysis, DaVita
How do you think the new bundled payment system will affect home dialysis?
Jackson: We are pleased that the proposed rules allow for more frequent hemodialysis treatments with justification. And it’s very good that the same bundle payment is applied to all modalities.
Unfortunately, the rules do not provide any adjustment for home training. Today, there is an additional payment for home training and some programs have exception rates. Those accommodations are going away.
The up front investment costs of home training are very significant. Often patients do not complete home training or they utilize home therapy for less than a year. In these cases the long-term payback of less costly home therapy is never realized.
The proposed 120-day bundle adjustor doesn’t help. Almost 55 percent of our new PD patients are trained after they have started hemodialysis, long past their initial 120 days on dialysis. Over 90 percent of our new home hemodialysis patients start after their first year.
QIP, a payment penalty program, could harm home therapy. KECC does not currently report PD adequacy. KECC does not fully adjust URR results for frequency or length of hemodialysis treatment (thrice weekly nocturnal, for instance). We recommend that HH and PD adequacy measures initially be exempt from QIP. If we are not careful, an entire year of facility treatments (in-center and home) might be financially penalized under QIP, all because of misleading home program outcomes. Talk about disincentives to offer home dialysis!
Sloand: We believe that the new Centers for Medicare & Medicaid Services bundled payment system will have a positive impact on the uptake of home dialysis modalities. Under the new bundled payment system, dialysis providers will go from being paid on an a la carte basis to a fixed basis for goods and services rendered during a patient’s treatment.
The previous partially bundled system created a reimbursement system that was more favorable to in-center hemodialysis treatment, despite compelling clinical data regarding outcomes and therapy costs. There is a large body of data that supports that home dialysis options, including peritoneal dialysis and home hemodialysis, provide equal or better outcomes and are more cost-effective.
Because of the hospitalizations, medications, access, co-morbidities and other factors associated with hemodialysis, total healthcare costs are higher. According to the U.S. Renal Data System, USRDS 2007 Annual Data Report, the annual healthcare costs (per patient) for Medicare patients with end stage renal disease total $53,000 for patients on peritoneal dialysis and $72,000 for patients receiving in-center hemodialysis.
Evancoe: I note that CMS did maintain “per treatment reimbursement,” and also the nephrologist's ability to justify more than three dialysis treatments per week. These maintain a rational approach in the proposed regulations that minimally allow home therapies to continue.
The elimination of the direct financial adjustor to compensate for the intensity of home therapy training is a real mistake. CMS has taken a position that they intend to dilute it into the “new patient first four-month adjustment.” This does not further what Congress laid out in the MIPPA law, nor actually support what CMS has re-stated, “The Secretary shall provide...the amounts of payments...that will more effectively encourage the more efficient delivery of dialysis services and will provide greater incentives for increased use of home dialysis...”
In fact, with only about 50 percent of all ESRD providers in the United States offering PD and only about 15 percent offering home hemodialysis therapies, redistributing the formerly targeted payments supporting home training—into the system-wide bundle—will reward more providers that do NOT provide home therapies than those that do!
This area of the proposed bundling needs active re-tooling to functionally support providers who do invest in staff expertise, training facilities, and the technology to grow and maintain home programs to provide more choice, freedom, enhanced clinical results and quality of life for patients.
Nissenson: CMS’ intent in the proposed bundling rule is to support the growth in home modalities. Their statements and actions are consistent with this intent given the constraints of historical coverage and payment rules. Certainly CMS’ proposal to pay for peritoneal dialysis on an equivalent basis as hemodialysis should facilitate this outcome. CMS has maintained the policy to allow billing for a fourth medically justified treatment which is appropriate to support selective patients access to more frequent dialysis or short daily dialysis. We feel that the support of home modalities would be strengthened even further if clear criteria for medical justification for a fifth or sixth treatment were developed and payment under those conditions was authorized.
