What's bad about incenter dialysis

I notice that web sites (e.g. kidneyschool,aakp) that present dialysis modality option pro/con comparisons always point to a pretty standard list of negatives for incenter hemodialysis: The treatment schedule you get may not fit your life or your job, etc but the lists don’t include the biggest “con”: Reimbursement tradition limits the dose of dialysis that is available incenter.

And by limiting the dose of dialysis that is available incenter, reimbursement tradition results in needlessly high mortality rates incenter. Why not say - Con: Incenter is clinically inferior.

Kidneyschool talks around the point by listing dietary and fluid restrictions as a con and feeling washed out. I know those cons are relative to higher dose home options but isn’t the central clinical selling point of home hemo that you can dialyze more? Then the consequences, the cons of dialyzing in center should include the clinical impact of dialyzing less.

Three day a week results should not be the baseline for comparison. Optimal dialysis results should be the baseline for comparison.

Excellent points, Bill, and we’re just about to update Kidney School, so we can incorporate those thoughts of yours into it. In fact, if you’d like to be a reviewer, just let me know which modules you’d like to comment on!

Medicare limits reimbursement for the number of HD treatments whether at home or in-center to three per week routinely according to Medicare reimbursement policy. Fiscal intermediaries (the insurance companies that pay the bills for Medicare) can require medical justification for additional treatments. Different FIs interpret Medicare reimbursement policies differently. Some clinics in some areas of the country are reimbursed for more treatments while other clinics in other areas of the country are not even using the same justification. No one wants to demand consistency out of fear that those FIs that reimburse for more HHD treatments will stop allowing additional treatments and patients will suffer.

I learned this week that some patients are being asked by their clinics to sign a financial responsibility form called an Advance Beneficiary Notice that states that the patient understands he/she will be responsible for paying for additional treatments if Medicare denies those treatments. I don’t know if employer or other health plans will pay for treatments Medicare denies, if patients are being billed for additional dialysis days if their insurance doesn’t pay, and whether those patients that are billed are in for-profit or non-profit centers. If anyone else knows more, I’d love to know it.

In my opinion, one way to discuss the advantage that HHD brings is that if the facility limits the number of treatments per week to three or every other day, patients can extend the hours they dialyze each day at home whether their facility supports nocturnal HHD or not. On the other hand, those patients who dialyze in-center have a set treatment length because of clinic operating hours and the number of shifts per day. I knew patients who did HHD 5-6 hours every other day which more than doubled the treatment time in-center patients typically receive. Patients who got more dialysis felt better, had a better appetite and ate a more liberal diet, had better labs, and were physically and mentally able to do more things that they enjoyed. They discovered the more is better advantage of HHD.

Some centers (like NKC) are willing to dialyze folks more often–even though it costs more and may not be reimbursed by Medicare, but that doesn’t mean that it can logistically be done in a center. Dr. George Ting, in California, spoke about the problems of trying to do daily HD in-center–it was next to impossible to get folks paired up into the available time slots so that time wasn’t wasted. It’s just not practical.

At home (payers willing–and the majority of doctors who write letters of medical justification are successful at getting a 4th treatment paid for, I’m told), it’s easier to do treatments that are both more frequent and longer. If I were a dialyzor, that’s what I’d want.

What gives?

I understood this board was for " Home Pt Only" and not talking “IN Center Problems”


This website does focus on home dialysis, but there are people that are doing in-center dialysis who visit it to see what the hype is all about. The concern about reimbursement for more frequent dialysis is the same for both home and in-center dialysis.

One advantage that home dialysis has over in-center dialysis is that people can dialyze longer without raising the costs for supplies like dialyzing more frequently does. This may make longer every other day dialysis more attractive to facilities that are considering adding home hemodialysis (or nocturnal in-center dialysis) programs until there is a change in policy that allows Medicare reimbursement for daily dialysis.

Commercial health plans pay for services provided so there is likely not to be a limit on the number of treatments a patient can have if the doctor prescribes them. Do dialysis providers allow patients whose employer group health plans pay primary during the first 30 months of Medicare eligibility to continue dialyze daily when Medicare starts paying primary when these providers are receiving reimbursement 2-3 times Medicare’s allowable rate? I hope so. I also hope that dialysis providers will to do all they can to help patients feel well enough to continue working for their mental and physical health as well as so they can have coverage for treatments that Medicare denies.

If I were on dialysis, my choice would be to dialyze longer and more frequently in the comfort of my home. If that’s what I’d want for me, I feel it’s my responsibility to advocate for this every chance I have.

[QUOTE=bobeleanor;13432]What gives?
I understood this board was for " Home Pt Only" and not talking "IN Center Problems"Bobeleanor[/QUOTE]
You’re right, Bobeleanor, but in this case, the discussion was about how to present the pros and cons of home vs. in-center clearly and accurately (so more people will realize the benefits of home treatments), and Bill was suggesting that we’d left out the most important pro of home therapies. So, even though the thread name has in-center in it, the discussion is actually about home.

In my case, an extra tx per week was paid for and justified by stating additional UF only was needed. Now that I’m doing HHD, it apears Medicare is paying about 14 of 28 tx per month. I haven’t followed that from month to month, but is probably pretty accurate. And you’re right, Dori, it did require a nephrologist’s request.

Rich Berkowitz

NxStage 2/06
In-center 3/03

It depends on the number of days in a month so far as how many treatments Medicare pays for – typically 12-14 treatments a month without justification.