Maybe you should suggest your idea to Northwest Kidney Centers. They’re usually pretty innovative. They could pilot it and show others how it can be done even in today’s high paced high stressed dialysis environment. Perhaps they could even develop a scheduling program using Excel that they could share with independent clinics and regional chains that may not have the personnel or creativity to think through the details.
My job is making signs - I already have 20 hours of OT this week and I’ll be here late tonight - it really doesn’t seem reasonable to expect me to figure out how to compel renal administrators to do their job. I have to sleep sometime, oh and dialyze, and feed myself, and get the dog to a park every now and then (and I need to set aside time to write thoughtful posts on HDC - my boss isn’t always in a meeting).
I spent 10 years advocating for payment that would support higher doses of dialysis - payment that would support more than 3 treatments a week. Now we have it. Current payment provides a $70 bonus for every treatment provided beyond 3 a week. It is more than I ever dreamed of asking - my work here should be done. Yet, … crickets. Nothing.
It is inexplicable. And my repetedly pointing out that EOD should be a reality isn’t making a bit of difference.
I thought if you were still on the board of NW Kidney Centers, you’d be the perfect person to bring up this option with their board. Please don’t think I was suggesting that you advocate for this with the whole community. If the pilot worked well for NKC, staff could publish their success and hopefully other clinics will see the benefits of offering this for their patients. One selling point might be that with more treatment, more in-center patients will feel well enough to continue working or get new jobs with EGHP coverage and higher payment for 30 months.
I have been trying for about 3 years to get on the speaker’s program for the NRAA so I could connect the dots for them about some of these things, with, so far zero luck. Likewise RPA. So, I do lots of singing to the choir at ADC, ANNA, NKF, ESRD Networks–but can’t seem to reach two of the key target audiences for change. Maybe someone reads these boards from those organizations and will consider listening to something new? 
I think you’re exactly right Dori. The advocacy focus needs to go from CMS to the NRAA.
If you do get the opportunity to speak in front of these decisions makers maybe it would help to walk them through the day to day operation of a unit offering EOD schedules.
Here is a first draft:
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Consider a 24 station unit operating six shifts Monday through Saturday at 80% capacity. The unit has a case mix and payer mix that matches the national average – we’ll imagine a unit with 115 patients dialyzing 3x/week on average for 4 hours.
36 patients have agreed to switch to EOD schedules.
The first step to make this work is to divide the EODers into two groups of 18. Instead of calling them MWF and TTS we’ll call them Group 1 (G1) and Group 2 (G2). I would guess that at most units interest in EOD would skew to the evening shift so to accommodate the 18 EODers in G1 the unit manager has to have 8 stations on the evening shift and 5 stations on both the morning and mid day shifts.
The key is that you also have to have 5, 5 and 8 EODers on G2. As the EOD census grows or contracts G1 and G2 have to stay in balance.
Day One
It’s Monday and G1’s turn to dialyze. The patients get themselves to treatment and arrive at their appointed times, receiving their treatments normally. If they use ESAs they receive their dose. This continues through the day. From an operational stand point it should look like any other Monday even as this tectonic shift in the provision of dialysis is taking place.
Day Two
G2 comes in for their dialysis. As with G1 this looks like any other Tuesday from an operational stand point. Unless you looked at their charts you wouldn’t be able to tell G2 patients from the conventional TTS patients.
This would continue through Saturday and then on Sunday G1 would come in for dialysis. From an operational stand point you would need to use your 24 station unit to provide dialysis to 18 people. So here’s where an administrator could look for efficiencies – if labor is tight maybe two nine station patient shifts would make the most sense allowing staff to work a 10 hour shift. I’ve worked ten hours on a Sunday. Sure I would have rather been at home filling my yard waste container but that doesn’t pay the bills.
To digress a moment and think of the actual job working on a Sunday vs working during the conventional six day dialysis week, I think the Sunday shift would be a pleasure. There would be a selection bias among the patients, the patients who chose EOD schedules would tend to be healthier, have fewer morbidities and generally be ‘easier’ patients from the staff point of view.
The two groups might be distinguished by their Sunday schedules. It might be that on Sunday G1 and G2’s dialysis is always during a window from 8AM to 2PM or it could be that G1’s Sunday is from 8AM to 2PM and G2’s is from 10AM to 6PM. From the patient’s point of view Sunday’s would be different. On every other day of the week you’d come in at your normal time but if dialysis fell on a Sunday you’d come in, most likely, at a different time. Additionally by operating the unit for only part of the day on Sunday it would still be available for maintenance tasks typically done during off hours.
Day 7
G1 comes in for treatment all at once – the unit operates 18 stations with a slightly higher staff/patient ratio since no medications, labs or on going education is taking place. There are no deliveries and few phone calls. Note that no formerly separately billable services are provided on Sunday but payment is the same.
Day 8
G2 comes in for dialysis . From an operational perspective it should look the same, setting up treatments based on a person’s prescription.
Lather, rinse, repeat.
I’ll assume we all agree that for the patients, clinically, this would be better.
For the unit financially the way to consider the impact is to think in terms of capacity. The EOD schedule in effect added 18 treatments to the unit’s capacity. Each station represents 18 treatment/week capacity so in effect implementing an EOD schedule added a station to the unit’s capacity. Administrators should understand the cost of adding a station is about $150,000, standard dialysis stations are valuable in themselves; implementing an EOD schedule is like adding a magical station so that has to be even more valuable.
It’s a magical station because it attracts patients who are healthier and better insured than the unit’s average patient. I mean really it should be the stockholders who are demanding EOD schedules.
EDITED TO ADD: Another way to value the EOD schedule is that it is as if you added 6 patients to the unit’s census - 6 patients who on average would be healthier and better insured than the unit’s average patient. The recent sale of companies - Liberty/RA/Fresenius deal for instance was priced at over $100,000 per per patient. So the EOD schedule in this example, by that reckoning, added over $600,000 in value.
One objection that nearly always comes up is that “my patients already skip” “I can’t get them to 13 treatments in a month, how am I going to get them to 15”
I’d say patients who skip are exactly the people who should be encouraged to use EOD schedules. If someone is going to skip once a month then with a EOD schedule they’d still be getting 14 treatments. If someone is skipping who is using a conventional schedule then that means they are either having three days off dialysis preceded and followed by two days off or they are going four days between treatments, with regular treatments on either side.
With an EOD schedule missing one treatment would always mean having three days off but it would always be followed by regular dialysis. The goal should be how much dialysis did you get in the month? meeting weekly targets is how you meet monthly goals but if someone is skipping the right response is to give them more opportunities to dialyze.
[QUOTE=PeterLairdMD;21731]Sorry, I didn’t mean to take the thread into a discussion on health insurance issues, instead, my point was to reiterate the obvious that the clinical decisions made by industry insiders should they end up on dialysis are diametrical opposed to what they offer their own patients. It is the utmost in hypocrisy.
Quick question, Dori, did you publish your survey findings on this topic. I seem to recall that it is published somewhere. If so, could you post a link to the survey on what treatments leaders in the industry would choose if they needed dialysis.
Thank you,
Peter[/QUOTE]
Peter, you are surprised by this hypocrisy? Believe me, I am not.
I agree, the non-compete agreements need to go, competition is key to protecting dialysis clients.
Beth:
The reason that I call it “ObamaCare” and I do hate the insurance companies, is that in my view, the government does not really have any business in health care or making health care decisions for you or me. Obama does not know anything about medicine, making cars, or running banks. In fact, Obama receives more money from Wall Street than all other Republican candidates combined(Wall Street Journal). Many in the government have a mentality that “I do know what is good for you, more than you do.” That also sounds like most of the people that I know who work in dialysis. I do not trust the government, the insurance companies, or the dialysis providers.
Yes, I would agree, 100 percent.