Seattle to Baltimore to Florida...and back

On Thursday I traveled from Seattle to Baltimore through Denver with a System One, it was a long day.

I had a 1:50 PM flight to Denver with an 80 minute layover scheduled, getting me into Baltimore at 11:30 PM - it could have worked.

I work just five minutes from the airport so at 10 AM I drove over with just my suitcase and parked in the garage. After renting a cart ($3) I met a buddy from work at the curb. Tony had the System One, the fluid warmer, the fluid warmer bracket and the dialysate/saline pole - four packages, together weighing about 130 lbs. After loading up my cart I made my way to the check-in line with over three and a half hours until my flight.

Check in was very smooth. The guy helping me stuck fragile stickers on just about every surface, printed my boarding pass and I was on my way back to work about thirty-five minutes after arriving. I had printed out Dori’s article so I was able to quote chapter and verse from the Air Carrier Act.

After working for a while I was dropped off about 1PM and I could go straight to security and my gate, so far so good. In Denver I hit a three hour delay because of snow and “mechanical” problems which got me to Baltimore about 2AM. Uhg, but all the stuff made it and my disposables were delivered earlier on Thursday so after a long days KDECing Friday, Saturday and this morning I am writing this post while dialyzing Sunday night.

On Monday I’ll head to FL (another two flight leg) and some R&R.

The System One was errorless Friday and Saturday. Last night I had company from start to finish - one of the KDEC attendees wanted to see the whole process - and the machine never alarmed. Tonight I am having numerous arterial alarms which has been frustrating not least because I’ve had to lower Qb 50ml/min which has turned this into a long run and once again I’ll be getting less sleep than I hoped.

I shot some video as I was getting the System One to the airport in Seattle but my video blogging ended when I got back to work maybe I’ll be able to pick it up again when I get to Florida.

[quote=Bill Peckham;10902]On Thursday I traveled from Seattle to Baltimore through Denver with a System One, it was a long day.

I had a 1:50 PM flight to Denver with an 80 minute layover scheduled, getting me into Baltimore at 11:30 PM - it could have worked.

I work just five minutes from the airport so at 10 AM I drove over with just my suitcase and parked in the garage. After renting a cart ($3) I met a buddy from work at the curb. Tony had the System One, the fluid warmer, the fluid warmer bracket and the dialysate/saline pole - four packages, together weighing about 130 lbs. After loading up my cart I made my way to the check-in line with over three and a half hours until my flight.

Check in was very smooth. The guy helping me stuck fragile stickers on just about every surface, printed my boarding pass and I was on my way back to work about thirty-five minutes after arriving. I had printed out Dori’s article so I was able to quote chapter and verse from the Air Carrier Act.

After working for a while I was dropped off about 1PM and I could go straight to security and my gate, so far so good. In Denver I hit a three hour delay because of snow and “mechanical” problems which got me to Baltimore about 2AM. Uhg, but all the stuff made it and my disposables were delivered earlier on Thursday so after a long days KDECing Friday, Saturday and this morning I am writing this post while dialyzing Sunday night.

On Monday I’ll head to FL (another two flight leg) and some R&R.

The System One was errorless Friday and Saturday. Last night I had company from start to finish - one of the KDEC attendees wanted to see the whole process - and the machine never alarmed. Tonight I am having numerous arterial alarms which has been frustrating not least because I’ve had to lower Qb 50ml/min which has turned this into a long run and once again I’ll be getting less sleep than I hoped.

I shot some video as I was getting the System One to the airport in Seattle but my video blogging ended when I got back to work maybe I’ll be able to pick it up again when I get to Florida.[/quote]

Arite Bill, on the road again! :slight_smile: Keep us updated…

As for KDEC (Nephrology News & Issues sponsored Kidney Disease Economics Conference I thought it was good and as a moderator I did get to air a couple pet issues plus I came away with some new insights and new thoughts. I introduced my dissatisfaction with the word patient, suggesting dialyzor instead and I received a number of positive responses. The new idea came yesterday as a speaker (who was not alone) disparaged Pay for Performance or P4P.

There is an expectation that Medicare (CMS) will change the payment system for dialysis and pay more money to dialysis units if they achieve certain benchmarks. I can wade deep into the weeds on this issue but simply put it is not clear which measures CMS should reward and it is not clear if the impact of rewarding those measures would be what we all want - ideal dialyzor care and better outcomes.

In my mind what this speaker was saying melded with the perennial complaint by renal docs and professionals that we dialyzors don’t do enough, don’t lobby enough, basically don’t care enough about our own care. I know, I know.

My response was to propose Pay Less for Performance - PL4P. I propose that if CMS wants to reward an important outcome - such as low dialyzor fluid gain between sessions - the way to do that was not to punish units when a dialyzor comes in fluid overloaded or pay more to a unit when people are able to limit their fluid gains. The better way would be to allow we dialyzors a break on our Part B Medicare premiums.

What do you all think? If you would save $50 a quarter on your premiums by keeping, say 95% of your gains below 4kg would that be an incentive? Wouldn’t an incentive like that get unengaged dialyzors asking their docs/staff for help to achieve this goal? Isn’t there a lot more we could do to achieve this measure than a unit could do with a whole sheet of smiley and frowny faces?

If the benchmark was phosphorus control wouldn’t a break on Part B premiums get more dialyzors asking for more dialysis?

There are also some useful policy/Congress strategy advantages between PL4P and P4P but as a tactic to reach Ideal Dialyzor Care do you think this would help?

[quote=Bill Peckham;10905]As for KDEC (Nephrology News & Issues sponsored Kidney Disease Economics Conference I thought it was good and as a moderator I did get to air a couple pet issues plus I came away with some new insights and new thoughts. I introduced my dissatisfaction with the word patient, suggesting dialyzor instead and I received a number of positive responses. The new idea came yesterday as a speaker (who was not alone) disparaged Pay for Performance or P4P.

There is an expectation that Medicare (CMS) will change the payment system for dialysis and pay more money to dialysis units if they achieve certain benchmarks. I can wade deep into the weeds on this issue but simply put it is not clear which measures CMS should reward and it is not clear if the impact of rewarding those measures would be what we all want - ideal dialyzor care and better outcomes.

In my mind what this speaker was saying melded with the perennial complaint by renal docs and professionals that we dialyzors don’t do enough, don’t lobby enough, basically don’t care enough about our own care. I know, I know.

My response was to propose Pay Less for Performance - PL4P. I propose that if CMS wants to reward an important outcome - such as low dialyzor fluid gain between sessions - the way to do that was not to punish units when a dialyzor comes in fluid overloaded or pay more to a unit when people are able to limit their fluid gains. The better way would be to allow we dialyzors a break on our Part B Medicare premiums.

What do you all think? If you would save $50 a quarter on your premiums by keeping, say 95% of your gains below 4kg would that be an incentive? Wouldn’t an incentive like that get unengaged dialyzors asking their docs/staff for help to achieve this goal? Isn’t there a lot more we could do to achieve this measure than a unit could do with a whole sheet of smiley and frowny faces?

If the benchmark was phosphorus control wouldn’t a break on Part B premiums get more dialyzors asking for more dialysis?

There are also some useful policy/Congress strategy advantages between PL4P and P4P but as a tactic to reach Ideal Dialyzor Care do you think this would help?
[/quote]

I think there’s a loophole there…I don’t like it at all…but who knows, I may be wrong.

I don’t like the idea either. I don’t really think it would work for that many dialyzors. How many overweight people do you think would loose weight and keep it off it they got a break on their insurance? I don’t think money as an incentive will help that many dialyzors and it could put even more pressure on those dialyzors struggling to comply.

I am talking about fluid weight and I would point out that if the goal was not achieved nothing would change - you’d be right where you are today.

How do you create incentives to reach optimal patient care?

Off to Florida.

If you are thinking of flying with the NxStage the first step is to print at least one copy of the article Dori wrote : “Leaving on a Jet Plane: Flying with a PD Cycler or NxStage System One” which is available on the main HDC site. The article quotes from the Air Carrier Access Act of 1990 and quotes rules under 14 CFR Part 382, these rules cover our rights when traveling with a System One - which is in the language of the Act an Assistive Device.

In the article a Department of Transportation spokesman is quoted too and his quote seemed to carry weight with the Baltimore gate agents for US Airways. I have a 4:45 flight and though it is a beautiful day I arrived at the airport about 2. It took a forty five minutes and four layers of management for the US Airways staff to allow the System One and four boxes (one more than on the way here because I’m taking the three unused cartridges with me and I filled the half full cartridge box with saline and other disposables). All together not counting my personal bag, the stuff weighs over 150LB.

Only with Dori’s article could I have talked them into letting me fly (unless I paid a big surcharge) with all the extra stuff . Without the article it would have been like talking to a brick wall but when something is typed I’m not the one saying it the article says it, I’m just following the rules. Thank you Dori.

I’m typing this to post later (no wi-fi at the Baltimore airport - lame) about an hour before my flight to Orlando through Charlotte. I just got off the phone with my friend John and he received 17 boxes today so as long as US Airways comes through I’ll be dialyzing tomorrow afternoon. My plan is to spend my afternoons dialyzing by John’s pool, leaving the evenings free to try to keep up with him and then sleep in each morning. That’s the plan, I’ll post the reality.

I suppose by the time I am able to post this I will know if I the NxStage made it, unless there is wi-fi in Charlotte where I have an hour layover. It is fun to be traveling - this morning I did some work in my room and then had a couple hours to walk around Baltimore’s beautiful harbor, spending an hour in their amazing Aquarium. It is a lovely, 70+ degree day here, bright blue sky with just a hint of a breeze. But I am glad I gave myself plenty of time to check in even though it would have been great to eat outside by the water instead of here at the airport. And I would have had free wi-fi in my hotel’s lobby but still this trip would have been tough without the System One.

If I was forced to arrange treatments incenter I would have had to dialyze Thursday morning at home and then taken a three day weekend before dialyzing this morning at some Baltimore area unit (unless like Seattle some units here are open on Sunday but today I would have needed a morning run). Assuming I went the Monday morning run route I would have had more sleep at the KDEC but I would not have been able to enjoy a liberal diet and the quantities of coffee, water and wine that I was able to enjoy.

If I had to I guess I could have tried for a Saturday night run but anything during the day would have meant that I would have missed some of the conference and Dori would have had to carryon on without me. Then I would have had to set up dialysis in Florida near my friend’s house which has been hard in the past and even then it is a sub-optimal unit. Or I would have had to set up dialysis 45 minutes to an hour away.
Or I would have dialyzed Thursday morning (after dialyzing in the morning all week) and flown home on Sunday night to dialyze at home - what I use to do to attend these conferences before being allowed to travel with a System One. This would mean that another year would have passed without visiting a friend I’ve had for over 35 years.

So yes a dialyzor flying with a System One has more inconvenience but it allows things that were never before available for people on hemodialysis. My take away messages: give yourself extra time and definitely print and bring with you Dori’s article.

I’ve made it to my friends house, all supplies and equipment are here, US Airways accommodated all of supplies, the System One made the plane change in Charlotte and was amongst the first things out on the conveyor belt. I even have video of the supplies being loaded on the plane in Baltimore - well handled by US Airways staff.

Off to bed. The plan is to dialyze by the pool tomorrow about 11. Just in time to participate in a conference call about how to promote optimal CKD5 care.

All went as planned - I write to you with thirty minutes left in my treatment, I’m sitting by the pool (didn’t quite factor in the contruction noise from across the fairway) and the sun is keeping me plenty warm in shorts and a t-shirt. Is there a problem with the System One being in direct sun? I have to cup my hand over the screen to read it so it would be a good idea to at least face the machine away.

I think tomorrow I’ll just dialyze in front of his fully enabled TV and enjoy the couch. No conference call tomorrow but that worked great today - the first two hours of treatment flew by and I had no alarms at a QB=450. The only alarm I had was because I left the drain line capped - R38 I think - once it was uncapped no more alarms (other than the yellow recovery indicators).

Speaking of multi-tasking I was also able to do some work remotely due to my works newly available VPN - which turns my laptop into my work computer - so I could cover most of my job from here. This run was all about multi-tasking - R&R/pool&sun, volunteering (conference call), work and oh yeah dialysis. And I wrote a post to HDC.

So tell me again why incenter dialysis three days a week is a good choice?

[quote=Bill Peckham;10943]All went as planned - I write to you with thirty minutes left in my treatment, I’m sitting by the pool (didn’t quite factor in the contruction noise from across the fairway) and the sun is keeping me plenty warm in shorts and a t-shirt. Is there a problem with the System One being in direct sun? I have to cup my hand over the screen to read it so it would be a good idea to at least face the machine away.

I think tomorrow I’ll just dialyze in front of his fully enabled TV and enjoy the couch. No conference call tomorrow but that worked great today - the first two hours of treatment flew by and I had no alarms at a QB=450. The only alarm I had was because I left the drain line capped - R38 I think - once it was uncapped no more alarms (other than the yellow recovery indicators).

Speaking of multi-tasking I was also able to do some work remotely due to my works newly available VPN - which turns my laptop into my work computer - so I could cover most of my job from here. This run was all about multi-tasking - R&R/pool&sun, volunteering (conference call), work and oh yeah dialysis. And I wrote a post to HDC.

So tell me again why incenter dialysis three days a week is a good
choice?

I think it would be nice, no dialysis at all! On the other hand, in-center dialysis 3x a week can save you all that work hassle compared to moving the NxStage around, but isn’t there drawback of doing 3x a week compared to daily-short? I mean c’mon don’t we feel better doing daily? I guess each has their drawbacks. Probably what may be nicer if the NxStage machine weighed alot less…and perhaps didn’t require so many dialysate bags, espcially for the traveler

[/quote]

[QUOTE=Bill Peckham;10905][SIZE=“3”]As for KDEC (Nephrology News & Issues sponsored Kidney Disease Economics Conference I thought it was good and as a moderator I did get to air a couple pet issues plus I came away with some new insights and new thoughts. I introduced my dissatisfaction with the word patient, suggesting dialyzor instead and I received a number of positive responses. The new idea came yesterday as a speaker (who was not alone) disparaged Pay for Performance or P4P.

There is an expectation that Medicare (CMS) will change the payment system for dialysis and pay more money to dialysis units if they achieve certain benchmarks. I can wade deep into the weeds on this issue but simply put it is not clear which measures CMS should reward and it is not clear if the impact of rewarding those measures would be what we all want - ideal dialyzor care and better outcomes.

In my mind what this speaker was saying melded with the perennial complaint by renal docs and professionals that we dialyzors don’t do enough, don’t lobby enough, basically don’t care enough about our own care. I know, I know.
Hey Bill

Don’t get to much sun now, I hear washington state isn’t know for 80 degree weather this time of year.

On your other front, do centers or companies that out perform others now get any more money? Or is the pay the same no matter what the center offers?

I found the infomation on the ideas on the pay changes. I"ll be emailing with some of my comments
bobeleanor

Just wanted to say treatments have gone well, R&R is proceeding. One last hurdle a 6AM flight Monday. I’ll strategize over a late dinner tonight and let you know how it turns out.

Dialysis facilities are paid a prospective reimbursement rate called the “composite rate.” The composite rate is adjusted based on whether the clinic is hospital-based (owned by the hospital) or free-standing (not owned by a hospital), rural or urban, and whether a patient is under 18 or over 69 and whether the patient is larger than normal or is malnourished. Drugs given during dialysis are separately billable from the composite rate. Facilities also got an adjustment to the composite rate because CMS (Medicare) developed a new payment method for calculating costs of drugs. Here’s a 4-page fact sheet on Medicare reimbursement for dialysis:
http://www.cms.hhs.gov/MLNProducts/downloads/april06esrdfactsheet.pdf

Facilities that have better outcomes are reimbursed the same as facilities that have average or worse than average outcomes. There has been talk of paying healthcare providers (including dialysis) for better outcomes (pay-for-performance). However, I don’t believe there is agreement on outcomes that should be considered. Should the outcomes to consider be just death rate, hospitalization rate, how many people have Kt/V and hemoglobin within the target range? Should clinics be rewarded for how care is provided–better staffing ratios, more qualified staff, providing direct treatment and/or referrals designed to improve patients’ physical and emotional well-being? How important is patient satisfaction with care and how should this be measured when patients may like the staff and feel satisfied with their care in facilities where clinical outcomes are poor? It’s not an easy task to find incentives that don’t have unintended consequences and no one wants to reward facilities for cherry picking the best patients and refusing to treat patients that aren’t easy to treat.

Beth wrote:“How important is patient satisfaction with care and how should this be measured when patients may like the staff and feel satisfied with their care in facilities where clinical outcomes are poor?”

In the facilitities we have been in, the majority of the patients we have spoken with act like their care is fine and the facility is good. Yet when we have asked what they know about dialysis, they are in the dark. Amazingly, we have even spoken with patients who have college educations and who had/have professional careers, yet they know almost nothing about the tx and don’t seem to notice that the facility conditions are dirty and corners are cut with care. They are beholdent to their medical caregivers and don’t want to rock the boat. So, I wouldn’t go by the average patient’s opinion when it comes to deciding reimbursement.

I also don’t put stock in Dialysis Compare as units can fudge on outcomes or even if they produce good #'s, can cheat on care in numerous ways.

I would think units should earn higher remibursements by scoring well in most of the areas you mentioned, not just one or two areas.

Hi Beth

Here is a part of my thinking on pay. I sent this and more to Agency for the Healthcare Research and Quality (AHRQ) and CAHPS® patient experience of care survey for ESRD patients, focusing on hemodialysis patients in chronic renal dialysis facilities.

I think it should be based on a # of things, not just monthly #'s. #1 - I think it should be based in part by how many companies can get consumers on home dialysis. At least try in the first two years to see which consumers might be able to go home. #2 - In the center I, the consumer, was public property, meaning that various doctors would make two month rounds at the center. The consumer might not see his /her own doctor but once a year. I think the consumer should go to the doctor’s office of his /her own doctor. #3 - On #'s, I think the #'s used should be based on consumers who have been on dialysis for at least a year. You know as well as I that it might take a consumer 6 months to a year to get things worked out. #4 - Also, it should be based on consumer understanding of the whole process, and also on centers that empower consumers to think and if they don’t make it to home dialysis, might be able to hookup and take off, etc. (self care). #5 - The pay should reward companies that offer consumers all the choices. The company that’s open 24/7 has self care space, home incentives, and has a professional staff that encourages and helps to empower consumers. Each consumer’s needs are different. #6 - When the consumer is put into a large group setting, each consumer should have a set space and have curtains that can be used for privacy. The alarms should be replaced by lights with call buttons. When a staff member must leave an area, he/she must make sure that a tech is there to see to any problems. I don’t know how many times the tech that was in my pod would leave for whatever reason and leave us to fend for ourselves.
The thing that troubled me the most was the unprofessionalism of the staff, both techs and nurses. ( just the centers I was i) Plus the company management must not have more power than the doctor and not use oral threats to end tx or move you to another center.
bobeleanor

I think I’ll start a P4P/P4LP thread when I get back. The trip went well, I am between flights in Denver (6AM departure from Orlando) all my treatments on the System One were uneventfull , I should be at my desk by 1PM west coast time.

Spontanious trips are dancing in my head - skiing at Whistler in February, a bare bones boat charter in the San Juans in May, these trips seemed out of reach and now they seen very doable. Not that I have given up incenter travel - I’ll try for incenter nocturnal for Christmas in Chicago and then New Years in Santiago? Iguazu Falls? Panama? I do love to travel.