SEATTLE––Should we blame the untrained nephrologists or the medical directors that are ambivalent? The dialysis providers focused on paying off their bricks and mortar? Patients not able to handle intensive dialysis or the cost of home renovations? Inconsistent guidance from Medicare's fiscal intermediaries on payment for more frequent dialysis? Bad surgeons?

The Annual Dialysis Conference is, in many respects, a preacher talking to their choir. The program is diverse, but those who attend this meeting that was built on advocating for peritoneal dialysis 33 years ago, and later home hemodialysis, tend to be advocates for home dialysis. As long as dialyzing at home remains an underdog, however, the ADC will work on ways to enlighten others.

Home dialysis: Barriers, obstacles … or opportunities?
Should we look at the 10% of patients on home dialysis and believe this can be better, maybe 20%-30% of the patient population? Some dialysis providers, like Satellite Healthcare and Northwest Kidney Centers, are in that range. Why can't other dialysis providers do the same? There are barriers that need to be addressed. Or perhaps opportunities that need to be explored.

(Congressmen urge better home hemodialysis incentives)

During a contentious session at the Annual Dialysis Conference this past Sunday afternoon, plenty of barriers were thrown up against the wall and there were lots of opinions on identifying the ones that would stick. Moderator and nephrologist Thomas Golper, who successfully sends half of his dialysis patients home in his Vanderbilt School of Medicine dialysis program and still manages to be profitable, grilled home dialysis program managers from Dialysis Clinic Inc., DaVita, and Fresenius Medical Care as to what the barriers––or opportunities––are for home hemodialysis.

Home hemodialysis was, of course, the mainstay of dialysis therapy in the 1960s and early 1970s, before the convenience of the outpatient clinic arrived. Why cook a hamburger at home when you have McDonald's around the corner? Staff at more than 5,000 dialysis clinics now care for close to 90% of dialysis patients in the United States.

Recent data has shown that peritoneal dialysis––with the help of incentives from the ESRD payment bundle and aggressive initiatives like urgent PD for new emergent patients––has shown some growth: a 1% increase each year from 2009 to 2011. Home hemodialysis, despite some promising results from the Frequent Hemodialysis Network trials and the NxStage Medical-funded and well-done FREEDOM trials, has not seen the same growth rate.

So what sticks?
During the hour-long discussion, Golper and the panelists––Nasser Hebah of DCI, Joseph Pulliam of Fresenius, and Shane Simon (filling in for John Moran) of DaVita, had a healthy exchange of ideas and reasons why HHD remains the least favorite dialysis modality choice. Everyone agrees: it is multi-factorial, and not an overnight correction.

Here is some of what stuck to the wall:
Lack of physician interest and knowledge.  Too many young nephrologists are doing rotations without seeing the inside of the home of a home dialysis patient – or see the positive affects of dialyzing at home. "How many fellows have seen a healthy, thriving patient who works 60 hours, plays golf," said Denise Eilers, who was a home partner to her late husband. "Yes, there is a burden for home, but so is there one for in-center," she said. Nancy Spaeth, a nurse and home advocate, remembers those days. "I remember the vomiting, the nausea, the cramping, being too weak to drive home from my dialysis…"

If young nephrologists see nothing else, they assume that's the best outcome that "optimal therapy" can offer. If they don’t experience, they don't learn, they don't encourage and promote home dialysis to their patients.

(NxStage launches campaign to raise awareness, Medicare reimbursement for home hemodialysis)

Ambivalent medical directors. The Conditions for Coverage that dialysis providers must follow to meet Medicare eligibility––and get paid––require that all patients be educated about the full array of dialysis modality options. If a dialysis clinic cannot offer a particular option, like home hemodialysis, it is supposed to tell a patient where they can find such a program. That can include offering training sessions during after-work hours or on weekends (Should patients with jobs or family responsibilities face this obstacle of 9-5 training hours only? They have). "We allow physicians to practice, and we don't hold physicians accountable," said Indiana nephrologist Robert Krause. Medical directors are the captain of the ship and need to make sure if a patient is suitable for a therapy, that option is offered. Can dialysis providers offer nephrologists contractual incentives—a withhold–to direct more patients home? Check with your legal team.

Weighing the financial incentives. Like any business, running dialysis clinics has a bottom line. Dialysis providers have been building bricks and mortar since 1972––it's what they know. And dialysis clinics are expensive to build, so an empty chair is lost revenue.

CMS built some strong financial incentives in the ESRD payment bundle in 2010 to send patients home––immediate payment on the first home treatment, plus a 51% bonus payment for the first four months of care to help cover training costs.  For in-center patients, clinics must sit back and wait. Nephrologists get less in the monthly capitated payment for home patients, but also see the patients less often.

In the global picture, patients who choose home dialysis therapies are a better deal: the cost of the therapy may be higher (for home hemodialysis, more treatments, supplies, etc.) but they tend to use fewer drugs, experience fewer hospitalizations, require fewer interactions with staff, tend to have a better quality of life, and stay employed (a benefit for society). But the ESRD Program and a combined Medicare Part A and B—which pay out separately for hospital services and outpatient/physician services, respectively—are not there yet. The upcoming renal ACO model may be a good test.

Who is paying the bill? Does the type of health insurance have swaying power? A high percentage of home HD patients have private health care plans as their primary payer. These plans, as Golper noted, pay 3-4 times as much per treatment as Medicare does; clinics negotiate the price when a patient starts dialysis. If you walk into a clinic with private health insurance vs. Medicare, does that give you an advantage in getting a home therapy?

Those commercial health plans have no problem paying for short daily or nocturnal dialysis 5-6 times a week. Employers or employees are paying premiums for that insurance, so they should get those services. What about Medicare? How many hoops does a provider and a nephrologist have to jump through to get 5-6 times a week dialysis covered for Medicare patients? And how often? Dialysis providers used to locate their billing offices in states where fiscal intermediaries were more generous. It shouldn’t be that way. CMS should reduce the 'discretionary' powers of the FIs and make the policy black and white for how Medicare will pay for more frequent dialysis.

Can dialysis patients handle it? Think about doing something 5-6 times a week for several hours, or maybe overnight. It makes you feel good when you are done, but getting there is a lot of work. That’s what intensive home dialysis can be like. "Some people start crying when I tell them they should dialyze longer" notes long-time home hemodialysis patient Bill Peckham. Not all patients are suitable for home dialysis therapy. Some don't have the infrastructure to store supplies, the family/partner support, and the comfort with self-cannulation.

Nephrologist Robert Lockridge, a home HD advocate, pushes "informed consent," which helps dialysis patients understand the advantages of therapy at home but also covers the work involved. Yes, there is a burden for going home, but nephrologists should also make patients aware of what awaits them when they agree to in-center dialysis.

This is a discussion that needs to continue. Everyone knows that home dialysis therapy can be a positive experience for the right individuals who are battling chronic kidney disease. Everyone who wants it––and agrees to work at making it successful—should be given the option.

"The power of the three-times-per-week, in-center business model is too often allowed to constrain a patient’s ability to act on their will…" said long-time home hemodialysis patient Bill Peckham. "We assume conventional dialysis is the default option. It's frustrating to hear from patients who don’t have the same access to home dialysis that I do. It shouldn’t be based on the zip code you live in."

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