Efforts to move dialysis care into the home are gaining traction, three years after then-President Donald Trump set a goal of having 80% of newly diagnosed kidney failure patients receive transplants or home dialysis by 2025.
Last year, 26.6% of Medicare beneficiaries with end-stage renal disease were receiving dialysis, compared with 13.3% in 2020, according to the Centers for Medicare and Medicaid Services,
New training initiatives for nephrologists that encourage home-based dialysis when appropriate, payer incentives and value-based care models are behind the transition to home dialysis, according to Dr. Edward Gould, co-chairman of the American Society of Nephrology's Home Dialysis Steering Committee.
Policymakers have sharpened their focus on kidney disease in recent years because the condition affects approximately 37 million Americans and accounted for 6% of Medicare’s $609 billion in expenditures in 2020. About 3% of those patients had end-stage renal disease requiring dialysis. Others will likely need dialysis or a transplant as their disease progresses.
Medicare pays the same bundled rate for home dialysis as it does for in-facility treatment. However, the average cost for a home dialysis treatment in 2021 was nearly $50 less than a facility treatment, according to Prima Health Analytics. Prima attributed the cost difference mostly to the cost of staff administering treatment at facilities.
In 2021, in an effort to save Medicare money and cut treatment costs, a CMS demonstration model as well as changes to Medicare Advantage slowly started moving dialysis more into the home.
The End-Stage Renal Disease Treatment Model randomly selected certain dialysis treatment facilities and physicians nationwide to increase home dialysis and encourage more transplants when possible through 2027. Providers receiver either financial incentives and penalties based on performance.
A study published in JAMA Network of the model’s first year of performance found only a slight increase in patients transitioning into home dialysis.
Showing more promise is a provision in the 21st Century Cures Act allowing patients with end stage renal disease to shift from fee-for-service Medicare plans to Medicare Advantage. At the end of last year, 42% of patients with end-stage renal disease were enrolled in Medicare Advantage plans compared with less than 24% in 2020, according to healthcare research company ATI Advisory.
Private health insurers are forming value-based care arrangements with kidney care solutions companies, such as Interwell Health and Strive Health as more of those patients sign up for Medicare Advantage. The companies partner with providers with the goals of catching the disease early, improving care and cutting healthcare costs. Home dialysis plays a key role in the value-based care arrangements.
Strive Health CEO Chris Riopelle said early detection of kidney disease gives patients time to learn about dialysis options and home-based care. Patients often don’t realize they have kidney disease until their kidneys fail, he said.
“You and I can’t think about [dialysis options] when we are lying in the hospital not sure what happened because our kidneys failed,” Riopelle said. “It’s a very difficult and stressful environment in which to make that decision and that is why people end up in in-center dialysis most of the time.”
Strive serves approximately 80,000 patients with chronic kidney disease and end-stage renal disease across 30 states, with approximately 22% receiving home-based dialysis. Riopelle estimated the company’s value-based care model has reduced hospitalizations by 42% and kidney care costs by 20% since it began treating patients three years ago.
Medicare Advantage chronic condition special needs plans for patients with end-stage renal failure are also helping move dialysis care into the home. In 2021, only nine plans were available to patients with kidney failure. This year, there are 25 plans, according to ATI Advisory.
Special needs plans target patients with specific diseases and provide supplemental benefits to help enrollees manage their illnesses.
Long Beach, California-based SCAN Health offers two such plans to renal failure patients in three Southern California counties. The plans’ benefits include caregiver respite, housekeeping and pest control to support kidney disease patients who want to receive dialysis at home.
“You have to have a clean, safe environment for home dialysis, so the idea is to support them from a benefit perspective, so they can maintain the ability to dialyze at home,” said Lena Perelman, SCAN Health’s senior director of market expansion and product development.
Gould credits new payment models with transitioning more dialysis to the home, but admits challenges remain. He said many patients are still resistant to the idea of in-home patients treating themselves and others simply don’t have the space or infrastructure to support home dialysis. However, he said he thinks those are barriers that can be overcome with time.