Medicare bundling just started in January and some facilities are still feeling their way with it.
Medicare reimbursement is much higher than it used to be for the first 4 months of dialysis for all new patients. If a new patient with Medicare receives training during those first 4 months of dialysis, because the facility is already receiving a much higher payment, Medicare does not pay extra for home dialysis training sessions for HD or PD. After the first 4 months Medicare will pay the equivalent of 1 hour of RN time per day for multiple hours of training per day so the training fee add-on should not really motivate a clinic to choose which patients to train.
The Medicare bundle now includes certain ESRD-related lab tests and injectable ESRD-related drugs and their oral equivalents, such as erythropoietin, iron, vitamin D, cinacalcet. This shouldn't deter a facility from training patients for home since home patients, especially those doing longer or more frequent dialysis, often need fewer drugs or lower doses than patients who do standard dialysis 3x/week for 3-4 hours per session, which should save a clinic money. In fact, many clinics are starting home dialysis programs because they believe they will make bigger profits on home patients.
I have not heard of any 20-point criteria that Medicare uses to determine whether to pay for home HD. Medicare pays for home HD for anyone who receives training for it. I bet the 20-point criteria is one the facility developed based on its understanding of Medicare reimbursement policies. The issue may be that the NxStage machine is typically used for dialysis more than 3 times a week. The number of treatments that Medicare routinely pays for is 3/week. In some cases, patients have certain medical conditions that their doctor can spell out to Medicare that will get payment for more than 3 treatments per week.
Dialysis facilities bill employer plans at a much higher rate than Medicare approves. Therefore clinics make a higher profit the more patients they have with commercial insurance. A clinic may be reluctant to put a patient on NxStage if the clinic or corporate management believes there won't be an immediate profit. However, the clinic or corporation may want to look carefully at data on studies of patients on NxStage that show that these patients have better outcomes, which may mean longer and reliable payment from Medicare and the supplement. In addition, it's possible as stated before that patients using the NxStage will need fewer drugs that clinics have to buy and provide. It's highly possible that this will be even more important as the dialysis bundle includes more drugs and the new "quality incentive program" reduces payments to facilities that have too many patients who don't achieve certain outcomes.
If your acquaintance wants to use the NxStage and cannot get that facility to approve it, I recommend that he/she look at the database on this website to see what other facilities in his/her area offer daily home HD. This may mean changing doctors. An alternative is for the patient to advocate with the doctor to advocate for him/her with the facility management who may be making this decision without physician input.
Just wondering, has your acquaintance considered PD. Medicare has no problem paying for PD, which patients can learn to do quickly and which that can do either manually 4-5 times a day (CAPD) or using a machine overnight while sleeping (CCPD). These would be good options, especially for a new dialysis patient not wanting to do in-center HD. PD helps patients keep whatever natural kidney function they have longer and PD works at least as well as standard in-center HD.
Finally, as more and more facilities see the health benefits to their patients and financial benefits to themselves, there will likely be more dialysis facilities that offer more home dialysis options.