Paying for Nocturnal Dialysis

I would like to review the ways 4-6x week nocturnal dialysis txs are paid for. I could get on the NxStage today if I opted for short daily txs., but from everything I’m reading, I’m leaning more toward nocturnal txs. My understanding is that units can afford short daily txs with NxStage as NxStage does not require a tech to come out if the machine breaks down and there is no overhead.

Now when it comes to nocturnal txs, since my unit does not have an existing nocturnal program, but my doctor is willing to start a program, can someone tell me if it is possible for my unit to get paid enough for me to begin doing nocturnal txs or would my unit have to take a loss until they could get more patients in a nocturnal program? I would appreciate any suggestions on how nocturnal programs are started and made cost effective enough for the providers.

Also, with nocturnal programs, should technical support be available 24 hrs a day and in starting a program what are the possible choices for who will do the machine repairs? ( the local unit’s biotech, nocturnal machine company’s biotechs etc)?

I have 24/7 support for medical issues, ie a nurse on call, but tech support for machine issues is generally M-F. I have not had serious machine issues so this is not a problem with me, the Fresenius is pretty reliable.

You unit should already have a contract for repair of their machines, I believe the lease rate on my machine includes semi annual checkups and 2 service calls per 6 months.

I believe units will lose money on home dialysis, (no difference in cost to my knowledge between daily or nocturnal) with Medicare patients, but if you have private insurance I’m really not sure they would lose money if they don’t hire additional staff as my insurance reimburses around 14,000 per month and I know the machine and supplies don’t cost anywhere near that.

In my program, I have Lifeline for emergencies, and a 24 hour on call nurse (via the hospital operator). The nurse (not the patient) has access to a 24 hour on-call technician, but they only actually do repair/maintenance calls Monday to Saturday. The technicians who fix the Fresenius machines are employees of the hospital, the same ones who take care of the in-centre machines. It really adds nothing much than if those machines were in the dialysis centre, except maybe for parking and the occasional parking ticket when people live downtown as I do. My setup is basically no different than the satellite dialysis units they take care of in smaller town in the region. To the technicians, it’s just an extension of the dialysis centre.

In terms of cost, in Canada, it’s a totally different scenario, because it’s a single payer system, with everyone basically insured by the government. It’s easier for hospitals to convince provincial governments to fund nocturnal programs, because they can show the savings to the whole system rather than just to the dialysis program itself.

But whatever the paying arrangements, you need a 24 hour nurse, but you don’t need 24 hour technical support for the machine itself. If something goes wrong enough that I can’t troubleshoot it and resolve it myself, and I have to phone the on-call nurse, it’s very likely that I will end up loosing the rest of that treatment anyway by the time anyone could do anything. You can only have the blood pump off for so long.


in a clinical dialysis program I think most will agree that staffing is one of the major cost factors. when you take dialysis out of the clinical setting the equipment and supplies (following training of course) become the major cost factor.
when I did nocturnal at Rogosin I was told that it took roughly 25 patients to reach a “break even” point, I am not quite sure I agree, but we did have nightly phone monitoring in case of alarms which were not readily repairable at home.
on NxStage monitoring was not done because dialysis was done during waking hours and problems are better solved while wide awake.
having done both I preferred the NxStage, but I agree we are all unique and what is important to me may be the opposite for you.
I will not try to convince you to choose NxStage but I will ask you to consider all your options, including your personal finances, before making a choice

I was told it would take 16 patients to break even and the biggest cost of the nocturnal program was the computer monitoring. Staff really isn’t a problem because it takes less nurses and techs. We have 1 nurse on call and 1 tech monitoring over 30 patients each night. If these 30 patients were in-center how many nurses and techs would it take. Our unit has contracted with someone to do our machine repairs and maintenance the unit personnel do the RO’s themselves. I was also told that private pay patients definitely helped the program to be profitable as they pay more.

What would be the difference in cost with the NxStage (SDD) vs a machine for SND? Because the NxStage is done daily yet is economically affordable/profitable.

To illustrate the other end of the spectrum, our home hemodialysis nurse only works on Tuesdays and Fridays. There are two backup nurses who may be called the other 3 weekdays during working hours. We are instructed for after hours or weekend problems to call our physician. This leads us to his answering service and ultimately a call-back from whichever physician is on call.

We have no online monitoring. Despite all these limitations we have managed quite well for nearly 3 years on nocturnal. I have called Fresenius perhaps a half-dozen times during that period and a tech always returns my call within 20 minutes with whatever machine help I need. I believe Fresenius also has a clinical nurde on call, but I am not certain as I have never tried to contact their nurse.

My sense is that the cost of home programs could be cut down thereby lowering the breakeven point. While safety is important so is making home dialysis economically available to more patients.


Mel, I agree with what you said. I was just giving the information on what we have.