Sometimes finding motivation requires a little nudge. And if the nudge has some purse strings attached, that’s not all bad.

For years, the percentage of patients dialyzing at home in the United States was a miserable sub-10% of the population. No matter what was offered or promoted (greater freedom, more liberal diet, stay employed), nephrologists seemed reluctant to educate and encourage patients to select the option, and providers were more mindful about keeping their dialysis center chairs filled. Home dialysis also requires a major commitment by both patient and family members. It is a choice that comes with responsibility for self-care (Do you want to self-cannulate? Do you want to deal with boxes of PD supplies in your house? Do you want to handle machine alarms?). Physicians who said they would pick home therapy for themselves if they had kidney failure weren’t as likely to suggest it for their patients, perhaps because they didn’t believe they could manage the rigors of the therapy.

For the past 20 years, Nephrology News & Issues has been tracking yearly patient growth among the 10 largest dialysis providers in the United States. Our annual survey looks at the subpopulation of home patients as well. Find the full results from 2009-2014.

In 1995, the first year of our survey, home patients represented 15% of the total patient population in our list (when the survey was done, home hemodialysis patients were included in the in-center patient population, so home patients tracked were PD patients only at the time). Twenty years later, in 2014, the percentage of home patients among the 10 largest providers is 11%. This percentage does not include the home population of Northwest Kidney Centers, a newcomer to our 10 largest provider list where home patients represents 16% of their total patient population.

CMS encourages more home dialysis

At 11%, providers in our annual ranking have made some strides in the last few years in improving their home patient counts. All providers in our list improved their home dialysis patient census from 2011-2014, except for Satellite Healthcare (slight decrease). See Figure 1.

The year 2011 is a key baseline when looking at growth in the home dialysis patient market. That year, the Centers for Medicare & Medicaid Services launched the new bundled payment system with built-in incentives for placing patients on home dialysis. Providers would get paid for patient care immediately if a patient started on outpatient peritoneal or home hemodialysis; if a new patient was started on in-center hemodialysis, it took 90 days of treatments before a facility got a Medicare payment.

Figure1

That incentive wasn’t in place before 2011; payments for all patients didn’t start until 90 days of treatment, regardless of which modality they choose. No incentive, no real growth in home dialysis. In 2008, PD and HHD patients represented 8.1% of the total population in our ten largest provider group; that crept up to 8.5% in 2010.

Show me the money

Things began to change in 2011 with the financial incentives in place. From 2010-2011, the home dialysis population among the 10 largest providers took a major leap forward, and never looked back (see Figure 2). There was a 1% increase from 2010-2011, and a 1.2% increase from 2012-2014. Overall growth in the patient population for these providers was around 6% per year.

Most of that home patient population growth came from PD programs. In 2008, there were 20,474 PD patients and 2,321 HHD patients among the 10 largest providers. Six years later, they reported 38,424 PD patients and 6,098 HHD patients in their census. That’s a growth of 17,950 patients on PD vs. 3,777 patients on HHD. Much of that HHD growth can be attributed to the introduction of NxStage’s System One home dialysis machine in November 2005. But those numbers could increase further in the next few years with the planned introduction of new hemodialysis machines for the home.

Figure2

Ultimately, the growth in home dialysis patients among the country’s largest providers is a positive sign – even if it took financial incentives from Medicare to get providers thinking in the right direction. Other things can help —  a broader curriculum in medical schools that exposes students interested in nephrology to all modalities; more education programs that encourage the mentoring of patients interested in home therapy by patients who have already succeeded at home; improved funding for home training, and perhaps some additional tweaking of the payment system so nephrologists get paid the same for treating home patients as they do for in-center dialysis patients.

Is a goal of having 15% of the prevalent patient population dialyzing at home realistic over the next few years, with the help of more education, the increase in rapid-start peritoneal dialysis, and more emphasis on the value of rehabilitation? Perhaps a percent increase isn’t the right approach; offering modality choices to patients who can benefit is the best way to treat kidney disease.