Home dialysis, while less riveting as a subject, if successfully expanded could mean cost savings and happier patients. Dialysis is a time-intensive treatment for kidney failure in which a machine filters fluid and wastes from a patient’s blood.
Only 12% of patients with end-stage renal disease start treatment with home dialysis, HHS Secretary Alex Azar said during a speech in March, despite research suggesting home dialysis is cheaper, and as safe as, the in-center option.
Home dialysis once required a significant infrastructure lift from the patient, including setting up the same machines used in dialysis centers. “New plumbing had to be put in,” explained Dr. Eric Wallace, director of the University of Alabama at Birmingham’s home dialysis program. But technology has gotten better, and today there are much smaller machines available—ones that don’t require any plumbing changes, he said.
There have also been financial considerations for healthcare providers, as payment policies have, until recently, arguably favored in-center dialysis.
Last month, President Donald Trump signed an executive order making sweeping changes to kidney disease treatment, and the CMS launched five new payment models to revamp kidney care, including models to encourage home dialysis.
While both in-center and home dialysis are time-intensive procedures, patients have reported better quality of life with home treatment.
For in-center hemodialysis, a patient will typically visit a facility three times a week for a treatment that takes about four hours. Home hemodialysis, by contrast, typically involves the patient performing the treatment on themselves five times a week, for about 2½ hours each day, Wallace said.
Another form of home dialysis, peritoneal dialysis, initially involves a surgeon placing a catheter into a patient’s abdomen, which the patient will connect to a machine before they go to sleep each night.
“In general, the mortality outcomes are similar,” Wallace said of in-center and home dialysis. “However, the other outcomes such as improved quality of life and flexibility of schedule is definitely in favor of home dialysis.”
Recent research has also suggested home dialysis is cheaper than in-center dialysis. Medicare cost report data filed by dialysis providers shows it cost providers an average of $256 to deliver a single in-center hemodialysis treatment in 2017, according to Prima Health Analytics, a health economics consultancy. Delivering home dialysis treatment cost them roughly $215 that same year.
And home dialysis offers savings in terms of personnel, because in-center dialysis requires paying nurses, technicians and other staff who are managing treatment, Wallace noted.
But while some savings are on the side of home dialysis, there are other resource considerations. It takes time to train patients how to perform the treatment—about six weeks. That means it can sometimes feel more cost-effective for a provider to treat multiple patients at the same time in a treatment center.
Although recent announcements from the CMS have helped to align incentives for home care, the shift toward home dialysis will also take some industrywide changes, Wallace said. For example, there may be a need for more clinicians who travel to patients—after all, if a patient has a complication at home, they need to either travel to a dialysis unit or find a provider to visit their home.
If there are more patients on home dialysis, “then the number of units that patients can go to when there is an issue will dwindle,” Wallace said. “That is fine as long as we have a system in place for someone to go to the patient’s home to do their dialysis. We don’t have those systems in place.”