[Dialyzers] To Re-Use Or Not To Re-Use

Hello, does anybody wanna share your thoughts about Re-Use and No-ReUse? I have a few questions about this…I’ve read around the net about Fresenius owned dialysis centers not re-using their dialyzers. Please share your thoughts about what you know or how you feel about this.

  • Does Medicare fully pay for each dialyzer or do they just pay a small part of it?

  • How many of you do No-Reuse and why?

  • Do you co-pay for non-reuse?

  • Would you be willing to Co-Pay for your dialyzers not to be re-used?

  • Why do in center dialysis clinics re-use?

  • The Aksys system also has a re-use system in place where dialyzer and
    lines are changed about every 30 days. How different is the re-use
    system on the Aksys than the system being used in center?

  • Medicare is running out of resources the cost of dialysis is at critical level and at same time the state budget is at stake. If you had a plan for dialysis patients where it would help the state budget and even cut down on costs what would it be?

Edit: Found very good information on this subject…

Medicare pays a set amount called the composite rate for most things associated with a dialysis treatment, including dialyzers. My first job working with dialysis patients was in 1978. At that time, the rate Medicare paid for each dialysis treatment was $150.

In 1983, Medicare introduced the composite rate. As I recall, it was around $120 a treatment. Today this rate is around $130 a treatment. Using the U.S. Bureau of Labor Statistics calculator shows that if the 1983 composite rate had kept up with inflation, today Medicare would pay twice what it does for dialysis.

Before the composite rate was introduced, dialyzers were relatively cheap and most clinics used dialyzers only once. Also, at that time, dialysis machines were less automated and patients often complained of headaches, nausea and vomiting, and horrible cramps.

As technology improved, dialyzers and dialysis machines became more expensive. Clinics looked to cost saving approaches including reusing dialyzers to keep costs more in line with payments. Guidelines were established to assure patient safety when dialyzers were reused.

Some clinics have chosen not to reuse dialyzers. This could be for a variety of reasons. Reusing dialyzers costs money in hiring or training personnel, purchasing equipment and supplies, and paying for extra utilities usage. Some companies, like Fresenius, not only have clinics that provide dialysis treatments but they make the machines and supplies to do dialysis (including the dialyzers). Companies that make their own equipment and supplies may cut costs for their dialysis clinics making the cost of not reusing dialyzers more reasonable. Clinics that don’t have the benefits of bulk purchasing or buying from a parent company must pay a higher price for their dialyzers making it more difficult for them to stop reusing as long as the Medicare rate only increases 1-2% every few years.

Finally I don’t think (I don’t know this for sure) it is legal for a clinic to charge a Medicare beneficiary extra for not reusing dialyzers. Medicare regulations require that providers (like dialysis clinics) that accept assignment not charge more than Medicare allows for covered services. Since the composite rate is intended to cover the cost of the dialyzer, Medicare might look on a clinic that charged extra for a single use dialyzer as fraud and abuse. No clinic or corporation wants to deal with the hassle or bad press a Medicare fraud and abuse charge brings. Other insurances may not have these restrictions and patients that wish not to reuse should check with their insurers.

Finally, patients have the right to request not to reuse dialyzers. However, clinics have the right to tell patients if they want to get treatment at the clinic in question that they will need to reuse. If this is not satisfactory to the patient, he/she can ask the clinic for help to find another place to dialyze that does not reuse or ask if the clinic requires home hemo patients to reuse.

I think Beth’s comments are, per usual, spot on but she leaves an important implication unstated - someone (a renal administrator for instance) could decide to go to no-reuse as a number one priority but with a fixed reimbursement any increase in cost would require a cut elsewhere. This is about choices and who makes that choice. Does the administrator increase staffing ratios? Eliminate evening hours?

As a patient do you choose to use a smaller kidney to do single use? That seems to be the most likely choice given rather than being able to pay some out of pocket premium (for the reasons Beth stated - I think tierd services would go afoul of CMS rules).

Like Beth said you get a lump payment. One additional revenue source are certain injectable drugs - primarily EPO - I would maintain that this cost shifting is dangerous. CMS should not “over pay” for EPO as a way to not pay an high enough composite rate. Also there are the private payors. For now most of us get a pooled service that is the same regardless of who is paying and how much they pay, as a CMS client I hope that does not change but there must be tremendous pressures/temptations.

I don’t think you could.

We copay now. But again no matter how reasonable the revenue becomes for whatever reason, choices will have to be made by someone. A one to one nurse/patient ratio is unlikely under all events.

Choices. Trying to find the best balance of resource use against the unlimited demand for resources.

For one thing Aksys uses a heat disinfection process that is chemical free and Aksys machines are only used by a single person.

Not sure what you mean. States like individual states? - Washington, Idaho etc - or the State as opposed to the individual? The feds have the greatest role in CKD. As we get better at keeping people from dying of one thing people will age until something else threatens death. The greatest money savings is probably to rethink the value of pallitive care and look at end of life issues. Things we as a country do not like to think about.

Thanks, Bill, for clarifying some of the hard choices that patients, administrators, and even insurers make every day in the world of dialysis. There is a bill in Congress now (see our legislative page) that would provide an automatic increase in the composite rate each year like other medical services get. There are many, many places where an update in the composite rate could be used:
– To offer newer technologies (like newer machines, daily and/or nocturnal dialysis)
– To provide improved patient/staffing ratios and more time for staff to listen and talk with patients
– To provide ongoing patient education starting before patients need dialysis or a transplant
– To establish programs of physical and vocational (age appropriate activities) rehabilitation
– To allow more clinics to use dialyzers once especially if patients request this

Even though most patients have Medicare and it does pay for the vast majority of the cost of dialysis, Gus is right that state budgets can be impacted by costs of dialysis. Medicaid (or Medi-Cal in California) pays for dialysis for those who qualify as primary payer (when a patient doesn’t have Medicare or other insurance) or as a secondary (or third) payer when patients have Medicare or other insurance. Some states (like Kansas) have limited the amount Medicaid pays for dialysis to an amount less than 80% of Medicare’s allowable so there is no supplemental payment for dialysis itself, although Medicaid may pay something on other dialysis-related charges.

The same is true of commercial insurance. Because Medicare pays so little for dialysis, clinics charge commercial payers more. Several years ago a GAO report said that extending Medicare secondary payer would not impact patients. However, this was because government looked at all patients and few of them were working then. However, when I looked at the data and studied the impact on just those patients who were working or whose spouses were working, I saw that large numbers had lost jobs, had not been hired for new jobs, or had been offered “incentives” to not take company insurance [which by the way is illegal]. I checked with the researchers who did the government study and they, like me, believed that something was going on.

Bottom line…In my opinion, Medicare should pay a reasonable rate for dialysis so that clinics can provide quality care without having to charge commercial payers as much…but enough from my soapbox.

There is a bill in Congress now (see our legislative page) that would provide an automatic increase in the composite rate each year like other medical services get.

Beth are you referring to the previous Bill (H.R.1784) or the new Kidney Care Partner’s Bill (HR 4927)?

I thought that both Bills require an annual review to see if a market basket adjustment to the composite rate is justified. In addition the review is to be made by an independent body. I think this is an important distinction rather than mandating an inflation adjustment the Bill allows an inflation adjustment.

The way I thought it was suppose to work is that the decision to make an adjustment to the composite rate is made by the Secretary of Health and Human Services following the recommendation of MedPAC. It maybe that an inflation adjustment is justified on a yearly bases but I think we need to split this hair when we talk to legislators. IMO.

The Medicare Modernization Act of 2003 (MMA) requires the Secretary to establish a demonstration project of the use of a fully case-mix adjusted payment system for ESRD services. CMS sought and is reviewing applications from those interested in serving in an advisory capacity to the Secretary regarding what should be included in the market basket of covered services.

The MMA also increased the composite rate by 1.6% in 2005. Clinics are grateful for any increase since it’s been a while. However, to put this in perspective, 1.6% translates to less than $325/patient/year (assuming a patient misses no treatment due to hospitalization or skilpping) or a whopping $32,500 for a 100 patient clinic. I don’t know anyone who believes this increase will be enough to vastly increase the availability of new technologies or improve the quality of care.

The ESRD Modernization Act of 2004 was introduced this month in the Senate (S. 2614) and House (H.R. 4927). S. 2614 (the only one of these bills currently online) states: “Beginning with 2006, the Secretary shall annually increase the basic case-mix adjusted payment amounts…” The Secretary is supposed to annually review what should be included in the “market basket” of goods and services covered by the composite rate. Under this bill, the Secretary must estimate how much the increase should be to cover costs of goods and labor based on the previous year’s costs. [Note: It’s my understanding that the current composite rate is based on decades old cost data.]

In addition to the automatic annual update, S. 2614 would provide funding for:
– demonstration projects related to public awaremess of kidney disease
– demonstration projects to promote patient self-management
– patient education programming
– demonstration projects on blood flow monitoring
– incentives for home dialysis
– an Institute of Medicine study to evaluate barriers to home dialysis

We’ll be posting information soon about these bills on our legislative action center. You can read about bills we’re tracking in action alerts and/or find a bill by key word or bill number.

What are they reusing??? Not the blood lines???

Yup. I reuse my F80 artificial kidney and the blood tubing 25 to 30 times - this is a design feature of the Aksys PHD. By reusing the blood circuit the Aksys provides the most biocompatible hemodialysis available anywhere, in any setting. And as an added benefit (as if optimal biocompatibility wasn’t enough) it makes daily preparation much easier because you only have to take the time to string the machine once a month.

By the way, the Aksys machine heat disinfects the entire circuit so that’s how you can reuse the dialyzer and the blood tubing that long.

What does it heat disinfect it with??? I am not so sure I would be keen on doing this in-centre! What about infectious diseases and what not???
Dont like the sound of that at all :?

The Aksys machine heats water to near boiling and runs it through the dialyzer and tubing. The hot water disinfects the whole extracorporeal circuit–which is reused for a month–without needing toxic chemicals that need to be rinsed out and might leave residuals. It’s quite safe and very effective.

You can read an article by Dr. Zbylut Twardowski about how the Aksys PHD works at http://ndt.oxfordjournals.org/cgi/content/full/18/1/19.

The Aksys PHD is only used in the home - one machine per person. I’ve been using the PHD since August 2002 without a problem: no infections, no hospitalizations. I think the PHD is well thought out, from the robust reused biocompatible blood tubing through the backflushes that increase convection - I like the PHD. I am satisfied that the PHD’s reuse procedure is very safe and offers an advantage. The benefit is that all of the surfaces that come in contact with the blood develop a protein coat during the initial treatment. This protein coat should minimize the immune response during subsequent runs because the protein coat keeps the blood from contacting a foreign surface.

The beef against the PHD is mainly that there were a number of service/reliability issues reported when the device was launched. A couple posters to this board reported having to back up incenter too often due to the PHD having a problem. The most common problems happen while the PHD is preparing the dialysate for treatment, I haven’t had or heard reported problems during treatment.

The PHD makes its own ultra pure dialysate. To do this it goes through a six or so hour process. If the PHD has a problem while it is manufacturing the 50 liters of dialysate it uses during treatment, I’ll likely miss that treatment and then I’ll have to miss the next day if the problem requires a tech to come out. If this happens to me I’ll set up a back-up run incenter. Getting a backup run incenter is probably as easy for me as is it could be for anyone and it is still a hassle.

In order to enjoy the benefits of infusible purity dialysate and high dialysate flow rates you need a machine that makes it onsite and that is not an easy thing to do. The PHD offers optimal, safe dialysis but as with every machine there are tradeoffs. When my machine needs to see a tech the inconvenience is manageable; when my machine is humming along I couldn’t be happier.