ATLANTA – When The Centers for Medicare & Medicaid Services introduced the End-Stage Renal Disease Program payment bundle in 2011, it included a three-month handicap for providers who started dialysis patients on in-center hemodialysis. To say it another way, it was really a three-stroke lead for providers who started patients on home dialysis.

In Australia, the rewards are similar, but even higher. And it seems to be working.

(ADC continues to offer diversity, champions home dialysis)

Getting government to look at the big picture
There has always been a payment incentive for doing home dialysis therapy, primarily peritoneal dialysis. Studies have shown it is cheaper than in-center dialysis. Aside from the overhead savings, there is generally a lower use of expensive drugs (under the ESRD bundle, a bigger incentive for dialysis providers now). For CMS and Medicare, home patients tend to be hospitalized less (reduced Part A payments and for dialysis facilities, better control of the patient’s clinical condition and steady payments for delivered treatments).

But home dialysis therapies as an option pre-bundle suffered because those expensive drugs were outside the bundle, and those charges to Medicare were greater for in-center dialysis patients. Home dialysis patients, in essence, did not generate as much revenue. Nephrologists were encouraged to fill the stations and maintain the “bricks and mortar” of dialysis providers that kept treatment shifts humming.

With the start of the ESRD bundle, those high-profit drugs were no longer payable outside the composite rate. Suddenly, dialysis providers started dropping dosages, and the home dialysis patient appeared to have a better cost/benefit ratio.  To sweeten the calculation, CMS decided that facilities would now get paid at the first treatment—assuming they were either a peritoneal dialysis or home hemodialysis patient. For in-center dialysis patients, facilities would have to wait 90 days (the CMS policy already long in place).

(To motivate patients on peritoneal dialysis, first motivate staff)

So the formula for dialysis clinics in the United States:

Home dialysis patients (particularly, PD) = lower use of now-bundled drugs, composite rate payment made at the start of dialysis (plus a 51% bonus payment during that time for new starts); lower overhead for patient care; fewer hospitalizations and less disruption of the patient’s health (i.e., fewer missed treatments), and potentially, a better quality of life for the patient. For CMS, lower hospitalization costs.

In-center dialysis patients = likely starting dialysis with a catheter (higher risk for infection), no Medicare payment for the first 90 days or the 51% payment for additional patient care needs, and the potential for higher hospitalizations and higher drug costs.

In the last three years, that policy change has led to a notable, but modest growth in home dialysis therapy, which represents around 10-11% of the total patient population in the United States.

Other countries set targets, take a more aggressive approach
What if CMS set a desired target for the percentage of home therapies, and rewarded those who hit that target? That’s the formula in Australia. In Canada, renal networks have set varying targets for patients on home dialysis.

(Defining key elements in promoting peritoneal dialysis to patients)

In the opening keynote address at the Annual Dialysis Conference here, nephrologist John Agar, MBBS, FRACP, FRCP, the Conjoint Professor of Medicine at Deakin University and Geelong Hospital, Geelong, Victoria, Australia, said the incentives work in a country that, while well urbanized, has some limitations. And simply, home offers a better quality of life. “[Home hemodialysis] should be started as the default position,” said Agar. His Geelong Hospital unit has offered nocturnal home hemodialysis for the last 14 years, and now has about 40% of its patients on the therapy, up from 28% in 2000.

And even with incentives to send patients home, nephrologists still recommend dialysis patients start later, rather than earlier. “We haven’t seen any real survival benefit from starting early,” said Agar. But, starting treatment early is not the question: getting referred early is the key, he said. “eGFR should not be the trigger for dialysis, but should be used to trigger what needs to be done” to prepare for dialysis, Agar said.