What has prevented the growth of home programs?

Discussions for Patients, Family, and Friends HD For Patients
21

It definitely costs less for nursing labor costs once a patient goes home. However, the rate that Medicare pays for treatments is based on the in-center reimbursement that really takes into consideration that the machine is going to be used by multiple people in the same day. Home patients have one machine designated to them. Even if the clinic rents the machine, if you’re a Method I patient, the clinic must pay the monthy rent on the machine up front and bill Medicare for each day you use it generally at the first of the next month.

If you do 3 days of treatments a week, you use a certain number of supplies. If you do more treatments, you use extra supplies. Again, the clinic has to purchase the supplies for you up front and wait for Medicare payment. Clinics may order a 2-month supply when you start home training so you have more supplies on hand than you will actually use in a month so if there’s a disruption in delivery for some reason, you can still do your treatments.

None of this counts having the machine for training which may or may not be the machine you take home and ordering training supplies which may include extra supplies so you can practice. I’ve written before about the Medicare reimbursement of $20 for a nurse to spend an entire training day with a patient.

It may not seem like an expensive undertaking but there are upfront costs that aren’t always seen. And of course, this doesn’t count the other administrative expenses that clinics have that are shared between the in-center and home programs.

22

Lin,
How many patients will in your home program?

23

I don’t know about other home patients but we went home with the machine we trained on. Beth, do they put such an emphasis on up front cost when they build new dialysis centers instead of starting home programs? What about the up front cost occured when the big corps keep buying other dialysis centers. What about the up front cost when machines in-center have to be replaced for dialysis. You don’t hear much about this stuff not getting done because of the “high” up front cost. I think the up front cost has merit in certain situations but I think as far as starting home programs it is being overplayed. I would bet you dollars to donuts if just one nephrologist had kidney failure you would see a home program arrangement made for him without any thought of up front cost. I don’t really always believe it is the up front cost holding centers back. I think it’s because they make “more” profit on in-center patients up front. I also think if we keep buying into the idea it’s all about the up front cost and not about the patients we will remain stuck in the mud. I’m sorry I don’t have much pity for the dialysis centers crying about up front costs, I have pity for the patients who can’t get better dialysis because some is crying the blues about up front costs. I’d like to know just how much this so called “up front cost” amounts to. I was told it would take 16 patients in our nocturnal program to break even. However, this was “largely due” to the cost of monitoring of patients. Daily programs don’t monitor so the 16 patient breakeven point should be less. With the exception of small dialysis centers in rural areas where the patient population is less than 30 for 3 shifts, I think this up front cost ordeal is like a millionaire crying poor because he doesn’t have 2 million. If someone can give me a dollar figure on these up front cost I’ll shut my mouth. Let’s face it whenever I don’t want to do something, I even use the excuse I can’t afford it but it doesn’t make it true. Why is it more expensive to order supplies for home patients and pay up front than it would be to order supplies for in-center patients and pay up front. Clinics have to pay up front for machines purchased or rented for in-center patients so what’s the difference? Sure home patients don’t share the machine. But our machines probably don’t get exchanged as fast as in-center machines either because they don’t get used as much. When a patient leaves a home program for a transplant or some other reason the machine is then sterilized and given to another new home patient a new machine isn’t bought/rented each and every time. I still think it’s more about maximizing profits and work involved than it is about up front costs. However if it is because of up front costs; I suggest we do away with the Networks give the money to the centers and get home programs rolling. Does Canada or Australia have or need Networks?

24

Lin one thing to consider when looking at the implications of leasing equipment – yes you do not have an upfront cost but there are other costs. Lease payments continue even when the machine isn’t in use. The lease rate is very close to the monthly revenue stream from the three day a week reimbursement rate so if the provider can not bill because of hospitalization or the dialyzor is traveling they will loose money for as long as the dialyzor is receiving dialysis outside of their home. (Which keep in mind, the Medicare composite rate varies a great deal from person to person and location to location these days. At the extremes, after the geographic adjustments fully kick-in in 2009, a 40 year old male in San Francisco would have an allowed composite rate in $170 range while a 70 year woman in rural Mississippi might have a composite rate in the $110 range. I would speculate that home program financial models look better in high wage areas than in low wage areas.)

Another factor to consider is that high dose home dialyzors are disproportionately transplanted – the lease continues after transplant. Until a new dialyzor is recruited and trained the unit will have a negative cash flow on that machine.

I’m just saying it is somewhat complicated and there are many factors at work.

My solution: take the training to the dialyzor. Training should take place at the same place and time that the dialyzor normally gets dialysis plus access to the sister shift. I would have Medicare allow full composite rate billing while the dialyzor is in training. During training if the dialyzor dialzes 6x a week I think Medicare should pay for six treatments.

Example: Danny dialyzor dialyzes on the M-W-F 5 PM to 10PM shift. Danny decides he would like high dose home dialysis. The unit looks for room on a sister shift – the 5 – 10 T-T-S shift – ideally paring Danny with T-T-S shift dialyzor who would like to go home.

Danny starts training committing to dialyze from 5 PM to 7 PM Monday through Saturday. The training nurse comes to Danny. If the machine that will be used at home is the in unit machine then it’s already at the station. The Aksys or the NxStage could be wheeled into position to prepare for treatment.

There could be someone running from 8 PM to 10 PM – that dialyzor from the T-T-S shift. Maybe Danny would go M-W-F at 5 and T-T-S at 8.

Why I think this is an optimal model. It allows the important demographic – those who work – access to high dose dialysis without changing their work schedule. It more easily scalable than a bricks and mortar space, staff could be added to meet demand. Perhaps home training could be done in stages with some stages taught by existing incenter staff – for instance cannulation. There could be no better advertisement for home self care and high dose dialysis than to watch someone make the transition right before your eyes. Imagine the impact on those who share Danny’s shift as Danny transforms from a dependent, uremic, sick person into Danny who is independent, well dialyzed and full of energy. Imagine the impact on staff who watch the transformation.

25

Bill, Sounds optimal. I know you’re very involved in the dialysis field and wonder if you’ve pitched this way or working things? The way things are now you are right; once I train, and assuming I do really well :roll: others might be impressed but they won’t be witnessing the change. I’m already planning on doing well and feeling better, having a more liberal diet plan after awhile so if the way training is done now isn’t changed I will just have to talk to the social worker about coming in for visits and speaking with other pts. and families that want to take on home training. I’m so impressed by all the good things home pts. have told me. I don’t want to travel like you, and I can’t anyway because of my family obligations but I sure could use more energy. I’m only 51 yrs. young and want the energy that matches my age. Thanks for all that you do ; just reading about it makes me tiried lol Lin.

26

Bill, I am sure there are many things that could be done to work a home program into a center. By reading your post to Lin, I would say NxStage has another advantage as when patients go on vacation (if it’s state side) they take their machine therefore no lapse in payments.

27

Hi

getting the gove’t to pay more now is a pipe dream In the US the gove’t is running in red. Did the gov’t just change the way medicare pays for RX for people? Now you need a second ins to help pay for RX.

The only way I see change is if the gove’t and companies that run dialysis work it that companies offer 24/7 dialysis and each person is screened to see how well they can handle home what ever. Just like any other problem.

Nurses in hospital on a surgical floor may have to deal with 4 to 6 patients and 4 to 6 doctors. (if not more) The only help they might have is an aide.
So are dalysis nurses so how not able to deal with 3 to 4 patients?
The center I was trained in had more people able to train than people to train. Before I look to the gove’t as the anwer to the money problem, I look at why the company got into dialysis.

bobeleanor :?:

28

We do have several things that are conflicting with one another for federal dollars. However, I always say never give up. There have been many changes in funding over the years, including funding for ESRD and funding for immunos that has been extended a few times.

Just to clarify, Medicare Part D is a NEW benefit for those with Medicare that now pays for many take-home drugs that were never covered by Medicare before. The coverage is through insurance companies and you pay a premium for it. The government subsidizes this benefit that is valued at $1,500 for anyone who spends $2,250. The low-income subsidy (also called “extra help”) reduces what those with limited income and resources have to pay in premiums and cost shares. You can find out more about extra help eligibility through Social Security at 1-800-772-1213 or online at http://www.socialsecurity.gov.

The new Part D benefit did not change coverage for drugs that have been covered under Medicare Part B. The amount of reimbursement changed, but clinics were given a larger than normal increase in their composite rate to make up for this change.

I agree that every patient should be screened for home dialysis before being offered in-center dialysis. Dori and I have referred to this as “Home Dialysis First.” We’ve been pushing this every chance we get. So far as clinics running 24/7, some do this to offer nocturnal dialysis and I believe in some large cities and vacation spots this is more common. However, one problem I always hear is that patients, especially older ones who don’t see that well to drive, don’t want to come at night. When I think about this, I wonder how many people would like it if their dialysis time was 1 a.m. - 5 a.m.?

In dialysis clinics regulations only require one licensed personnel (RN or LPN) while patients are dialyzing. The rest of the patient care staff could be technicians. Technicians have a few weeks training in how to run dialysis and do needle sticks. But in most states technicians aren’t licensed. Therefore, the RNs license is on the line so if he/she is smart, he/she is making sure that technicians are well trained and do only what they have the training to do. There are few if any all RN clinics any more. There are certain things that technicians can’t do because of state nurse practice acts that were established to protect patients in all settings, not just dialysis so the RN has to do all these things. Most dialysis clinics have a ratio of 4-5 techs per patient. The regulations allow one RN to have responsibility for all the patients during his/her shift. This is a pretty heavy caseload if you have unstable patients.

Just like the discussion in another thread about what doctors do, RNs are doing many things behind the scenes that patients may not see. This includes reviewing lab tests and hospital records, making sure new MD orders are recorded and followed, talking to patients about changes in their treatment or medication prescription, making sure that patients are taking drugs as ordered, training and mentoring new staff, calling doctors for patients, making appointments, participating in meetings (staff, care plan, continuous quality improvement, etc.), and much more. Nurses are very busy and hard working people.

29

If a transplant saves more money Vs. home dialysis then hmmm, perhaps the whole idea is saving time and money, so home program haven’t really kicked off for the reason of saving time and saving money. Currently, we look at all the implications of managing dialysis machine for the home patient…what have we learned? Whats the best method of saving time and money in terms of training, and maintaining the dialysis machines of home patients. What’s the best route to take…so basicly I think dialysis clinics are most likely to take a route that not just benefits the clinic but the patient as well…However, I think this won’t happen too soon until there’s more dialysis machines companies offering some enticing package deals that may come with much more than just the machine itself. Technology that will be proven to save training time(low learning curve)…and best of all, save money (low maintenance costs) …after all, time is money… :stuck_out_tongue:

30

Gus, Our initial training time was 5 weeks 4x a week. Since then for the next 5 1/2 hrs. we have been setting up our own machine and doing treatments. You don’t think this 5 1/2 years has saved the dialysis center time with us doing our own treatments?
Also during this time frame the staff for 25 to 30 patients has been 1 nurse (except 1 day a month then there are 2 to 3) and 1 tech. You don’t think the center has saved money. If all of us were in-center expecting to be put on and taken off the machines what do you think the labor cost would be? Take a look at utilities, we pay our own electric, water if required etc. is this not saving money?
The place where the centers seem to loose the most time is traveling to repair the machines but with NxStage this isn’t required.
There is no doubt the easier and cheaper things get; the more centers will be enticed to have home programs the question is just how cheap and easy does it have to get?

31

Everyone has made great points. I would still like to know, are nephs dependent on the corps to finance the home prgrams or can nephs afford to do their own financing? When the corps buy the units from nephs, do the nephs no longer have any say so on matters related to starting home programs?

32

Jane, I think the questions like most of the topics we discuss have a broad range. Our Nephrologist at home could not make the decision of having a home hemo program. The dialysis center is owned by the hospital, therefore it is there money being used to start a program. He may influence the decision or persuade them to spend the money but he cannot make it happen. Same way with the Nephrologist in the clinic we use for home hemo.
He has tremendous clout in getting things such as a home program, however it is the clinic board of directors who decide if the money will get spent or not.
If a nephrologist actually owned a dialysis center,and he wanted to use his money to start a program he could. If the Corps buy out any dialysis center they will then make the decision on how money is spent. I am sure nephrologist and nurses and other staff can always have their point of view considered but they cannot make the final decision as to whether the program will get started because they aren’t spending their own money to do it.

33

If the savings on home hemo were that obvious, there would be no need to promote it. The fact is that the savings are not that obvious, and probably not that dramatic. The savings have a greater impact on costs in a system such as in Canada where they can look at all the overall costs at all levels, including fewer medications, fewer hospitalizations over a certain period of time, etc. An individual dialysis clinic would not directly benefit from all these potential savings, but in a system where everything is paid for by the same government, every dollar saved counts, no matter where it is. So, if the whole system can save $10,000 per patient, it adds up to a lot over the years. Even so, home hemo still has limited availability, because the cost savings are not enough to set this up everywhere and for unlimited numbers of patients. The primary motivation should better health for the patients, even if the cost of home hemo vs in-centre hemo is about the same.

Pierre

34

Without additional reimbursement for MFD, home hemodialysis for Medicare patients generates losses significantly greater than those of Medicare patients taken care of within a center. LeAnne Zumwalt, Vice President, Investor Relations stated, “The basic facts are: first, reimbursement from payors is not generally adequate to support more frequent dialysis; second, home technology specifically designed for more frequent dialysis does not provide adequate dialysis when used three times per week.”

35

LeAnne Zumwalt works for DaVita. I don’t know why she said what she said. DaVita has DaVita at Home, a program that is now offering PD and different types of home hemo in a number of locations throughout the U.S. In fact, one of the local DaVita clinics is planning to restart its home hemo program that has been dormant for years. Patients living around Kansas City who want home hemo will be able to be trained there for daily dialysis. KU Dialysis is also starting a daily dialysis program. Two other clinics in Kansas City have nocturnal home dialysis programs (DCI and FMC-Kansas City). The same DCI clinic has a daily in-center program and one FMC clinic offers in-center nocturnal 3 nights a week.

I realize that some corporations believe they can’t make enough money doing more frequent dialysis. I don’t think they’re thinking outside the Medicare box. Based on Medicare reimbursement, dialysis clinics may not be able to make the profit they need to make to satisfy stockholders if that’s all they’re looking at. However, I suggest that some people are not thinking outside the box. They may not have talked enough with people in non-profit and for-profit independent clinics that seem to do OK financially offering more frequent treatments at the current Medicare reimbursement rate. They may not have considered these factors:

  1. If you offer more frequent treatments and patients can learn to do them faster, they can keep their jobs and their employer group insurance. EGHPs pay about double what Medicare pays for dialysis and more than that for drugs. Having a better mix of people with commercial insurance compared with Medicare makes up for Medicare’s lower reimbursement rate and helping patients to keep their jobs not only helps with the clinic finances, but helps the patient’s personal finances too.

  2. Offering more frequent dialysis gives your clinic a marketing advantage over clinics in your area that don’t offer this treatment. If you can get what you offer into the local news media, you will get calls from patients willing to change dialysis clinics. Plus patients who know they will need dialysis will contact the clinic about coming there for dialysis. Circle Medical Management in Chicago (www.cmmdialysis.com/index.htm) and Northwest Kidney Centers in WA state (www.nwkidney.org/) have both done this quite well.

  3. When corporations and clinics are considering cost effectiveness, they need to compare the costs of building or adding on to an existing building, hiring enough staff to take care of added patients at the in-center vs. home ratio, and paying added utilities to run more machines in-center when comparing in-center to home dialysis programs, plus the hospitalization and mortality rates for in-center for home clinics. Patients that stay in the clinic vs. in the hospital and that live longer mean a more consistent and longer revenue for the clinic.

Speaking of Circle Medical Management, the administrator, Sheri Floramo, from Circle Medical Management in Chicago presented on starting a home hemo program at an administrator’s session at The Renal Network (ESRD Network 9-10) meeting a few months ago. The room was packed. She told how they were able to set up their daily home hemo program. She also presented to the National Renal Administrators Association along with the NRAA president, Tony Messana, on starting a home hemo program and reimbursement issues. Hopefully their talks and this website are helping to convince people.

The more clinics that have successful home hemo programs, the more likely it will be that the patient numbers will grow. Having more patients on a modality makes it possible to meet the test of statistical significance which is what is necessary for data to be taken seriously.

36

Davita is there to profit, that’s why they think like that. Awhile back I wrote something concerning this…non-profits Vs. profits…

The last clinic I left were for profit, and my Dr. was co-owner of the clinic. A few times I mentioned to him about home hemodialysis-dailyshort but I couldn’t convince him, so basicly I left them for good and went to the nearby non-profit dialysis clinic…

Though they did offer PD, he didn’t want to offer HomeHemo… :?

What generally strikes me is this…

“Home technology specifically designed for more frequent dialysis does not provide adequate dialysis when used three times per week.”

You see what she’s saying there? That home dialysis machines that are specific for home use are useless for use 3x a week…

Something doesn’t make sense here…Is she reffering to Aksys and NxStage? Those are the only two machines out now specificly made for home…

Perhaps she’s not telling the truth? Perhaps she’s protecting special interest groups?

37

If she means that someone dialyzing 2 hours at home 3 times a week wouldn’t get enough dialysis, this is true (and kind of a no-brainer). However, if that same person dialyzes as long as he/she would in-center 3 times a week, this would provide the same dialysis adequacy as is currently provided in-center. I don’t think many of us believe that is enough. So is she saying that 3 times a week dialysis in-center isn’t adequate? If so, she’s making our point.

38

I took it to mean that machines such as the Nxstage that were designed specifically for home use didn’t have the same clearance as the incenter machines so therefore had to be used more frequently. To my way of thinking that is right, but the only benefit doesn’t come merely from better clearance per tx. but the fact that toxins, potassium ect. don’t have to build up and only be removed three days per week. That is why such a machine doesn’t need to remove as much as an incenter machine does. The dialyzer adds to the pkg. too. I’m considering the Nxstage program which would be six days per week, approx. 2 hrs. per tx… and think that is closer to what real kidney function is than letting things build up like I do now. She clearly didn’t put much thought into things! Lin.

39

There was an interesting article in Nephrology News and Issues this month that strongly suggested the reason more home programs weren’t being started was because of cost. Not because of the cost to start the programs but because in order to pay for the investment in the dialysis centers themselves it requires 1.9 patients or almost 2 patients on each machine per day. Therefore the centers do not want to loose patients from in-center treatments. Especially those with insurance. It was also suggested it has nothing to do with proving the benefits of more dialysis. It also suggested
if a change is going to occur; it will more than likely need to come from patients and patient advocates and some push from CMS. Expecting the centers to make the move with the investment of the center they have to cover and stockholders to pay it just isn’t going to happen.

40

In my province, the operation of dialysis is public - part of a public hospital. As such, as long as home hemo doesn’t cost more, they want to have more patients on it, as it frees up spaces in the dialysis centres. Otherwise, they might need to build more spaces. The number we have today on daily home hemo is about the same number as a whole shift of patients in one of the acute dialysis centres (just this city). The limitation seems to be more in how many and how quickly patients can be trained.

BTW…

NxStage was not originally designed for home use. It was originally designed and tested asd a hemofiltration machine – in the unit here, as a matter of fact, at least 3 different times, as part of clinical trials performed by the Kidney Research Centre.

http://www.ottawahospital.on.ca/hp/dept/med/nephro/research-e.asp

It’s original configuration was for hemofiltration in a hospital setting, not for hemodialysis. There were a few shortcomings regarding hemofiltration, and it’s now a home hemodialysis system. I almost got into one of those trials, but at the time, I didn’t meet the requirement of having been on hemodialysis for 6 months.

The Fresenius systems we use at home are identical in operation to the in-centre machines (the only difference is that the body of the machine is shorter). It can do anything, from short daily to regular in-centre to daily nocturnal with no adaptation whatsoever. Therefore, there are zero differences in efficiency. Treatments only differ in length, blood pump speed, dialysate pump speed and dialysate prescription. Otherwise, everything is identical.

Pierre