NxStage and Medicare


#1

I am asking this question on behalf of an acquaintance whose heart is set on doing home hemo with NxStage. S/he has been told by his/her clinic that s/he is “too healthy” and doesn’t meet their 20 point criteria for Medicare to pay for home hemo. This sounds extraordinary to me because this clinic is essentially saying that there is inherently a two-tier system, ie, that people with private insurance get to do home hemo with NxStage but Medicare patients do not. The clinic in question has said that Medicare bundling has changed how patients are given availability to home hemo with NxStage.

I have asked this acquaintance to come here and ask you directly, but I think s/he is so despondent that that may not happen, so I will ask instead. Could you please clarify exactly what Medicare will pay for re home hemo with NxStage? Thanks so much!!


#2

[QUOTE=MooseMom;21264]I am asking this question on behalf of an acquaintance whose heart is set on doing home hemo with NxStage. S/he has been told by his/her clinic that s/he is “too healthy” and doesn’t meet their 20 point criteria for Medicare to pay for home hemo. This sounds extraordinary to me because this clinic is essentially saying that there is inherently a two-tier system, ie, that people with private insurance get to do home hemo with NxStage but Medicare patients do not. The clinic in question has said that Medicare bundling has changed how patients are given availability to home hemo with NxStage.

I have asked this acquaintance to come here and ask you directly, but I think s/he is so despondent that that may not happen, so I will ask instead. Could you please clarify exactly what Medicare will pay for re home hemo with NxStage? Thanks so much!![/QUOTE]

Moosemom,

I would suggest to ask for the exact policy or documentation that states this from the clinic. Also ask to see the 20 point system that they are basing this on… Dialysis is dialysis and it should matter if it is performed in-center, at home, or in a barn. When your kidneys fail, you need dialysis to survive. How does one give a point system or level on how healhty you are. Ask them how many points out of 20 they received… what what they need to work on so that they can become sicker to qualify…

///MM


#3

I’m assuming you meant to say, “Dialysis is dialysis and it should NOT matter if it is performed…”

I will direct my acquaintance to this thread. I, too, am most eager to see the exact policy/documentation at this clinic. This sounds bogus to me. Thanks so much.


#4

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.


#5

She did PD for 8 years, then had a transplant, and is now back on dialysis. Because of issues with scar tissue, she is no longer a candidate for PD.

I will direct her to your post. Thanks so much for your very quick reply. I really appreciate it.