| Merging
reimbursement for home hemodialysis training into the proposed bundle is
a serious mistake Christopher R. Blagg, MD, FRCP, and Robert S Lockridge, MD Question: Several government agencies - MedPac, GAO, CMS and the Congress - have all expressed interest in seeing more individuals with end-stage renal disease dialyzing at home in the future. Why does CMS believe that their proposed inclusion of home hemodialysis training costs in the proposed bundle will encourage more use of home hemodialysis? Comment: As of 2007, the USRDS reported only 2,999 (0.8%) of 368,544 prevalent U.S. dialysis patients were on home HD. At the same time, 11 countries had a higher percentage of their dialysis patients on home HD than the U.S. . We have known for more than 40 years that home HD is the best dialysis treatment for patients willing and able to do it, and who are fortunate enough to have access to a training program. Now, with the even more striking patient benefits found with daily and nightly HD - including patient survival that appears similar to that with a deceased donor transplant - and with the development of more patient-friendly equipment, there has been a recent small but steady increase in the use of home HD. Current estimates are the prevalence is now slightly over 1%. We believe that the proposal to include payment for home HD patient training in the general bundled rate is a serious mistake. In the proposed rule, the bundled per dialysis rate for Medicare entitled patients during the first four months of dialysis will be 1.473 x the standard rate to account for the extra costs associated with stabilizing patients at home, administrative and labor costs associated with new patients, and the “initial costs incurred to train patients and their caregivers to perform home dialysis,” This shows a lack of understanding of realities of home HD training. According to the USRDS Report, 43% of new patients have not seen a nephrologist before starting dialysis, and so will almost certainly need vascular access surgery, time for the access to mature, and time to learn to needle their blood access before they can go into training for home HD. In fact, only 10 to 15% of home HD patients complete or even start training in the first four months of dialysis. Some will already be Medicare entitled because of age or disability or will have Medicare as secondary payer, but others will not become Medicare entitled until 60 to 90 days after starting dialysis and so will only be eligible for the proposed increased bundle for between 30 and 60 days. In fact, most home HD patients start training after the first four months of dialysis, having decided to change to home HD months or years after starting dialysis. PD patients often begin having difficulties with their treatment after one to three years and have to change to HD (the dropout rate for PD is about 30% per year). At least some of these, having experienced the advantages of self-dialysis at home, will welcome the opportunity to be trained for home HD. In addition, there are also occasions when patients already on home HD require one or more retraining dialyses on new equipment or for other reasons. Thus, the great majority of home HD training dialyses occur after the first four months of dialysis. CMS notes that training costs used in its calculations are based on cost reports, but details are not available. In general, cost report data for home HD training suffer from the fact that details of what should be included have never been clearly defined and so costs reported to CMS (and the GAO) almost certainly are not comparable between different programs. What is certain is that current reimbursement of an extra $20 per training dialysis is grossly inadequate. ESRD facility training costs are also proposed to be included in the base period bundled payment rate. Based on USRDS 2007 data, assuming 425 patients a year train for home HD (based on 1,253 patients trained between 2005-2007) and if (for example) cost report data show an average additional cost of $250 per training hemodialysis above the proposed regular bundled rate, then for 20 training dialyses (most patients can be trained with this or fewer dialyses once able to use their blood access) this would result in a total cost of $5,000 per patient trained and the total extra cost would be $2.125 million. However, if distributed across 46,622,520 dialyses (based on 333,018 prevalent hemodialysis patients at the end of 2007 and an average 140 treatments per year per patient) this is slightly less than five cents per dialysis. If CMS were to use estimates of home HD training costs based on the current extra $20 per training dialysis 3 times weekly for 13 weeks, a total cost of $780, and distribute these costs similarly, this would be less than one cent per dialysis. These amounts would hardly be an incentive to train patients for home HD! For the majority of patients who are trained for home HD after the first 4 months of dialysis (currently about 80 to 90% of home HD patients), it will take a year or more depending on the frequency of dialysis before the training costs are recovered, even though the cost of a hemodialysis at home is significantly less than the cost of an in-center dialysis. It is also well recognized that when a new home HD program starts up it needs to train and send home 12 to 15 patients before it recovers its start-up costs. CMS has elected to describe home HD training costs as “renal dialysis services” and include them in the regular bundle. With only about 1.0% of U.S. prevalent dialysis patients on home HD and only a small proportion of dialysis facilities actually providing training this is hardly a routine service as yet. Proposal: The simplest and fairest way to reimburse home HD training and the retraining of patients in whom Medicare is primary, whenever it occurs, would be to remove the “initial costs incurred to train patients and their caregivers to perform home dialysis” from the bundled rate for the first four months of dialysis and to provide an adjustment to the basic rates for a home training HD at a level based on cost report data. This could be for an initial course of up to say 25 training dialyses and a similar rate for individual retraining dialyses. This would help incentivize providers to train more patients for home HD. Summary The decision by CMS to continue one single payment for an individual HD treatment, whether in center or at home, and the equivalent for PD, is praiseworthy. However, inclusion of home HD training costs in the general bundle will hinder, not help, in encouraging, use of the best forms of dialysis, including more frequent nightly nocturnal home HD. The latter was the choice of knowledgeable nephrologists in a recent survey when asked what treatment they would choose for themselves if they could not have a kidney transplant. |