In which programs do you reuse dialyzers?
So then, is everyone using new dialyzers each tx? Which dialyzer model do you use? I read where someone said that the only two economical machines for daily txs would be Aksys PHD, which reuses the dialyzer and lines appro. 30 times, or a machine like Fresenius with reused dialyzers. But, of course, that would be a nusiance for patients in home programs to deal with returning and picking up reused dialyzers.
I just read about Medicare Type 1 and Type 2 Payments for home hemo dialysis and it stated that Medicare pays for 3 dialyzers and line set ups per week. Since daily txs are 5 or 6 per week, who pays the extra costs? Since there is no overhead, does it come out of what would normally be allotted to overhead costs?
I don’t reuse anything in my program. My dialyzer is a Fresenius F70NRe. Apparently it’s still cheaper for the healthcare system to do it this way than what it costs to treat patients 3 times per week in a dialysis centre - but I think that’s when they consider reduced medications, reduced hospitalizations, etc.
Around 60% of dialysis clinics were doing reuse until recently. Fresenius recently stopped reusing dialyzers as part of its Ultra Care program. Fresenius has the advantage of both running dialysis clinics and selling machines and supplies plus it’s the largest dialysis corporation if you count the number of patients that are treated by Renal Care Group, a corporation that Fresenius is in the process of buying now.
If you want to read about reuse in general (not about how home patients reuse dialyzers), you might want to read this articlke in the AAKP newsletter:
The Aksys machine uses heat to clean and disinfect dialyzers so they can be reused up to 30 times. Other machines do not do this and if a home patient reuses, he/she must return used dialyzers to the clinic where they are reprocessed and returned to the patient for the next use. Clinics have processes in place where a patient gets several dialyzers to use and returns all of them and gets his/her dialyzers back after disinfection.
So far as costs for daily and nocturnal dialysis, because Medicare only pays for 3 days worth of supplies and because the overhead is lower for home dialysis, some nonprofit clinics have said that if Medicare would even pay for one more treatment a week, it would be possible for them to financially afford to treat patients 5-6 days a week. The lower overhead is reportedly not sufficiently different to totally offset the higher supply costs for more frequent treatments. Finding ways to finance more frequent dialysis is why all dialysis clinics that offer convention HD or even PD modalities are not also offering these newer modalities.
If PHD reuses the same dialyzer and lines up to 30 times does that mean that the PHD is the only machine for home use that can be profitable for companies?
Keep in mind that whatever I mention about my home dialysis, even though I use a Fresenius machine, there is no connection at all with Fresenius the company. It’s not a Fresenius program.
I don’t know what any of the companies charge for machines but suspect that the more bells and whistles a machine has, the more expensive would be. You’d have to talk with the machine manufacturers or dialysis providers about the cost of the various machines.
I suspect that the dialysis machine is probably the single biggest outlay. If the clinic buys instead of rents, it does eventually own the machine but it takes a long time to recoup the costs of the machine. I’m not sure which machine makers rent machines to clinics but the downside would be that the clinic would never own the machine and would always be paying for it even years later. The upside might be that it might be easier to get newer machines since the clinic wouldn’t have to worry about an inventory of old machines.
I suspect the next biggest cost for home hemo to the clinic is for training. Training generally ties up one nurse for 3-6 weeks, depending on the type of machine. Medicare only reimburses $20 per training session in addition to the composite rate. I assume someone at Medicare thought at one time that $20 would offset the costs. I can’t imagine that even when this amount was established in the 1980s that $20 per training day would have paid for 5 or more hours of a nurse’s time. I think advocating for higher reimbursement for training might also encourage clinics to teach patients how to do home hemo.
I am wondering why the costs involved are such a mystery. I have spoken with two of the machine companies as you suggest to do… The reply given to me when I asked about costs was that my unit would make “about the same amount of profit” on me as they do in-center as there is no overhead. Can you imagine buying a car or a home and the seller says the price is “about” whatever? They would not tell me the price of the machine or the rental fee. I would think that with you being the moderator of this board, Beth, that you would be privy to this info. Do they release this info only to doctors or unit administrators? I can tell you it stressed me out to talk about this with the machine company reps I contacted and the last thing I need is stress trying to get into a home hemo program. It did not give me a feeling of trustworthiness.
One thing to consider is that the machine is just one part of a multipart business deal. In the car analogy it’d mean that you’d have to buy your gas from the company that makes your car and that this relationship would continue for as long as the car was in use. That would complicate your reckoning of the car’s cost because the relationship is long lasting. I’d say there isn’t an easy way to answer your question. Or rather an easy answer - X dollars - would be misleading. You’d have to include other parts of the equation, including the cost of the supplies to run the machine, the cost of the tech support to keep it running and the cost involved if the machine is idle - because the user is traveling or gets transplanted for instance.
So the answer is complex but I don’t think the manufacturers are acting untrustworthily, I think they see the transaction differently. I think the manufacturers are reluctant to spell it out for you because it is believed that we users do not have standing to know this information. The logic goes: since the details of the business agreement do not change the cost for the user(we consumers), the user does not have standing to know the details of the business agreement. I think they’re right. The purchase/transaction takes place between the manufacturers and the provider so it’s up to both of them to decide if they want to make the details of the transaction public.
There are competitive pressures that make allot of the information you want about the “price” of each machine confidential from both their points of view but I’d say the interest in keeping the details confidential is mostly from the point of view of the manufacturer. I think the provider could share the details of their agreement more easily and I think the user has more standing with the provider. You should ask the programs you are using or thinking of using for the details of their agreements. You may get it - it’ll depend on the program - but it isn’t too surprising that the manufacturers are keeping their cards close to their chest.
How are you guys that are not using either the Aksys PHD or the NxStage System One machines to do daily dialysis (3+ times/wk) handling the fact that Medicare only pays for 3 kidneys and 3 blood tubing sets per week?
I remember when I first learned about daily and nocturnal dialysis, it was about a year ago, that when I went to the factility that would be training and supporting me on home hemo if I decided to pursue it at that time, the nurse I was getting evaluated by told me that, unfortunately, there was no way that I could do daily dialysis unless I paid, out-of-pocket, for all the supplies needed for the extra days (meaning any days I chose to dialyze over 3/wk), including the cost of a new kidney and blood tubing set for each additional treatment.
Since the only insurance I have is Medicare, and my other health-related monthly bills are very high, I knew I couldn’t afford to pay for anything “extra”. So, at the time, I unfortunately had to forgo choosing daily home hemo.
Luckily for me, the Aksys PHD came out a few months later and I was able to convince my clinic to offer it for daily hemo since it resued the same blood lines and kidney for up to 20 treatments.
Have things changed as far as what the clinics are willing to pay for now, regardless of what reimbursement Medicare allows per week? I read of other people on this board doing daily dialysis on machines other than the PHD or the System One. You guys aren’t all paying for the additional treatment items out-of-pocket, are y’all?
Can you imagine buying a car or a home and the seller says the price is “about” whatever? They would not tell me the price of the machine or the rental fee. I would think that with you being the moderator of this board, Beth, that you would be privy to this info. Do they release this info only to doctors or unit administrators?
“How much do the machines cost” is the # 1 question we’ve been getting over the past few months. We have asked all of the machine manufactureres (who are all our sponsors) to share cost information with us, but they have declined to do. So, yes, I think only clinic administrators get this info. It’s not like you’re buying a car, though, because you’re not the one buying the machine (or renting it), the clinic is. So the analogy is more like if you asked an X-ray machine supplier how much they charge a radiology suite for their equipment–basically, it’s none of your business. (Or ours, either, apparently. :roll:)
My sense is that the cost is based at least in part on the number of units a clinic wants. Some companies (Aksys, at least) make their machines available via a lease that includes maintenance. Others allow for the machines to be purchased. One issue that I’ve heard from clinics directly is that the “profit” depends on the lease terms–if, for example, a clinic is locked into a multi-year lease, there may be months when they must pay for the machine without deriving any income from it (if enough patients aren’t trained yet or if a home patient gets a transplant, for example). This can be very costly for the clinic. On the other hand, some costs can be offset if the machine reuses the dialyzer and lines, as you’ve noted the Aksys machine does.
So, I’m sorry that you’re finding this so stressful, but in the end it comes down to whether–with all of the cost factors–a clinic that you would feel comfortable getting care at will offer the type of treatment you decide you want.
I’ll bet that another item that would most likely factor into the “ultimate” cost of a home dialysis machine would be how strongly the manufacturer of a particular machine wants to get their machine out into the hands of paying patients.
Theoritically, the more patients that are aware of their home dialysis machine and want to use it would translate into more money the manufacturer of that machine would stand to make.
I’ll bet that the manufacturer and the clinic are going to have some amount of negotiation for the rental/purchase price of the machine. The manufacturer wants to get their machine out to as many patients as possible, which would increase the income for the manufactuere (the more machines being leased/purchased for patients directly translates to more money for the manufacturer), while the clinic wants to try to be profitable in the rental/purchase of the machine knowing that their reimbursement amounts are limited by the insurance companies (mainly Medicare). The more patients that a clinic could get using that “new” machine then the more reimbursement they could get from insurance companies to, hopefully, make it profitable for them to offer that machine to thier patients.
Let’s say, for example, a manufacturer named “Dialysis Plus” has a new machine that they are desperately trying to get into the home dialysis maket in, say Illinois for example. Let’s also say that currently, no clinic in the MidWest is offering their dialysis machine to their patients. It makes sense that “Dialysis Plus” would make the cost of their machine as attractive as possible to the first few clinics in Chicago that are interested in using their machine. They would do this in order to facilitate getting their machine out into the hands of patients, in order to start creating a buzz about their machine which in turn would hopefully create a demand for their machine. Once the demand was great enough, they could then possibly increase the price of their machines to clinics because they know that any clinic in that area wanting one of their machines would have enough patients interested in using their machine in order to make a profit.
On the other hand, if their machine is already the preferred home dialysis machine in the MidWest and is currently used by several clinics offering home dialysis in the MidWest, they would most likey charge more for a clinic to lease/purchase the machine because they know that any clinic that wanted their machine most likely already had enough patients on the waiting list for their machine in order for the clinics to be able to make a profit almost immediately.
The cost of leasing/purchasing a home dialysis machine seems like it really just boils down to simple supply/demand, and the “ultimate” cost of the machine to a particular clinic is one that is negotiated. That’s probably why none of the manufacturers are willing to say “Our machine costs X amount of dollars”.
At least, that’s how I think it works. Hopefully, home dialysis machines will become much more utilized than they are today and the clinics will stop having to try and figure out if it makes economic sense for them to provide a specific home dialysis machine to their patients. Instead, they can start looking at which home dialysis machines are the best choice - speaking about the quality of dialysis one machine provides over another - for their patients.
Just my 2 cents worth.
Lets make it plain and simple…
Raise your hand on those of you who want a brand new dialyzer for each treatment?
Raise your hand for those of you who want a used dialyzer for each treatment?
I definitely prefer a reused heat sterilized F-80. The Aksys PHD reuses it’s dialyzer and blood tubing up to 30 times, after the first treatment the whole circuit has a protein coat. This protein coat makes the whole circuit more compatible with my immune system. The reuse of the dialyzer and blood tubing minimizes my body’s immune response to dialysis. Add ultra pure dialysate and you lower the immune response even more. It’ll be interesting to see if a study can isolate the benefit of reuse on lowering chronic inflamation in hemodialysis consumers.