I don’t know of anyone who said they thought it was simple. Even though I have laid out the steps as to how I think it would work, I didn’t mean to imply it was simple. I don’t know. I’d have to do a lot more investigating into how DME’s and the machine suppliers set up agreements. Is it just for the machine or machine and service too? Then you have to have a nephrologist who really trusted you, and thought that what you wanted to achieve by doing it was important enough to work with you. Obviously, George’s nephrologist didn’t want him to have to give up his lifestyle either. Then you’d have to learn the proper way to bill medicare. George didn’t set out doing this because he wanted too, he was forced into a situation of give up his love of travel and lifestyle or tackle the difficult. I wouldn’t even consider this unless someone was going to pull our ability of doing home hemo out from underneath us. Thank God more programs are being started and not closing this gives some comfort. However, it would also be comforting to understand this just in-case the situation was such that you really felt it was your only option to live the life you want or the dialysis prescription you needed. Maybe being prepared a head of time of knowing what you had to do would make the difficult a little less hard to confront when your left with no other options. I don’t think anyone here is even up to the challenge of learning how it would work much less doing it.
I agree with you Marty; my thinking has been around the money and what role CMS should play to ensure that Method II is viable.
For instance why isn’t Method II case mix adjusted? Marty do you know what your Dad’s case mix adjusted composite rate is currently? I bet his is about $150 so 13 x $150 - just for the sake of parity the Method II allowable rate should be around $2,000. I think Beth put her finger on it - CMS would like Method II to die on the vine. Sounds like a job for advocacy.
[quote=Country Girl;11943]I don’t think anyone here is even up to the challenge of learning how it would work much less doing it.[/quote]I have to disagree with you here, where is this coming from? It should be spelled out more clearly but if we had to we’d learn while doing, as always.
Bill, If we had too we would learn. I just meant that without having the need, I don’t think were facing the challenge of getting all the information required to understand it completely. I know I am being lazy. I really would need to connect with someone who does actual billing to ask for the details. I’d need to talk with DME suppliers and I need to find out just how much a machine would cost.
I don’t understand how anyone knows method II isn’t viable. I did read under method II CMS would pay 1490.00 per month for the dialysis machine and supplies. I don’t have any proof this isn’t viable. (I don’t know if this meant the centers couldn’t charge for other things if that’s the case it may not be viable.) But if this is what they can charge for the machine and machine supplies and separately bill for the treatments then I think it is viable). My guess is the reason Method II is under utilized is because Method I pays more and once the center has paid for the cost of the machine, the machine is then generating a profit for them. If they used Method II the DME would see the profit of the machine once it was paid for.
I also thought Patients had a choice if they wanted to be Method I or Method II. If they do, we certainly don’t get enough information to make an informed decision or at least I didn’t. Unless I just wasn’t listening.
These thoughts come from just things that have been said to me that I have made opinions from and my opinions could be right or wrong.
Right now, most of the services provided by a dialysis clinic are under a bundled rate called the composite rate. At this point drugs are separately billable. Even certain lab tests are covered under the composite rate.
A dialysis facility cannot be a Method II provider. I’ve spoken to people that work in CMS survey and certification section about how about Method II is regulated. As I recall, it is regulated under the DME section of CMS, not the ESRD section. However, the dialysis facility that the DME must have an agreement with to provide support services and backup dialysis is regulated by the ESRD regulations. It may be that having two different sections of CMS that are charged with assuring quality of care increases the hassle factor. I talked with a Method II DME in GA nearly a year ago. It had a contract with a dialysis provider to provide staff-assisted home dialysis. When the dialysis provider was sold and the DME tried to establish a contract with the new provider, the new provider only established a short-term contract to transition the patients. I haven’t talked with the DME since then so I don’t know if the company was able to prove that it was providing a valuable service or if the large dialysis provider made those patients previously receiving staff-assisted home hemo come in-center.
After a Method I patient has been on dialysis a couple of years, the dialysis provider with a clinic large enough to warrant having a full-time nurse in home training can start to make more than it is spending every month for dialysis and water treatment equipment, dialysis and all ancillary supplies supplies, labor costs for a home training nurse, part of the salary of the dietitian and social worker, costs for labs that are not separately billable, items like dialysis chairs, blood pressure monitoring equipment, etc. Under Method II, the dialysis facility only gets payment for support services. I cannot figure out how the clinic could ever recoup the cost of training at reimbursement of $1490 per month.
When I was frantically searching for a home hemo program, and was writing every government official I got the name of complaining because home hemo wasn’t available, I remember distinctly getting an e-mail from either the network or someone in the government in CMS telling me point blank they encouraged home hemo and that they paid so much per hour for the cost of home training nurses. Maybe this amount was thrown into the support payment I don’t know but they seemed to think they were taking care of it.
I think in order to base a judgement on whether or not the payment is sufficient, I would really have to dig into things. I have experienced some things that would knock your socks off. Like seeing a Medicare payment for 850.00 for a medication it took less than 1/2 hr. to administer, plus the usual gauze pads, alcohol wipes, masks, gloves and medicine. The same medication purchased at a pharmacy and done at home $50.00.
I thought the 1490 a month was the amount the DME could bill for. I didn’t know this was the support payment under method II.
I think dialysis patients should advocate for CMS to provide a clause that states dialysis patients have the right to choose the modality of their choice and the machine of the choice. Maybe there shouldn’t be so many restrictions on what a home programs has to be. I can see insisting on a Training Nurse but after that they should be able to handle their home patients as they need. If the control, of patients, weren’t still totally in the hands of the centers, we wouldn’t have to be looking for away around the current systems. All patients should have the priviledge of choosing their machine and modality. After all the patients know what they can and want to do. In-center is great for some, home hemo for others, some need to do night time do to working conditions in the family, some prefer night time. Some prefer daytime and aren’t comfortable sleeping on the machine. It’s not like dialysis is a temporary condition. Patients live with this for years, so why aren’t there needs taken more seriously.
Sorry I was typing this late at night after being in mentally draining meetings all day. My fingers were typing faster than my brain cells were working. The $1490 is what the DME is paid for home hemo. What I should have said is that when a patient is Method II, once the patient is home, the clinic only gets the support service fee which is $121.15 a month no matter how times the patient calls or comes to the clinic.
The dialysis clinic that trains the patient gets the usual composite rate for each dialysis session plus $20 for up to 25 treatments. The nurse doing the training is using a machine, supplies, and utilities just like they do in-center. By regulation, the nurse in charge of home training must be an RN instead of a technician like many staff doing patient care for in-center patients. In addition, the nurse to patient ratio is much higher for home training patients - usually 1 to 1 vs. 4-6 to 1. Training sessions usually last 5 hours or more each training day. Therefore, the clinic is paid its usual rate for equipment, supplies and utilities but only a maximum of $500 ($20 x 25) for more qualified staff, a better nursing ratio for longer, and comprehensive training materials that the patient can use at the clinic and take home with him/her. The training rate should be one of the first targets for advocacy no matter whether the patient is Method I or II, in my opinion. I suspect this is a barrier to clinics offering home hemodialysis.
Sorry I overlooked a couple of other things that I should have commented on in your posting:
Most legislators and even CMS employees know very little about Medicare reimbursement for home dialysis. You need to talk with the folks that know reimbursement or read the Medicare manuals which can be found at www.cms.hhs.gov/manuals or look at our Medicare FAQs. Medicare DOES NOT pay per hour for home training. There is a flat $20 allowed reimbursement which actually means Medicare pays $16 (80%).
[QUOTE=Country Girl;11984]I think in order to base a judgement on whether or not the payment is sufficient, I would really have to dig into things. I have experienced some things that would knock your socks off. Like seeing a Medicare payment for 850.00 for a medication it took less than 1/2 hr. to administer, plus the usual gauze pads, alcohol wipes, masks, gloves and medicine. The same medication purchased at a pharmacy and done at home $50.00.
I thought the 1490 a month was the amount the DME could bill for. I didn’t know this was the support payment under method II.[/QUOTE]
If you’re talking about medication given in a dialysis clinic and billed to Medicare (not a commercial insurance), the clinic is limited on what it can bill for medications and supplies for administration of the medication. I don’t know what medication you’re referring to, but if you provide a little more information, I’ll try to check this out.
I’d need to talk with folks that know. I have tried reading some of those manuals and with no one around to interpret some of the things, I’m not sure I know just exactly what they mean. I’d also have to have a lot more center information to compare the cost against reimbursement before I could make an intelligent analysis. I’d also need to know things like the depreciation schedule on the machines. I’d also need to know the write off’s regarding electric, gas water etc. All of this stuff has a significant impact on the bottom line. To determine the true profit of any business you can’t just compare the cost against what’s charged. For example if I am selling copies for $1.00 and they cost me 75 cents and I sold 100 it’s looks as though I made $25.00 now if you take into consideration I could write my electric, gas and water off plus depreciate my equipment, I saved $300.00 in taxes. Therefore my actual profit was more than what was obviously visable.
I would suspect that part of the decision in when to exchange dialysis machines has a lot to do with the depreciation schedule on those machines.
I hesitate to mention the drug over the internet for fear of getting a rift going like we had with IV iron.
OK, this has been a great discussion, I didn’t want to interrupt, you were going so good, thanks to all Bill and Beth, etc and especially Marty.
you seem to have caught my intention in posting this thread…
It definitely is independence…or as a ‘brave heart’ said FREEDOM!
I have been doing this for 26 years and am still trying to dialyze the way I want…not the way the business community …I mean medical community wants me to.
[QUOTE=Country Girl;11988] All patients should have the priviledge of choosing their machine and modality. After all the patients know what they can and want to do. In-center is great for some, home hemo for others, some need to do night time do to working conditions in the family, some prefer night time. Some prefer daytime and aren’t comfortable sleeping on the machine. It’s not like dialysis is a temporary condition. Patients live with this for years, so why aren’t there needs taken more seriously.
Marty[/QUOTE]
I think the answer Marty, inspite of what brain/blood washing happens to alot of us, is that our needs aren’t taken more seriously because it’s not in the interest of the business profile. While the medical industry is supposed to answer to a higher calling, they are in the business of taking care of the sick…you will note that I don’t say ‘healing the sick’…that would be bad business. Just as the energy companies are in the business of providing energy to a demanding population…it will never be in their interest to provide unlimited free energy…so that ‘invention’ will never ‘happen’…
Now, I think there are exceptions to this ‘rule’ and hooray for those exceptions, sincerely.
But until those exceptios ARE the rule, I will try to maintain the maximum contral over my health and well being that I can.
Thanks, Marty for the itemized steps, they were helpful.
Thanks everyone for the serious discussion and many useful viewpoints and resources.
A Traveler
Can somebody please give me insight to a unique situation of setting up home
hemodialysis treatments for four patients currently receiving treatments at a
center, travelling 104 miles, 3x a week? These four patients ages ranged from 63
to 85 years old do not have suitable homes to do dialysis treatments, therefore
leading the community to strategized on its resources in my small community. A
non-profit organization is willing to hire trained care-givers to do the
treatments, A home was donated to our four patients to use as their second home
for dialysis. Liberty dialysis feels it would like a center and Medicare might
not buy it. However a proposal for a community home dialysis is in process,
where Liberty, and the Health Dept. is working on. In the mean time, the biggest
concern is why can’t we start a home dialysis treatment in one home for our four
patients? Liberty says to do one patient first, instead of four at a time. We
even thought of staggering. Please share
your thoughts on this, as we are in crisis of travelling, the incumbent weather
has been real scary, with falling boulders from cliff top, debris on the one
lane road, and trees falling, blocking the highway. We want to start it at home,
except it would be a rented home. Help!"
> Can somebody please give me insight to a
unique situation of setting up home hemodialysis
treatments for four patients
currently receiving treatments at a center,
travelling 104 miles, 3x a week? … the biggest
concern is why can’t we start a home dialysis
treatment in one home for our four patients?
Liberty says to do one patient first, instead of
four at a time … We want to start it at home,
except it would be a rented home.<
"I am assuming you are in some area of the USA,
right? Home dialysis is an available option for
an ESRD patient as long as s/he is able to be
personally trained and have a trained caregiver
render assistance during the dialysis treatment
process. This being stated, all of the dialyzors
if they so fit the standards of what they must
undeerstand to be home dialysis certified, should
be able to receive such treatments in a place
s/he call home. It is the personal dialyzor
caregivers who are the first concern, then the
standards of being Medicare approved for a rented
home dialysis facility to provide
Medicare-approved dialysis treatments at a
proverbial home, ie. central non-home
environment.
Liberty’s suggestion of trying one cli9etn at a
time seems like the best route to take in the
onset of such a proposal. This would permit
everyone to gain an understanding into the depth
of the requirements to do dialysis as well as
gauge if the staffing issue is indeed ample
enough to render safe and effective care.
Furthermore, one dialysis machine could do the
work for all four dialyzors at different times
during the day versus four machines available all
at once to do the dialysis all at the same time.
I’d start out slow and work the other three into
the equation as things get easier and more
repetitious. One fault or failure is far easier
to manage then to have all four dialyzors
experiencing a similar crisis at the same
identical time.
I think if the issue of billing for a home
dialysis client treatment comes up, then one
could easily construe by the letter of the law,
it is not truly a “home dialysis treatment” as a
home dialysis dialyzor does not get paid for
their personal treatments. The center (Liberty)
would likely be able to bill for each dialyzor
who receives home dialysis as would be done
outside of this special consideration, but only
for the supplies and medical chart recording, but
not for the actual service of a dialysis
treatment which a home dialyzor literally does
for free on themself. Neither the caregiver nor
the dialyzoir are paid to do home dialysis at
home. — except for George Harper in Georgia who
accomplished billing his dialysis treatments as
if his Medicare approved home was a dialysis
clinic and thus, he was able to bill for services
he did for himself. The yet undisclosed secret is
how he accomplished this Medicare approval home
clinic status and was able to bill for his home
dialysis treatments and successfully get paid for
it too.
I look forward to more insights into this unique
situation as it does appear to have worthwhile
merits especially when winter dilemmas do place
some dialyzors in a rather risky and
unintentional position of seeking care in
naturally dangerous environments where
circumstances demand special considerations.
Heather, I posted Beth’s reply to the dialysis_support list. Cross-posting isn’t going to get our attention any faster. We monitor both (and several others besides) and get to the replies as quickly as we can. I also don’t think it’s right to post private list mail to a public forum.
Dori,
To clarify, I was not trying to get your attention so you or Beth would respond to the post. Was simply posting the dialysis_support posts for readers of this board as I thought it fit in well with this thread. Also, I remember that in a past thread you stated you weren’t sure if cross posting is an ok thing to do, because it is posting private list mail to a public forum. But did you note where the moderator of dialysis_support came out with a post where he said it was fine to do so and encouraged the sharing of information? I think Bill P. remembers what I’m talking about. So, please know I was under the impression that we had already settled this issue in favor of cross posting. Sorry for any misunderstanding. If you decide that you disagree with the dialysis_support moderator and want to set a policy against cross posting, I will certainly abide by whatever you decide. Thank you, Heather
Heather, Dale is free to have whatever policies he wants for the dialysis_support listserv. I’ve known him for many years and have the utmost respect for him–he is truly one of my peersonal heroes. But I just don’t feel comfortable with the cross posting from a private list into a public forum. It just somehow doesn’t sit right with me, unless the person whose post it is has a chance to say if it’s okay with him or her. So, I’d prefer to avoid it unless that’s done first so everybody’s cool with it.