Home dialysis grows despite cost and logistical hurdles

Robert Richardson, 46, discovered eight years ago that his kidney function had deteriorated to the point where he needed dialysis. It resulted from glomeril nephritis, a chronic condition he's had since age 5.

“The doctors caught something on a physical, and they had me see a nephrologist,” Richardson said. “The nephrologist told me my kidney function was down around 15%.”

By fall of that year, Richardson, newly married and working as a teacher and a tour guide in Savannah, Ga., was performing peritoneal dialysis several times a day at home. The procedure removes toxins from his blood by filling his abdominal cavity with a special solution. After three-and-a-half years using that treatment, Richardson said it left him feeling tired. He switched to home hemodialysis, in which each night he connects to a machine that filters his blood while he sleeps.

Richardson is one of a growing number of U.S. patients having dialysis at home. Research shows that patients on home hemodialysis or home peritoneal dialysis who dialyze five to six times a week have better health outcomes than those who visit an outpatient center three times a week because home-based patients filter their blood more frequently. But experts say Medicare payment policies, cost issues for providers and patients, patient demographics and physician comfort levels have gotten in the way of broader use.

A New England Journal of Medicine study published in 2010 comparing the health outcomes of patients receiving hemodialysis in a center three times a week versus six times a week found that those receiving more frequent dialysis had a better quality of life, including improved control over hypertension and anemia and fewer days in the hospital.

“Once you get someone home, they feel better at home than they do with in-center dialysis,” said Dr. Leslie Spry, a spokesman for the National Kidney Foundation and medical director of the Nebraska-based Dialysis Center of Lincoln. Over the past five years, Spry said he has seen a rise in the use of home dialysis. “Most people who are in in-center dialysis will tell you that they are usually very much incapacitated after going in for their treatment.” Home dialysis users tend to recover in about 30 minutes, he said.

But Dr. Rajnish Mehrotra, a professor of medicine at the University of Washington, said providers face financial disincentives that prevent many from offering home-based services. “Most patients do not have access to home dialysis because either their insurance, mostly Medicare, is not going to pay enough to cover the costs, or (the patients) lack sufficient socio-economic resources to be on it,” he said.

Some experts say more end-stage renal disease patients would be served by home dialysis if more clinicians recommended it. Though the number of patients using peritoneal dialysis has increased by about 40% over the past five years, a 2011 study published in the American Journal of Kidney Diseases found that up to half of dialysis patients choose home treatment.

“Most programs that train nephrologists don't have enough people who are on home dialysis,” Mehrotra said. “As a result, the nephrologists are not comfortable offering home hemodialysis, which in turn it feeds into the cycle of it not being offered enough.”

For providers, there are big upfront expenses associated with having nurses train patients on dialysis. Training for each patient can take up to six weeks. Also, providers have to provide ongoing home-based support. In most cases, clinicians must have at least one face-to-face visit a month with home patients to qualify for Medicare's monthly capitation payment.

Spry said for in-center dialysis, he can train a technician supervised by a nurse to serve three or four patients at a time. In contrast, with home dialysis, his center has to pay a nurse $25 to $50 an hour to work with a patient one-on-one daily for at least three weeks.

For patients, the energy cost of running a dialysis machine at home can be a significant barrier. Also, many ESRD patients live alone and are unable to perform the procedure themselves because of physical or cognitive limitations. Medicare no longer covers the cost for home health nurses to visit patients' homes to help with dialysis.

Still, hemodialysis is more intrusive. It requires patients to set aside three to five hours for treatment plus travel to and from the center three times a week.

One year of hemodialysis can cost up to $72,000, while a year of peritoneal dialysis costs about $53,000, according to information from the U.S. Renal Data System.

Despite cost and logistical challenges, the use of home dialysis, particularly peritoneal dialysis, is growing. Large dialysis providers such as Fresenius Medical Care and DaVita Kidney Care are moving to increase the share of their patients who receive home treatment. Large providers are better-positioned to bear the upfront costs associated with home dialysis, knowing that serving these patients at home eventually will reduce costs.

Keith Lester, vice president of home therapy services for Fresenius, the largest U.S. dialysis provider, said his company has increased the percentage of its patients receiving home dialysis from 6% in 2008 to 11% by 2014.

For DaVita, peritoneal and home-based hemodialysis represented 16% of the company's total revenue in 2013, according to the company's annual report.

That's still far below the level of home dialysis in the U.S. decades ago. In 1972, 40% of dialysis in the U.S. was performed in a home setting, according to the U.S. Renal Data System. By 1980, the rate had plummeted to less than 5%.

Home dialysis is used significantly less in the U.S. than in some other countries. Only about 8% of the more than 400,000 dialysis patients in the U.S. are on home dialysis. In contrast, eight other countries— Australia, Canada, Denmark, Finland, Iceland, Mexico, the Netherlands and New Zealand —have home dialysis rates at or above 20%, according to a 2011 article published in the Clinical Kidney Journal.

Experts say the decline in home dialysis in the U.S. was related to the introduction of the Medicare End Stage Renal Disease Program in 1973, which paid for dialysis for nearly all Americans with ESRD. That program created a strong financial incentive for providers to maximize the number of patients who could receive dialysis treatment. So they shifted to outpatient dialysis centers.

The growing interest in home dialysis comes as projections indicate increased demand for dialysis care in the coming years. More than 20 million adults have some form of chronic kidney disease, according to the Centers for Disease Control and Prevention. By 2025, that number is expected to rise by 50%. The prevalence of Americans treated for ESRD grew by nearly 600% between 1980 and 2009, from 290 cases per million to 1,738, according to the National Institute of Diabetes and Digestive and Kidney Diseases.

In recent years, the CMS has tried to get providers to put more patients on home dialysis by revising its payment system. It has waived a 90-day waiting period for reimbursement for home-dialysis patients that is required for in-center patients. In the agency's rule on ESRD payments issued last November, the CMS increased the rate for training patients to perform home dialysis by 50%, from $33 a session to $50.

Medicare pays 80% of costs associated with dialysis care for services either at home or at a dialysis center. For home dialysis, the federal government pays for training, dialysis equipment and supplies, including drugs and doctors' services.

Mehrotra said he was encouraged by the CMS' effort to incentivize more home dialysis use, and he predicted that up to 25% of dialysis patients would eventually receive treatment at home.

Richardson, the Savannah patient, endorses the home approach. “I had gotten so used to thinking that I can't do things because I'm sick,” he said. “You get your life back.”

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