One thing became abundantly clear after sifting through the 490 comments on the 2016 proposed rule for the ESRD payment system and Quality Incentive Program: the renal community does not think home hemodialysis training is adequately reimbursed.

The majority of comments, 86%, came from home hemodialysis patients or their care partners, who attested that they required, and received, far more than 90 minutes of training a day. Nurses, patient organizations, and nephrologists were also vocal about the need for better reimbursement. They wrote about dialysis centers not providing home hemodialysis because of the cost of training, and patients fighting to get access to the modality.

“Please make the payment equitable so that I can continue to offer this option to my patients. I have no problem getting PD patients trained, but HHD patients are often put on a waiting list and sometimes do not end up on the therapy that I feel would give them the best quality of life,” wrote one nephrologist.

Perhaps NxStage said it best:

“CMS has received over one thousand comments to date on the inadequacy of the training payment since the implementation of the bundled payment system, including those comments posted already in the current comment period. Constituents have provided data consistently demonstrating that the training payment is inadequate and is a bar to the broader adoption of this important, Congressionally mandated therapy. And CMS has failed to respond. It has failed to address the inadequate payment. It has even failed to meaningfully respond to the myriad of commenters, many of whom are patients who took the time to write to CMS so that future patients could avoid the challenges many of these patients had to overcome in fighting for access to home dialysis therapy. We and other stakeholders have waited too long for CMS to fulfill its legal obligation to engage meaningfully with us, and to consider fully the ample evidence that the Medicare payment for home dialysis training is inadequate. The time to act is now.”

In their comments, the American Association of Kidney Patients also mentioned the need for better training funding, and the large amount of patients who have commented on this issue.

“Last year, CMS heard directly from hundreds of patients asking that barriers to home dialysis be removed. Many of these patients were longtime and new members of AAKP. The AAKP, as an organization that independently advocates on behalf of kidney patients, respectfully asks that you honor those who commented along with other patients directly impacted by CMS policies by acting now to make home dialysis options available to more kidney patients … To meet the legislative intent of the U.S. Congress, CMS should establish an appropriate payment for home dialysis training consistent with the actual costs of providing the service. In fact, in order to meet the Congressional mandate for the maximum reasonable number of patients to utilize home therapy, an adjustment to the current training payment must be reasonably applied.”

How should the new costs of training be paid for?
NxStage offered options of how to pay for the costs of training, and was clear that the cost should not come out of the bundle.

“We see at least three possible approaches to funding an increase to the training payment. Option A would be to use an incredibly modest sum of new money, which CMS has the statutory right to do, to fund the increase. Option B would be to use a small portion of the “leakage” that is projected to result from CMS’ payment adjuster-driven underpayment on the PPS and underpayment of the outlier pool (calculated to be $2.29 per treatment in total, and $0.28 for the outlier pool by The Moran Company)18 to fund the increase without any reduction to the bundle. This would be an appropriate, policy-supporting move to employ funds that would otherwise be lost forever in the system. Or, Option C, and least preferable, would be to implement the increase in a budget-neutral fashion, acknowledging that CMS would be creating short-term financial winners and losers in the provider community in support of an important beneficiary policy objective.19 Whatever approach CMS ultimately decides to follow, however, it cannot continue to ignore the inadequacy of funding for HHD training.”

Obviously, providing more training will cost more money, but many commenters highlighted the economic benefits of increased home hemodialysis use.

“It is a wise economic decision for Medicare because more dialysis is better for patients and therefore the patients will be healthier reducing hospital stays and medications,” wrote Lana Schmidt, a dialysis patient, advocate, and editorial advisory board member for NN&I. “Patients on in-center are barely surviving, costing Medicare high medical costs.”

Increasing the number of home hemodialysis patients would likely save CMS money in the long run. CMS saw the financial benefit in peritoneal dialysis; it is time to give home hemodialysis a chance. The patients and organizations at least deserve a response.