Buyer Beware! Group Health of Seattle Does Not Cover Frequent Home Hemodialysis

Buyer Beware! Group Health of Seattle Does Not Cover Frequent Home Hemodialysis
By Peter Laird, MD

Mark Pennington is one of the few on hemodialysis that is able to continue work and be productive, but this may all come to an end if his new health care provider has their way in this matter. Mark has an extensive history of complications while on usual care in-center hemodialysis to include multiple hospitalizations and disability making work impossible. This all changed in 2009 when he trained for home hemodialysis with the NxStage System One. Since that time, his health has improved dramatically and he is now able to work once again.

Insurance Company Will Not Support Home Hemodialysis
(Comment #40 from Home Dialysis Central - used with permission from Mark Pennington)

For several years, I have suffered from Kidney Disease. In July of 2006, I was placed on in-center hemodialysis. This treatment was a mixed blessing. On the positive side, my overall health greatly improved. On the minus side, I suffered numerous infections – including a bout with osteomyelitis of the spine that almost claimed my life and left me disabled. Additionally, the 3 time per week, in-center dialysis would frequently leave me feeling tired and wrung out. This caused difficulty on my job and added stress to my family.

In December of 2009, my wife and I attended training and became certified to perform home hemodialysis. This 5 time per week schedule allowed for more gentle cleansing of my blood and greatly reduced the side-effects I’d felt in-center. My employer was delighted as dialysis no longer controlled my schedule and I could even work during dialysis. Also, since the machine is portable, we took the first long vacation in years last summer, camping in the Olympic Peninsula in our travel-trailer. . .

In January of 2o11, various concerns prompted me to change my employer-provided health insurance to Group Health. The Dialysis support staff at DaVita warned me that Group Health did not cover this treatment. However, that seemed contrary to the Group Health reputation as an innovator in the medical care field. Additionally, I was in great need of the managed care for my diabetes that Group Health could provide.

On January 23’rd, I received notice that my request for Group Health coverage of my frequent home hemodialysis was denied and that I would have to switch back to 3 day per week in-center dialysis.

I have appealed this decision, but doctors at Group Health have told me that it will not be overturned.

Mark R. Pennington

This is the second case of Group Health denying an optimal dialysis strategy for a patient that I am personally aware. Last year, my nephrologist in Spokane, WA asked me if I could help him with one of his nocturnal in-center patients that was doing well on the thrice weekly regimen, but Group Health decided to withdraw payment and return her to a different dialysis center for usual care. I contacted a noted dialysis researcher from Seattle who agreed to write a letter of support for this patient as well as a leading dialysis advocacy group who also offered support for this patient. Group Health has a stated policy on their website against any of the frequent dialysis strategies many simply call optimal dialysis.

Clinical Review Criteria

Frequent (Greater Than 3 Days a Week) Home Dialysis, Nocturnal or Short Daily


Objective 1:

 There is insufficient evidence that home nocturnal dialysis improves important health outcomes compared to in-center dialysis. An RCT found improvement in LV mass and phosphate level, intermediate outcomes, and mixed findings in QOL. There is weak evidence from a single cohort study that nocturnal dialysis lowers the rate of dialysis-related or cardiovascular- related hospitalizations. In this cohort study, all-cause hospitalizations did not decrease significantly.

 There is insufficient evidence that home short-daily dialysis improves health outcomes compared to in-center dialysis. One statistical analysis found a lower mortality rate with short daily dialysis compared to national rates, but patients may have differed in ways that affect outcomes, and there was potential financial bias.

Objective 2:

 There is insufficient evidence that home nocturnal dialysis 6 nights a week improves important health outcomes compared to home hemodialysis 3 times a week.

 There is insufficient evidence that home short-daily dialysis 5 or more times a week improves important health outcomes compared to home hemodialysis 3 times a week.

For questions or comments contact: Clinical Criteria Documentation Team

The conclusions of the Group Health Clinical Review on frequent hemodialysis are simply false in my opinion as shown by the outcomes of the FHN and Group Health has yet to update these guidelines even though they cited the FHN in their 2008 review. In such, the denial by Group Health of Seattle of home hemodialysis to Mark Pennington is based on out of date data. Last week, I attempted to contact Group Health at the email provided on the Clinical Review page for frequent dialysis asking them if they have any plans to review this issue again since the publication of the Frequent Hemodialysis Network Trial Group results last November, but to date, I have not received a reply.

Perhaps others will have more results than I did should some of you choose to also ask Group Health when they shall recognize the results of the randomized and controlled, IOM sponsored FHN trial that definitively proved the benefits of frequent hemodialysis. If Group Health has their own peer reviewed randomized and controlled trial disputing the FHN results, let them bring them forth now. If not, it is time for them to stop denying life saving home hemodialysis to any of their patients.

Since Group Health is my default health care provider through my Kaiser policy when I am in the Pacific Northwest, it is an important issue to me as well and is one of the reasons I have not yet moved to Idaho permanently. In my own personal opinion, Group Health is not in the same league as Southern California Kaiser that does provide and does recommend frequent home hemodialysis according to the physician in charge of the Kaiser renal care program, Dr. Peter Crooks.

Home Dialysis Revives Patients Lives While Saving Substantial Costs

There are compelling reasons for a shift to home treatment, pointed out Dr. Peter Crooks, medical director of the renal program at Kaiser Permanente Southern California, which has taken a leading role in analyzing home hemodialysis outcomes for the HMO.

“Most nephrologists would like to get their patients on home dialysis,” said Crooks. (Nephrologists specialize in treating kidney diseases.) “You have a way to improve patient outcomes, and it’s more cost-effective.”

Crooks said that not only do patients report feeling significantly better with the regular dialysis home treatment allows, but hospitalizations due to complications from kidney failure, even while on dialysis, were halved for Kaiser patients on the home regimen _ from 14 to 7 days of hospitalization a year. Most of these hospitalizations are due to heart conditions linked to or worsened by kidney failure.

Crooks described the overall cost savings of home treatment versus dialysis center care as “substantial.”

Nevertheless, Group Health is a Kaiser network affiliated provider for visiting Kaiser members. For me to move permanently to Idaho, I would have to give up control of my health care to Group Health which would deny my own coverage of home dialysis under their stated policies. In such, Group Health is having a profound impact on my own personal and health care decisions. Both my wife and I would move immediately to Idaho today if we could only continue the same exact coverage I now enjoy with Kaiser, but the story of Mark Pennington brings home to both my wife and I how precarious it would be to depend on Group Health for my care. For the near future, we will have to limit our visiting time to summer and fall only.

The irony that a patient in Seattle where home hemodialysis was the standard of care 40 years ago is now denied home hemodialysis that gives him his life back declares to all that the false dichotomy of health plan clinical review criteria failing to recognize the benefits of frequent hemodialysis must end. Until that time, buyer beware, Group Health of Seattle does not cover home hemodialysis and they continue to ignore the overwhelmingly positive results of the FHN as well as nearly 50 years of positive observational data. It is time for Group Health of Seattle and many other health care insurers across America to recognize the life saving benefits of longer duration and more frequent hemodialysis. This is all just my humble and honest opinion.

I see this as a victory in the battle, but the war goes on.

Citing my claims in the appeal that I would be unable to work or travel while forced to endure in-center dialysis, the review board at Group Health has partially approved my request for home hemodialysis.

They are allowing me three sessions per week of home dialysis. Their explanation for this seems to suggest that daily short home dialysis is not considered effective compared to in-center dialysis. However, the letter does quote a study that claims three time per week nocturnal dialysis is the best option short of kidney replacement

At this point, I’m uncertain whether I’ll continue the fight for 5-6 day per week home dialysis or switch to 3 time per week nocturnal.

In any case, I do want to say that the care I have received from Group Health since switching to them as my provider, has been super. The doctors are top-notch; they diagnosed and are treating some long-standing conditions which seemed to mystify my previous doctors.

Thank you for the support you’ve given me,

Mark Pennington

It’s a start! 3x/week nocturnal (or every other day, if you can push them just a tad further) is an excellent therapy that can improve your quality of life and survival, and make work easier. It can feel less burdensome than short daily, since so much of the treatment is done when you’re asleep.

The Scribner Oreopoulis Double product for thrice weekly 8 hour dialysis sessions is the same as for 6 times a week 2 hour dialysis and we have nearly 50 years of evidence for it’s efficacy. The best part is that they have allowed you to stay at home and out of the center, so that is a major victory. The patient last year in Spokane was kicked out of her nocturnal in-center slot. At the ADC I saw the DSI manager in that area who updated me on her situation and states she was not allowed to return to nocturnal dialysis to date. I will relate your experience with Group Health with the nephrologist in that area, perhaps we can help get her back into nocturnal in-center once again. It is time for dialyzors to stick up for each other and support the right to access optimal dialysis in all health care settings in America.

The sad fact is that Group Health has still not yet addressed the FHN results. They are definitive findings. I know Dori and many other dialysis advocacy folks will not rest until the obvious benefits of optimal dialysis are the gold standard of care and people will need informed consent and direct warnings about the conventional in-center, American style dialysis care that in my opinion has harmed hundreds of thousands if not millions of patients in the last 3-4 decades, especially since the NCDS institutionalized “adequate” as the standard of care.

Why is Mark not on Medicare primary like the rest of the dialysis patients are after the coordination period? If he was on Medicare primary would this still be an issue?

I believe from prior posts on another thread that Mark has Group Health through his employer. I likewise have Kaiser through my employer and Medicare Advantage. Medicare is now my primary, but with these dual coverages, it ends up out of the same pot for the most part.

Once you are on Medicare signed over to Kaiser or Group Health, the Medicare Advantage programs have different coverages than the basic Medicare and there is a wide disparity in those coverages, for instance, this is not at all an issue with daily home dialysis at Kaiser, yet it is with Group Health.