Commentary to CMS: An Australian View of U.S. Dialysis

I write as a concerned Australian nephrologist, interested in the welfare of all home haemodialysis patients.

As have all Australian and New Zealand (ANZ) nephrologists, I have had a professional lifetime interest in home dialysis of any persuasion, type, prescription, and level of assisted or unassisted care. My particular interest has been in home haemodialysis, on which I believe I have both national and International recognition.

In ANZ, nephrologist training in the management of home dialysis—both home HD and PD (both CAPD and APD)—has long been mandatory. It is thus with some disbelief that we view the paucity of uptake and failure of funding for home haemodialysis in the US.

Let me tell you why that is so.

Home haemodialysis, on a bi-national basis, currently provides ~14% of all dialysis, with NZ leading Australia in individual national penetrance. A synopsis of the data can be downloaded from the bi-national Australian and New Zealand Dialysis and Transplant Registry website. In brief, this PDF shows that:

1. In Australia, 9.4% of all dialysis is home HD + 20.4% is PD = 30% of dialysis is done at home.

2. In New Zealand, 18.3% of all dialysis is home HD + 31.6% is PD = 50% of dialysis is done at home.

The clinical benefits and survival outcomes of home haemodialysis have been clearly documented and they starkly contrast in the many studies and reports from ANZ, Canada, the U.K., many parts of Europe, Turkey, and, especially in the context of this submission to CMS, with the reports that have been generated in the US. All of these studies attest to the superiority of home care in these programs and, while some of these international studies may oddly still seem questionable to US nephrologists, a recent study from the US also confirms this array of international data.

It goes without saying that home haemodialysis is a uniformly accepted, embraced and encouraged dialysis modality in ANZ, and it is actively encouraged and fully funded, irrespective of its duration and/or weekly frequency.

In ANZ, all home haemodialysis is—at a minimum—alternate day (or night) = 3.5 treatments a week, or 7 treatments per each 14 days/nights. Further, in ANZ, a majority of home patients prefer overnight 7-9 hour treatments, and many dialyse 4-5 days/nights per week. As the global costs of home care well undercut the costs of any centre-based care, all regimens of time and frequency are fully covered and funded under the umbrella payments made to services by the state. Physicians and patients are not restricted in their choice of dialysis prescription or equipment—except that the NxStage system is rarely in use throughout ANZ where a predominant preference remains for single-pass systems. This has led to longer, slower and more frequent prescription profiles being the most commonly chosen.

Regarding the impact of home programs on Federal and individual state budgets, clear and careful research and comparison of the clinical outcomes and the global costs of home haemodialysis and peritoneal dialysis against those of any options in satellite or in centre haemodialysis has led all governments—Federal and all states—to preferentially encourage, incentivize and resource home dialysis providers.

In ANZ, the providers of dialysis—and of all home programs—are not for-profit companies, but clinical, public, hospital-based renal units funded, in turn, through state health departments and subject to state audit and control. From clear data provided by government review after government review, the appreciation that the costs of home care are consistently approximately 2/3 those of any form of centre-provided care has meant that all providers are now being encouraged to grow their home haemodialysis training, installation and maintenance programs.

Several national reports and government websites document the profound financial benefits to the state of home care. In Victoria, my own state, where a hub-and-spoke model underpins dialysis funding, the “hub” is the state-approved major hospital renal unit, while the “spokes” are the satellite services or regional hospitals linked to the hub which provide the dialysis service. The following data described (in Au $) the reimbursements for the three main modalities:1,2 facility-based HD, home PD and home HD. For the current 16-17 year:

1. The public admitted WIES (for Metro & Regional services) = $4,640/WIES.

2. Haemodialysis L61Z WIES weight = 0.1055

Each HD service is thus $4640 ÷ 0.1055 = $489.52.

Cost per patient per dialysis session (in-facility care) is therefore = $489.52/dialysis delivered.

Of this $489.52 paid by the state to the SPOKE (the “treating” satellite or regional hospital) or treating unit, the HUB (the managing tertiary referral hospital renal service) recovers $108 for providing the equipment & consumables and $77 for providing specialist (nephrology) support. The SPOKE keeps the remaining $304.52.

The current home dialysis capitation grant (for both home HD and PD) is a flat rate $54,879 per pt. per annum. This is calculated and adjusted annually from the full true and assessed costs of training, installation (machine and RO plus plumbing, carpentry etc) in the home.

From this, HUBs are required to pass on the following amounts to home patients (as a pro rata payment) to cover utility costs (power and water):

■ $779 for PD patients

■ $2,054 for home HD patients

In 2010, Kidney Health Australia (the Australian equivalent to the NKF in the US) commissioned a report¹ into the projected economic impact of dialysis for the (then) coming decade 2010-2020, a decade we are just over halfway through. This described the economic impact (benefit) that would accrue from increasing home care. The extraordinary savings (Markov modeling) are detailed on page 35 of this report: a page with implications that are worth the while of CMS considering.

Further, and recognizing the financial relief provided for the state—but the potential financial burden imposed on families when taking dialysis home—home patients, both HD and PD, are provided with state-by-state reimbursements for their utility costs to ensure patients are not out-of-pocket by going home. A comparison of the pro-rata reimbursements, state-by-state (albeit 3-4 years out of date with significant increases made since then) is shown below:

While I do not profess to understand the extraordinary complexities of US dialysis funding—a system which is, to me, inexplicable against our easy-to-comprehend ANZ funding process—on behalf of home patients everywhere, I thought it might be useful for CMS to understand that the United States is a logarithmic last in home dialysis compared to some other parts of the first world - ANZ, Canada, and parts of Europe—and that this is not only disadvantaging US patients, but is costing you billions through a US-specific and utterly incomprehensible failure to properly encourage and resource home programs.

I implore you to consider carefully how home dialysis is viewed and resourced in the US. This is a serious chance for CMS to take positive steps to correct the current imbalance that is apparent between facility and home-based models of care in the United States.

John Agar

Prof John Agar OAM, MBBS, FRACP, FRCP (London)

Conjoint Clinical Professor of Medicine

University Hospital Geelong and Deakin University School of Medicine

Renal Services: University Hospital Geelong

325 Ryrie Street, Geelong 3220, Victoria, Australia

Work email: john@barwonhealth.org.au

References and Links