Cost savings, disruption threat pushing more providers into home dialysis

In an era when just about every medical treatment that can be done at home is moving in that direction, only about 12% of patients receiving kidney dialysis do so at home, despite it being cheaper and research showing it's just as safe.

There are a host of reasons why. Most people cite physicians' lack of training on home dialysis and their resulting reluctance to suggest it. Sometimes patients themselves are too sick or overwhelmed to take on that task.

But experts in the field say there's another major factor at play: money. More than 80% of the nearly 6,500 dialysis facilities nationally are owned by two for-profit companies, DaVita and Fresenius Medical Care. Providers aim to see a return on the money spent building and staffing those dialysis clinics, which some say means keeping patients in those dialysis chairs.

“An empty chair is kind of like an empty seat on an airplane,” said Dr. Brent Miller, professor of medicine and clinical chief of nephrology at Indiana University. “If we were just looking at this not as people and not as healthcare but just as a business like an airline, our goal would be to fill all those slots.”

On the contrary, the country's biggest dialysis providers insist they're all-in when it comes to home dialysis, and reject the notion that their own reluctance has contributed to the slow uptake. DaVita said it wants to bump its home dialysis patients from about 13% of dialysis patients currently to 25% by 2025. And Fresenius said it wants to go from 12% currently to 25% of dialysis patients receiving some home therapy by 2022. Fresenius is even looking to buy home dialysis devicemaker NxStage for $2 billion.

One potential driver of companies' apparent enthusiasm for home treatment might be CVS Health's announcement last year that it plans to disrupt kidney care by expanding home dialysis, identifying kidney disease earlier and developing new home hemodialysis technology. CVS hasn't released many details, but Dr. Harry Jacobson, a nephrologist and co-founder of the investment firm TriStar Health Partners, described it as a “breakthrough.” He declined to share more detail because of a confidentiality agreement with the company.

“It's disruptive and it's my opinion that it will be a real catalyst for increasing home hemodialysis,” he said.

Academics like Miller and Dr. Thomas Golper, a professor of medicine at Vanderbilt University, said they welcomed the innovation, but know traditional providers are nervous.

“That's the 800-pound gorilla,” Golper said. “There's a lot of people who are very nervous about that.”

CVS plans to launch a clinical trial to study the safety and efficacy of its new technology ahead of a planned Food and Drug Administration submission, a company spokeswoman wrote in an email. The device is intended to make home hemodialysis simpler and safer, and to facilitate longer, more frequent treatments.

“We expect to provide more information on the device, and our associated activities throughout this year,” she wrote.

Whatever the reason, the percentage of patients with prevalent end-stage renal disease who receive the treatment at home has grown only slightly, from 11.3% in 2013 to 11.8% in 2016, according to the U.S. Renal Data System, which publishes information about end-stage renal disease treatment.

“It's not a huge groundswell,” said Mark Stephens, owner of Prima Health Analytics, a Weymouth, Mass.-based firm that researches and shares data on the treatment of chronic diseases.

Medicare pays for the vast majority of patients who receive dialysis treatment, a population that represented less than 1% of Medicare-eligible patients in 2016 but more than 7% of total fee-for-service claims that year, or $35.4 billion, according to the U.S. Renal Data System, or USRDS.

Since 2011, Medicare has bundled its payments for end-stage renal disease patients, so the payment providers receive is the same whether patients receive dialysis in facilities or at home.

Home dialysis can generate a better margin, however, because it's cheaper for providers to deliver. Medicare cost report data filed by dialysis providers show it costs providers an average of $256 to deliver a single in-center hemodialysis treatment in 2017, according to Prima Health Analytics. It cost them roughly $215 to deliver a home dialysis treatment that year. The average staff hours allocated to a home dialysis treatment is about one hour versus 2.5 hours in a facility, Prima's data show.

“That is clearly very profitable for providers,” said Dr. Joel Glickman, a professor of clinical medicine at the University of Pennsylvania and director of its home dialysis program.

Kent Thiry, CEO of dialysis giant DaVita, called home dialysis “very capital-efficient growth because we don't have to build another clinic,” speaking at the J.P. Morgan Healthcare Conference in San Francisco in early January.

In an interview, DaVita executives emphasized patient enthusiasm and increased awareness as their rationale for heightening their efforts around home dialysis.

Tad Stahel, group vice president of DaVita Kidney Care's home dialysis and hospital services group, played down the cost factor, noting that the company still provides the supplies and medications for patients who choose home dialysis, as well as the nurse who supports the patient.

Stahel and Dr. Martin Schreiber, DaVita Kidney Care's chief medical officer for home dialysis, flatly rejected the notion that the company didn't get into home dialysis sooner because of the need to fill dialysis centers. Schreiber said therapy decisions are always made based on the patient's ability to do home dialysis.

“You make the decision based on the clinical value,” he said.

Schreiber blamed the slow uptake on both a lack of physician training on home dialysis and staffing to train patients on home dialysis, as well as patients' economic issues, such as not having transportation to training sites or a large enough home to be able to perform home dialysis. Stahel said home dialysis supply shortages have also played a role.

Peritoneal dialysis works by sending cleansing fluid through a catheter into the abdomen that filters waste products from the blood. After a certain amount of time, the fluid and waste products flow back out of the abdomen and are discarded. With hemodialysis, a machine uses a filter to clean the blood. A small proportion of hemodialysis treatments are currently done at home.

Nonetheless, Schreiber said he thinks the slow growth in home dialysis is about to change, especially with the development of telehealth, which helps patients feel less isolated.

“I think as we move forward into the millennial generation, you're going to see more and more people who want to monitor their diseases at home rather than going to a dialysis facility,” he said.

Asked whether financial incentives have slowed the transition to home dialysis, Fresenius Medical Care's Dr. Frank Maddux said his company is committed to offering patients the treatment modality that best suits their lifestyle and care needs.

Significant progress has been made over the past decade with respect to having the right technologies, policies and social conditions that are now “finally aligning” to help Fresenius achieve its home dialysis goal, said Maddux, the company's chief medical officer and executive vice president of clinical affairs.

Both DaVita and Fresenius said new remote communication technologies are helping the transition toward home dialysis.

“Back in the early days, patients were really just on their own,” Maddux said. “We had very little visibility of what was happening during their treatment.”

That's part of what drove Fresenius' interest in NxStage, Maddux said. The company has a user-friendly machine and connected health device that supports patients on home hemodialysis, he said.

Some physicians said part of the reason for the slow uptick in home dialysis is that dialysis patients are increasingly sicker and less able to perform the treatments at home. Research has shown home dialysis patients tend to be healthier compared to their in-center counterparts.

For his part, Vanderbilt University's Golper said he believes the biggest reason home dialysis hasn't caught on more is a lack of physician education. He said not enough academic programs are training nephrologists to teach patients to perform home dialysis.

Miller agreed and said the country's top nephrology training programs by and large are not proficient in training providers on home hemodialysis. And while other industries are quick to provide continuing education, he hasn't seen it in this area.

Golper said he's also skeptical that DaVita and Fresenius are truly making the necessary investments in home dialysis to make it work. He has offered faculty support for both companies' home dialysis providers, but neither has accepted.

The CMS launched an accountable care demonstration for end-stage renal disease in 2015 that experts say may encourage more dialysis providers to use home dialysis. As of 2017, there were nearly 40 participating organizations, and that's expected to grow once the program progresses. Fresenius has the largest presence, with 24 organizations, and the company said it decreased patients' hospitalization rate by almost 9% and saved more than $43 million in the program's first year.

Indiana University's Miller said he thinks a big reason more providers are turning to home dialysis is because they're recognizing that their current model, which relies on expensive buildings, lots of nurses and transportation, is unsustainable.

“I think they're a little bit afraid of the sustainability of their current business model,” he said.