Cost of Nocturnal

What is it costing units to run 3x week nocturnal programs, 6x week? What is stopping more nephrologists from startiing programs?

A clinic’s costs depend on a lot of factors – costs of staff, supplies, machinery, rent, utilities, insurance, etc. When dialysis is done in a patient’s home (as nocturnal is done most offen), a home training nurse’s costs are less because one nurse can take care of more home patients and the patient pays for the water and electricity used by the machine. However, clinics still must pay for the machine itself, supplies, and fixed costs to keep the clinic open such as rent, insurance, other staff salaries, etc. We hope to soon have some cost models for home dialysis on this website.

No matter how many times a patient does dialysis, Medicare reimburses for dialysis 3 times a week at a rate that has not changed much since 1983. If Medicare reimbursement for dialysis had kept up with inflation, it would be twice what it is today. You can read about Medicare reimbursement for home dialysis in the Medicare FAQs section of this website.

When a patient does home hemodialysis 6 times a week, some costs are twice as much as when a patient does home hemodialysis 3 times a week. Some clinics have chosen to take on the added costs because small studies have shown that there are cost savings due to fewer hospital stays and need for fewer medicines. Best of all, patients feel better, enjoy a more liberal diet and can drink more fluids, and are more active. I know daily (and nocturnal) hemodialysis patients that keep working and have heard of others that have returned to work after being on disability because they feel so much better. Helping patients live a more full life was one of the goals that led Medicare to pay for dialysis in the first place.

The government plans to do a large study of the cost-benefits of daily dialysis. Medicare plans to wait until the study is completed in 2008 or later to consider paying for more frequent dialysis. Visit the Legislative Action Center from the Home Dialysis Central home page and read about the House bill – Kidney Patient Daily Dialysis Quality Act of 2003. This bill needs a senator to introduce a companion (similar) bill in the Senate to even be considered before Congress adjourns this year. If passed, this bill would get Medicare coverage for more frequent dialysis If you support this bill, tell others and let your senators and representatives know what you think. You can find and write them through the Legislative Action Center.

IF Medicare pays for 3x week hemo currently, then why couldn’t all home hemo patients do 3x week nocturnal and why couldn’t units offer in-center nocturnal 3x week? Also, I have heard of home hemo patients who do txs 4-5 times a week. How are they able to do it?

Regarding legislation, is there a cost model to show what units take in in order to prove whether or not they require higher reimbursements? And shouldn’t higher reimbursements be contingent upon proof of quality care/outcomes?

Hey Josh, I found more indormation pertaining to more frequent dialysis which might interest you…

By Robert Jaffe M.D

It is essential that you become aware of your treatment options and advocate for the best possible care you can have.

Dear patients, providers, family and friends,

I am a family physician and dialysis patient in Seattle. I have dialyzed from 3-6 days a week, and have found 5-6 day/week dialysis to be much more effective in reducing my fatigue, anemia, and other problems. Patients in the US, Canada and Europe are doing more frequent daily and nocturnal hemodialysis with remarkable results - fewer uermic symptoms, better quality of life, and less need for drugs to treat anemia and high blood pressure.

In the US, this treatment is not available to patients because Medicare only pays for dialysis 3 times a week. The government are interested in more frequent dialysis and is planning a study for several years. Patients, physicians and staff who have experienced or seen the benefits of more frequent treatment feel they cannot wait for availability through the Medicare program.

Seattle Congressman Jim McDermott (D) and Congresswoman Jennifer Dunn ® have introduced legislation (HR1759) to pay for more frequent hemodialysis. Attached is a copy of their letter asking colleagues to co-sponsor this bill and also some background information. For more frequent dialysis to be available to all patients who wish to use it, Congress must direct Medicare to provide payment so dialysis units can provide this service. At the same time, Medicare will save from fewer hospitalizations and lower drug costs, while the improved quality of life will allow more patients to return to work or school.

For HR1759 to pass Congress a grass-roots effort is needed for each of you to:

  1. Write, call, email and/or fax the Representatives in your state asking them to co-sponsor HR1759.
  2. Write John Davis, Chief Executive Officer, National Kidney Foundation,
    asking the Foundation to support HR1759.
  3. Write Kris Robinson, Executive Director, American Association of Kidney
    Patients, asking the Association to support HR1759.

Sample letters are attached. Keep it brief and to the point. Phone calls, faxes and emails are also effective. A visit to the district office of your Congressperson is even better. Let meknow whom you have approached and their responses.

If you or someone you know have experience with frequent dialysis, describe these experiences. You may also write to comment on current experiences with 3 times a week dialysis and why you would like to have more frequent treatment as an option that you and other patients could select if you wished to do so.

If you have questions, contact me at bob@kickbutt.org. Thanks for your support.

Robert D Jaffe MD

Dear Congressman (woman)_________
There is increasing evidence that hemodialysis five or more times weekly rather than the usual three times a week provides great benefits for many patients with end stage renal disease. Patients feel better during and between dialyses, their quality of life is markedly improved and opportunity for rehabilitation is enhanced. These benefits have been reported in many papers from this country, Canada, and Europe. The Medicare Program currently only pays for hemodialysis three times weekly. While more frequent dialysis will increase the cost of dialysis, this will be offset by savings to both Medicare and patients from reduction or elimination of the need for erythropoetin and drugs to control high blood pressure, and reduction in frequency and days of hospitalization.

I (My family member__________ or My friend______) have/has been on more frequent dialysis in (place)_____ since (date)_________confirms these findings.

On May 8th, Congressman Jim McDermott (D) and Congresswoman Jennifer Dunn ® introduced HR1759, the “Kidney Patient Daily Dialysis Quality Act of 2001” to amend title XVIII of the Social Security Act to provide for payment under the Medicare program for more frequent hemodialysis treatments.

On behalf of dialysis patients here and throughout the United States, I urge you to support this bipartisan legislation and to consider becoming a co-sponsor of this important bill.

If you have any questions, please feel free to contact Representatives McDermott or Dunn or their staff or to call me at __--.

Sincerely yours
_____________(Patient, Family of Patient, Friend of Patient)

John Davis
Chief Executive Officer
National Kidney Foundation
30 East 33rd Street
New York, NY 10016
Phone: 800-622-9010
Fax: 212-689-9261
Email: info@kidney.org

Dear Mr. Davis,

There is increasing evidence that hemodialysis five or more times weekly rather than the usual three times a week provides great benefits for many patients with end stage renal disease. Patients feel better during and between dialyses, their quality of life is markedly improved and opportunity for rehabilitation is enhanced. These benefits have been reported in many papers from this country, Canada, and Europe. The Medicare Program currently only pays for thrice weekly hemodialysis. While more frequent dialysis will increase the cost of dialysis, this will be offset by savings to both Medicare and patients.

I (My family member__________ or My friend______) have/has been on more frequent dialysis in (place)_____ since (date)_________confirms these findings.

On May 8th, Congressman Jim McDermott (D) and Congresswoman Jennifer Dunn ® introduced HR1759, the “Kidney Patient Daily Dialysis Quality Act of 2001” to amend title XVIII of the Social Security Act to provide for payment under the Medicare program for more frequent hemodialysis treatments.

On behalf of dialysis patients throughout the United States, I urge the National Kidney Foundation to support this bipartisan legislation - HR1759. This is an important quality of care issue, as well as a choice issue for all ESRD patients.

Sincerely yours
_____________(Patient, Family of Patient, Friend of Patient)

Kris Robinson
Executive Director
American Association of Kidney Patients
100 S Ashley Drive, Suite 280
Tampa, FL 33602
Phone: 800-749-2257
Fax: 813-223-0001
Email: info@aakp.org

Dear Ms. Robinson,

There is increasing evidence that hemodialysis five or more times weekly rather than the usual three times a week provides great benefits for many patients with end stage renal disease. Patients feel better during and between dialyses, their quality of life is markedly improved and opportunity for rehabilitation is enhanced. These benefits have been reported in many papers from this country, Canada, and Europe, and there are now more than 150 papers in the world literature documenting them. The Medicare Program currently only pays for hemodialysis three times weekly. While more frequent dialysis will increase the cost of dialysis, this will be offset by savings to both Medicare and patients.

I (My family member__________ or My friend______) have/has been on more frequent dialysis in (place)_____ since (date)_________confirms these findings.

On May 8th, Congressman Jim McDermott (D) and Congresswoman Jennifer Dunn ® introduced HR1759, the “Kidney Patient Daily Dialysis Quality Act of 2001” to amend title XVIII of the Social Security Act to provide for payment under the Medicare program for more frequent hemodialysis treatments.

On behalf of dialysis patients throughout the United States, I urge the American Association of Kidney Patients to support this bipartisan legislation - HR1759. This is an important quality of care issue, as well as a choice issue for all ESRD patients.

Sincerely yours
_____________(Patient, Family of Patient, Friend of Patient)

In response to Gus, these letters were circulated a couple of years ago during the last session of Congress when there were bills in both the House and the Senate. At the end of a congressional session, all bills that aren’t acted on die. When the new congressional session began in 2003, Drs. Blagg and Lockridge had to find legislator(s) to introduce the daily dialysis bill again. The current bill that is before the House is HR 1004. Although Drs. Blagg and Lockridge have put forth a lot of effort to get this bill introduced in the Senate, no senator has introduced it yet. Since it improves the chance that a bill will become law if it is introduced in both the House and the Senate and has more representatives and senators as co-sponsors (supporters), this bill may die again this year and have to be re-introduced in 2005. Don’t give up! There are many advocates out there. It’s important to realize that good legislation often takes years to get passed and if at first you don’t succeed, try and try again!

In response to Josh’s earlier questions:

Why can’t all patients do 3x weekly nocturnal either at home or in a clinic? Nocturnal dialysis is not a commonly used treatment. Most doctors and nurses have no experience with it. I suspect that those that don’t know much about it, worry about its safety and their risk of being sued. The more clinics that do it and the more patients that do well and advocate for it, the more common it will become. Check out our Find a Center database to see where nocturnal (and daily) home hemodialysis are offered.

A few centers are starting in-center nocturnal dialysis and most probably offer it 3x/week since Medicare only routinely reimburses for 3 dialysis sessions weekly. These clinics had to find nurses that were willing to work nights and probably pay more per hour. Personally, I can’t imagine why anyone would want to do nocturnal dialysis at a clinic. I wouldn’t want to be away from my family that much or to have other patients and medical personnel making noises around me while I tried to sleep. Also, knowing how much patients complain about spending 3-4 hours in those wonderful dialysis recliners, I suspect most patients would choose their own bed at home over spending 8 or more hours in one.

Why can some patients do 4-5 treatments a week?
– Some patients may have private insurance that will pay for as many treatments as they need.
– Some may be in areas of the country where the companies that pay Medicare claims are more likely to accept doctors’ statements of medical justification and pay for more treatments.
– Some patients get dialysis in clinics that have more patients with commercial insurance instead of or in addition to Medicare and these clinics can afford to lose money on some patients who get more treatments that Medicare denies payment.
– Some patients are getting extra treatments as part of a study that their clinics are conducting to try to show the cost-benefit of extra treatments.

Regarding cost models and justifying higher reimbursement, the kidney community has asked for higher reimbursement for years. Every clinic sends Medicare a cost report that shows how much it cost that clinic to treat its patients that year. Clinics report that they lose money on Medicare patients. They point to the fact that other areas in healthcare get automatic Medicare reimbursement increases every year. Dialysis does not and must depend on Congress to approve increases. Actually there is to be a very small increase in the reimbursement in 2005. Check out the Legislative Action, Current Legislation for Medicare Renal Dialysis Payment Fairness Act of 2003 (S. 1098 and H.R.1784) that would update Medicare reimbursement for dialysis annually.

Beth you wrote:

Personally, I can’t imagine why anyone would want to do nocturnal dialysis at a clinic. I wouldn’t want to be away from my family that much or to have other patients and medical personnel making noises around me while I tried to sleep. Also, knowing how much patients complain about spending 3-4 hours in those wonderful dialysis recliners, I suspect most patients would choose their own bed at home over spending 8 or more hours in one.

I like the in-center 8 hour option and think the excellant results from thirty years of experience in Tassin France means that a dialysis consumer should consider this option carefully if home nocturnal or short daily is unavailable. I’ll be dialyzing on a nocturnal in-center shift when I am in the Chicago area in two weeks and when I am at the AAKP convention over Labor Day weekend.

There is no question that is inconvienant but that is true of all forms of dialysis. One nice thing about in-center nocturnal or in-center dialysis in general is that you can use ear plugs or a personal sterio because staff are there to hear and answer alarms.

I’m off to explore rainy Copenhagen. But I would like to note that there is one other reason some people have the option of more frequent home dialysis - if you dialyze through a nonprofit provider that operates to fulfill their mission rather than the Medicare minimums. A provider like my provider the Northwest Kidney Centers.[/quote]

How is it determined how much of a profit units should be allowed to make? Should profit be contingent upon proof of quality of care/outcomes?

I think a percentage of dialysis conumers would want the in-center nocturnal option. Yes, it would be more comfortable at home, but there are consumers who need assistance.

Some dialysis clinics are non-profit. Others are for-profit. Insurance companies, including Medicare and Medicaid, set limits on payments to dialysis providers whether they are non-profit or for-profit. Commercial payers may pay at a higher rate than either Medicare or Medicaid. Commercial payers’ rates are negotiated with dialysis providers. Dialysis providers have said for a long time that Medicare and Medicaid rates are less than what it costs to do a dialysis treatment. This means that commercial payers are being asked to make up the difference.

Like any other business that wants to stay in business, dialysis clinics (for-profit and non-profit) must make enough to pay their bills and if they’re publicly traded (on the stock market) enough profits to keep stockholders happy. The same is true with your grocery store, utility company, bank, drugstore, and any other business.

There has been discussion of linking payment with outcomes and even legislation in the past that would have done this. Although this sounds like a good thing that many people would support, one of the problems with it is that you have to figure out what outcomes are important and how to measure them accurately.

With the help of expert teams of patients, professionals, providers, and researchers CMS has developed a set of things that they look for and report that address at least some of the medical aspects of care. These include such things as:

  • PD and hemodialysis adequacy
  • anemia management
  • vascular access
  • blood pressure control
  • nutrition
  • survival
    Although quality of medical care is important, patients are often interested in things other than medical care as well. Therefore, Medicare is developing a patient satisfaction tool which may help clinics to assess and improve this key aspect of care.

One thing that is not currently evaluated against any standard or compared among clinics is how well clinics do at helping patients live as much as possible as they did prior to starting dialysis (also called rehabilitation). Patients who are able and want to work should be given every opportunity to do so, including the option of doing dialysis at home. Research shows that working patients are better insured, have a higher standard of living, are less depressed, feel better about themselves, and stay healthier. Employment is significantly higher for those on home dialysis than for patients doing in-center hemodialysis. Our hope is that Home Dialysis Central will promote knowledge about home treatments and allow more patients access to them so they can live full, active lives and feel that the care they’re getting is worth the price.

I just read an article where in Rochester, NY they are dialyzing patients at midnight because the ESRD poplulation has grown so much. Also in the article was a mention of opening up new dialysis centers and expanding current ones. However, I find it interesting that all of this money can be put forth for in-center treatment and there was no mention at all of initiating any type of home hemo program to help with the problem. I would like someone to show me that it is cheaper to buy property and open new facilities rather than start a slow nocturnal program, or daily dialysis program.

Good point…and one that I’ve been making for years every time I talk with anyone about in-center vs. home dialysis. It drives me crazy to see dialysis clinics build more buildings or expand clinics to sizes that appear to foster patient/staff or patient/patient conflicts. Home dialysis could be the obvious solution to rapid growth in the numbers of people with kidney failure and the shrinking nursing population.

MEI plans to post cost models from an administrator who has been a leader in the National Renal Administrators Association on this website. We believe these will dispel the myth that home dialysis is too expensive to offer.

It takes preparation and money to start a home dialysis program. You must have qualified staff, space to train patients, educational materials, and you must have enough patients that want to be trained and will stick with home dialysis long enough to make up the start-up costs. I believe there is a point at which home dialysis is more cost effective and it is probably sooner than many people believe.

Another thing many administrators don’t seem to consider is that if patients do dialysis at home, more of them can keep their jobs or return to work. Patients who work are more likely to have commercial insurance with or without Medicare. Commercial insurance pays more as a primary payer than Medicare and may not have the same limits as Medicare (treatments/week, hemoglobin levels, etc.). Having a changed payer mix (more commercial vs. Medicare primary patients) could make cost savings occur even sooner and allow clinics to offer more things to their home as well as in-center patients.

For what it is worth. Our nocturnal program no way skimps on anything to cut cost. New dialyzer everytime, Night Monitoring via computer, 6 nights a week dialysis. We were told right up front at 1st they would loose money at 16 patients they would break even. We are now up to 30 patients and growing. The only patients not sticking with the program are those who have moved or been transplanted and I think 1 man became to ill to do it at home.
Patients don’t quit nocturnal dialysis because they don’t want to feel sick again. When patients in our program take vacation and have to go back in-center they all come back saying they can’t wait to get doing it at home again.

I think the money issue is myth and I also think the idea that patients won’t stick with it is a myth. I think the issues “may” have some creditablity but not anywhere near the extent it is being played.

Keep asking the question…why are we always looking to solve the problem by adding centers and not offering home options because I don’t think were getting to the bottom of it yet.

Hi Marty,
You’re right. There are lots of myths about home dialysis that people like you and other home dialysis evangelists need to dispel. Apparently your clinic has figured out that by providing a service that people want and need, it will attract more patients. It’s the old “if you build it, they will come” routine.

I hope your clinic is listed correctly in the Home Dialysis Central database. If your clinic chooses to become a center sponsor, patients (and staff) that visit Home Dialysis Central looking for where nocturnal dialysis is offered can read whatever your clinic wants to share about how it decided to offer this unique treatment, how many patients your clinic treats on this an other home treatments, your staffing, patient outcomes, etc. It’s a great way to let others know the clinic’s commitment to home dialysis.

I’d love to know your clinic’s payer mix – how many nocturnal dialysis patients have primary Medicare vs. commercial insurance. It would help to know how many commercial insurers as primary payers it takes to offset Medicare not paying for extra treatments or if this is required at all to breakeven. What I’ve heard from staff at clinics that offer nocturnal and daily dialysis is that they make up some of the losses in Medicare because patients are hospitalized less since they’re healthier. I believe upcoming studies will document the cost benefit of these newer treatment options and look forward to a better future for people on dialysis.

Beth if you want to tell me how to e-mail you by e-mailing me I can give you a name of the person in charge of our program. She has been very helpful at giving people information regarding the cost of the program. I know for sure that 1 place in NYC visited the center to find out about it and 1 place in Sayre, Pa. I was there when they came. I’ll see if I can find out about the patient ratio Medicare vs Insurance. Off the top of my head I would say there are a lot more Medicare patients as almost every patient in the program I have talked with has been on Medicare. As far as the reason for starting the program this is a quote. The nocturnal staff asked the Nephrologist why are we starting a nocturnal program if it is going to loose money. His reply “It’s the Right thing to Do” Well as you can see it turned out right for the patients and the center as they are beyond the breaking even point. I have no doubt that the program will continue to grow as more patients hear of the health benefits in regards to nocturnal. I can give you an example about hospitizations. My father will be 80 in 2 weeks and in the 4 years he has been on nocturnal he has not been hospitalized or sick. Prior to that in-center 2 years I know of at least 3 times he was hospitalized with hypotension. I also think Nephrologist shouldn’t be too afraid because they don’t know much slow nocturnal. We are no different that in-center patients. Our labs are drawn and decisions made accordingly…just as in-center. The only difference is we always have good Kt/V and Urea reduction. Dad’s Kt/V is always in the 2. something range and Urea Reduction 85% upward. I could go on along time about all the changes I saw in dad and he labs but I think the info is out there. If you want a contact to ask questions about slow nocturnal my e-mail was posted under the topic of tips for home patients.

P.S. I am very greatful to the person(s) who started this board. The mysteries and the myths need to be erased from home dialysis. Had it not been for a few caring patients who responded to my post on other boards, we would not be where we are at today. I was scared at 1st and their assurances got me past that. This board will help others with that.

I’ve been a dialysis pt. for over three years, in center. I’m now at a newer center closer to my home. The first center was an FMC unit, with a sister unit that offered home-hemo (hd). I signed up and was told I would be what they felt was an excellent home pt… Most of what we needed to do to our home was already done, my husband is supportive and willing to help with cannulation, and I’ve worked in healthcare for a long time prior to dialysis, knowing about infection control ect… I was so excited about starting the program because I’ve read what Marty and others have said about home-hemo, and how it makes pts. feel better. It was a slow nocturnal program so I figured I could work at least part time. To be honest, in center dialysis is sucking the life right outta me; I know older people (not on dialysis) that have more energy than I do! I was told I couldn’t do home hemo without paying extra for the water disenfection because I have my own well, and it run into the hundreds of dollars per month! Mind you, no one ever came to my home, tested water, ect. so that wasn’t the problem. My ins. co. at the time was paying over 13k per month for my txs… so my feeling is that should’ve been enough. Other pt.s have wells and are on home hemo. My feeling is that sometimes the companies only offer home hemo because they have to, and do whatever they can to discourage pts. away from it, and that’s not right! The center offering the home hemo closed about 6 mths. later and moved operations, so that too might’ve been the real reason they discouraged me. I guess I’ll never know for sure what happened.
The unit I’m at now doesn’t offer home hemo, but when they do I’m signing up, and will likely be the first pt. to do so.
After all, if someone like Marty (a caregiver of a pt.) talks so highly of home hemo it must be good! I don’t hear anyone “talking up” in center hd, but I sure do hear a lot of folks talking about how they and loved ones feel much better/have more energy on home hemo, and I want in too. I’m tired of being tiried at the young age of 50. Lin.

Hi Marty, You are right on about it all, as usual! It seemed to me (at least in my case) that the center just wanted in center, and didn’t want to both with home pts… aside from that they were buying up other units in the area, and even talking about building new ones. It just makes more sense to utilize assets one already has and offer an incenter slow nocturnal program. In my mind it would be a win/win situation. I was told that the first unit I was at wanted to start a program but had a problem staffing, but of course they just asked their current staff. Hospitals have night shifts, so what would be different about finding staff for a dialysis program? I would prefer to do home hemo/slow nocturnal, but of course would jump at the chance to switch to incenter slow nocturnal as there are no home programs where I live (yet!).
Marty, Beth, others, What would you suggest one who wants a program do? The center I’m at is a brand new one, that offers pd but not home hemo/hd; how can I politely persuade them to offer a program? Lin.

Lin, That is the million dollar question. I don’t think you can persuade staff and in a lot of cases even the Nephrologist. I think the decision to start programs comes from higher up the line and I don’t know how one even gets to talk to the person who can make the decision. Maybe that in itself creates the problem; it takes more than 1 person to make the decision to start a program and if someone opposes it obviously the suggestion will just lay in wait or die. I can’t even get permission to talk to patient support groups about slow nocturnal.

I’m not sure what others might suggest, but here are a few thoughts that I have about ways to encourage your clinic to think about starting a home hemo program:

– Ask the facility administrator, nurse manager and/or your doctor what each thinks about home hemodialysis in general and the possibility your clinic might have a program in the future (if so, when). [Don’t be surprised to hear negatives as there are many myths and misconceptions.]

– Ask whether the clinic currently has staff that are experienced in training new nurses and technicians in hemodialysis who might be interested in training and working with home hemo patients and family members. [State that patients wanting to do home hemo may be even more motivated to learn because their lives depend on doing a good job.]

– Ask how many interested patients would it take for the clinic to consider starting a home hemo program. [Expect to hear that few would be interested since many staff think patients aren’t interested in learning or taking responsibility for themselves or their care.]

– Ask what specifically is being done to educate existing and potential patients about other options for treatment, such as home hemodialysis. [If the clinic does not have a designated patient educator, education may slip when workload increases.]

– Ask if the clinic to offer an education program on treatment choices. Make sure that it includes information on home hemodialysis and has at least one patient speaker who is doing home hemo. This person could come from a sister clinic of the same corporation so if patients choose to go to another clinic that offers home hemo, it’s not a competitor. I’d recommend that part of this discussion be that patients wanting home hemo should commit to sticking with it for at least a year unless something unforeseen happens (transplant, serious health setback, loss of partner, if required, etc.).

– Ask the clinic to survey patients who attend treatment education classes about what treatment they want to do before and after the class. Others have found an increase in the number of patients wanting to do PD or home hemo when these options are discussed.

What other suggestions do people have? Has anyone successfully advocated for a home hemo program at a clinic?