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January 6, 2007, 01:00 AM #11Senior Member Registered User
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- Seattle, WA
Thank you Beth that was a good post.
January 6, 2007, 05:16 PM #12Country Girl Guest
OK Bill I'll see if I can shed some light on this for you.
First of all our needs for dialysis issues are met by our home nephrologist and the center he is connected too. They don't have a home program and they don't use the machine I do.
Our nephrologist goes over our labs, (just like your home training nurse does)
if he sees a problem like we need to increase our EPO he calls us or has someone on the staff call us to tell us to increase the dose. If the white blood cell count was low, he would call us or have someone on his staff call us and tell us to come to the center at such and such a time to have a blood culture done. We would go to the center he is affilated with and have it done. If I know I have a machine problem and need a backup treatment, I call the nephrologist near our home and tell him. I suspect you call the home training nurse. He then calls the center and arrangements are made for us to come in. We have been doing this for so long the center now is very familiar with us as being home patients through the Rubin but taken care of by them. IF I can't get a hold of the nephrologist I just call the head nurse at the center she makes the arrangements and then calls the nephrologist for him to OK it. It doesn't matter that they don't have a home program or use the same machine we use they provide us the service all dialyzers get. Home dialyzers are no different than in-center when it comes to what medical issues come up so they are well equipped to handle the medical issues.
Once you are throughly trained on a machine, having someone besides yourself knowing the machine is kind of irrevelant. I can't remember how many years it has been since I asked a questions in regards to setting up the machine and running a treatment. I am also just as good at calling for service on a machine as someone from the center is.
I have a Nephrologist
I have my labs drawn and sent to my home nephrologist or to whoever he has look over the labs of his in-center patients.
I have a center the Nephrologist can send me to.
What am I lacking by not being connected to a specific center, or home program?
The big difference is, the nephrologist and I take on the responsiblity that most home hemo nurses carry and instead of giving my supply list to the home hemo nurse I'd be purchasing them some other way.
If you can give me an example of the details that concern you, I think I can probably be more specific.
If I had away of getting the machine and the supplies we needed, I don't actually know why I would need our home training center. In reality because of the distance from our home training center, I have had to find a way to meet our needs without them. This was done by establishing a relationship with a Nephrologist closer to our home.
I don't want anyone to get carried away with this thinking our home dialysis center doesn't do anything for us they do. They go over our labs and call me on them. They provide me with a way to draw labs and send them in. They write prescriptions for us. They give us our supplies. Our home nephrologist let's the home program nephrologist make most of the decisions regarding dad's labs. They monitor us at night. I was just trying to explain to Bill why you wouldn't really need to be connected to a home program to accomplish home dialysis as long as you had a nephrologist. I clearly see how it can work.
Gus in response to your post. I don't think it's as bad as you think it would be. I don't think there is anything hard to do, I just am having a whole lot of trouble understanding what's actually required to do it. I do agree you would need to have some cash to lay out until you could get reimbursed.
I agree with Bill, being your own provider should be a viable option. Giving credit to each dialyzor being different with different life styles and needs this would be 1 more way to help patients become home patients and become more independent.
January 6, 2007, 08:42 PM #13Senior Member Registered User
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Hemodialysis initial Start: 1978
Home Hemodialysis: 11/2004 - Present
January 7, 2007, 09:05 AM #14Country Girl Guest
Yes, I see what you mean
Gus, I do see what you mean. The supplies don't create extra work. We are required to fill out a supply form for our center so the same thing would be done and sent to someone else if we were our own provider. Machine maintenance and repair is the same scenario. We have to call our center when were having a problem we would just call the machine co. direct. Phone calls I think do increase. If you can call your home training nurse and she arranges appointments and contacts the nephrologist or center for you, it's easier. I don't think there would be a lot of paperwork once your set up but having none is better than having a little.
Having said this, if I weigh it against the option of not having home hemo because a center isn't close enough I think it would be a time saver. The 3 to 4 hrs. you spend sitting in-center for treatments you could spend at home doing your paperwork while your dialyzing and still have plenty of time to spare.
I also think that as dialyzors we are so used to someone holding our hand as you mentioned that we tend to make mountains out of molehills. The thought of changing the way things are done always brings on some anxiety and fear and its normally not until you work through it that you realize it's a whole lot simplier than you thought it was going to be.
I don't think patients who are content with their travel or home programs would have any reason to even consider being their own provider but for those like George Harper who was having his travel taken away by a center or for those who have to travel miles to be in a program it could be the answer they are looking for.
January 7, 2007, 09:54 AM #15Country Girl Guest
Beth, I can imagine a DME Method II supply company providing daily HHD for this amount. The reason I say this is because even though NxStage may not be a DME or Method II supplier, I read they charge centers 1500.00 per month for the NxStage and all it's supplies. This fits real close to the 1490.00 amount allowed by Medicare to DME's.
January 7, 2007, 10:58 AM #16Country Girl Guest
After reading George Harper's accounts on his experience again and having heard of patients going to home hemo without the center having a home hemo program I wonder if this is how it was done.
George was doing fine as a Method II patient getting his machine and supplies through a DME. It wasn't until the DME was going out of business that George had trouble. The trouble became because the center wouldn't supply him with a machine if he was going to travel. Thus his motivation to become a DME and supply himself with the machine and supplies.
Now for the question.
If I were a dialysis patient and my center didn't have a home program and I wanted to become a home patient with the consent of my nephrologist could it be done this way.
I am put in as a Method II patient. I get my dialysis machine and supplies through a DME.
The nephrologist asks someone at the center to train me.
I now have a machine and am trained.
I still have my nephrologist and center.
Is there a law that says you can't do this if the center doesn't have a home program?
January 7, 2007, 12:30 PM #17Country Girl Guest
My brain has been certainly spinning on this this morning. I came up with another scenario.
I read where Medicare pays DME for dialysis equipment by rental payments.
So lets suppose I became a DME bought a Fresenius Machine for $30,000.
I have had my machine for 7 years.
I have billed Medicare the 1490 per month for 7 years. Suppose I allowed
$990.00 for supplies. Dialyzers, Acid, Bicarb, Saline, Tubing. I put $500.00 per month toward the cost of the machine. In 5 years I would recoup the machine cost.
I have had the machine now for 7 years and am still able to bill the rental so aren't I now $12,000 ahead. This would allow supplies of $200.00 per week seems to me that should cover weekly supplies.
Perhaps the reason dialysis centers have more patients under Method I as that they realize the profit from the machines once they have gotten back their initial investment? Nothing wrong with this I think it's called return on investment.
January 7, 2007, 04:11 PM #18Resource/Policy Associate Registered User
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That would be a good question to ask NxStage or other suppliers of equipment. Remember, Medicare only pays 80% of the allowed charge after the annual deductible is met. If the patient has supplemental insurance or can afford to pay the $300 a month, and if NxStage is truly charging clinics $1500, the clinic will just recoup its cost for supplies and equipment which doesn't do anything to recoup the high costs of training a patient for home dialysis.
In my opinion, facilities probably do better financially if those patients on more frequent treatments who have Medicare have chosen Method I (composite rate). Clinics may bill for all treatments and may send the Fiscal Intermediary a letter of medical necessity that states why the patient needs additional treatments. These letters may also include statements from members of other disciplines and even state what the patient says about why he/she believes additional treatments would be best. FIs have the discretion to pay for more treatments when they are deemed medically necessary. I don't think there is any consistency from FI to FI about payment for extra treatments.
Some new patients who are started on daily treatments have EGHP coverage. Dialysis providers typically bill EGHPs several times Medicare's composite rate for each treatment. As I see it, here are some of the incentives for clinics to offer more frequent dialysis:
-- Helping more working patients keep their jobs (and EGHP coverage) by training them to do dialysis at home;
-- Allowing the clinic to treat more patients without having to expand or hire more staff;
-- Improving patient and staff satisfaction;
-- Proving better toxin removal with more frequent dialysis so patients get all their treatments at home instead of being hospitalized and losing money to the hospital for dialysis treatments done there;
-- Spending less on drugs and requiring less time to administer IV/injectible drugs if patients need fewer drugs because of fewer toxins in the blood;
-- Billing (and potentially collecting) twice as much weekly for an EGHP patient who dialyzes 6 days a week compared to the patient who dialyzes 3 days a week.
I hope that dialysis clinics that start patients on more frequent treatments when they have primary EGHP coverage will allow them to remain on these treatments when their coverage switches to Medicare primary. I also hope that EGHP lifetime benefits will not be exhauseted for patients on more frequent treatments because providers charge EGHPs so much for each treatment.Beth Witten MSW ACSW LSCSW
Medical Education Institute, Inc.
January 7, 2007, 04:56 PM #19Resource/Policy Associate Registered User
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I suspect you'd be a lot better off if you had lots of money so you could buy the machine outright and not have to take out a loan and pay interest on it. Another thing to consider is how long do you want to keep that dialysis machine and what do you do with it when newer technology makes it obsolete. A lot can happen in 7 years and you'd probably hate to be stuck with an older machine if a new one comes along that's more efficient and smaller or that you can wear. Clinics that upgrade their purchased equipment have to find a place to get rid of their old equipment and some donate it because they've been able to depreciate it over time.
You can read Medicare's payment policies related to the machine and supplies for home dialysis in the Medicare Benefit Policy Manual, Chapter 11 -- ESRD (Section 50)
http://www.cms.hhs.gov/manuals/Downloads/bp102c11.pdfBeth Witten MSW ACSW LSCSW
Medical Education Institute, Inc.
January 7, 2007, 07:17 PM #20Country Girl Guest
I don't want to get into money rangling. I was just pointing out that I think if you were your own DME supplier you probably could make money. As far as to how long I would want to hold on to the machine. If my dialysis were good and I was making money, I probably wouldn't complain if I used the same machine for 10 years. Also depending on how good the new technology was "I" could make the choice to take a loss and go to the new technology.
As a dialysis patient working through a center, I am stuck with the machine they gave me until they decide to trade it in. So far going on 7 years, I heard one time they started exchanging them at 10 years but I don't know if this is true. Also as an in-center patient there is no guarantee I would be able to utilize the new technology. The Rubin is not letting all the Fresenius patients change to NxStage and a center closer to home isn't going to use NxStage at all simply because of cost or so that's what they tell me.
George Harpers reason for becoming a DME was to have more independence. He was going to travel with the Dialysis Machine and the center wouldn't furnish him one when they heard this.
Traveler started this post, pointing out he was looking for more independence.
I would also like to know there is away dialysis patients can be more independent if they don't have available to them through a center what they are looking for.
If the only way you can get home hemo and not have to travel 100 miles is to become a DME why wouldn't you want this to be a viable option.
I don't see any point in comparing being a DME to being center connected. Patients who think in these lines are looking for more independence and less restrictions imposed by what a center offers and doesn't offer.