Medicare & Tips to Increase the Use of PD and Home Hemodialysis (HHD)

I recently downloaded the National Kidney Foundation’s Spring Clinical Meeting app for my iPhone and started checking out meeting sessions and presenters (Dori Schatell presented there). Because I have an interest in modality selection, I looked at the posters and found one that had an interesting find.

Health Insurance and Peritoneal Dialysis Use in the United States by Qureshi et al. (Poster 299) looked at patients reported in the national registry (United States Renal Data System) from 2006-2011 and the association between insurance status and:

1. initiating PD in the first three months, or
2. switching to PD after three months.

The authors compared patients ages 60-64 who had “limited insurance” and those 66-70 who had Medicare and Medicaid. They found a highly significant difference (p<0.001) between Medicare patients who started PD in the first three months (4%) compared to those with limited insurance (2.2%). The latter were 54% less likely to be on PD in the first 3 months after adjusting for patient and geographic differences. Even more interestingly, they found that after being on in-center dialysis for 3 months, those with limited insurance were three times as likely to switch to PD than Medicare patients. The authors’ interpretation was that “insurance is a barrier to PD use in patients with limited insurance. Some providers may wait until patients are eligible for Medicare before switching them to PD.” Their recommendations included: “Educating providers about Medicare reimbursement policy for PD and expanding coverage for PD education may help to overcome these barriers.”

Let’s deal with the recommendation for patient education first. The Medicare Kidney Disease Education (KDE) benefit under Part B took effect January 1, 2010, and is for those with stage 4 chronic kidney disease who have Medicare. That would include those at least age 65 or who have received Social Security Disability Insurance (SSDI) checks for at least 24 months. To get Medicare coverage, the patient must be physician-referred to a “qualified provider.” The Medicare Learning Network provides instructions for billing KDE services.

There are many educational tools to help qualified providers inform patients about the multiple topics that the law requires to be discussed, including options for treatment:

• How to Have a Good Future with Kidney Disease is one of those tools and includes the option for qualified providers to download free slides and use them for Medicare covered KDE services. Anyone can view the presentations.
• A book that may help patients understand kidney disease and treatment options is Help! I Need Dialysis! 
• MEI built an online interactive tool called My Life, My Dialysis Choice that walks patients through dialysis options and helps them consider how each may fit his or her lifestyle and values.
• The Renal Physicians Association has a page with links to multiple items to help nephrologists take advantage of this benefit for their patients.

In spite of these and many other tools, in 2011 (the most recent data), only 2% of stage 4 CKD patients received patient education billed to Medicare. Two of the recommendations in the 2015 U.S. Government Accountability Office report entitled End Stage Renal Disease: Medicare Payment Refinements Could Promote Increased Use of Home Dialysis were that HHS revise its payment policy for nephrologists caring for home patients and that it revise the KDE benefit. HHS concurred with the former—but not the latter. Without sufficient unbiased education and encouragement, it’s no wonder so few patients choose a home modality as their first treatment —which impacts when Medicare starts and the potential for financial hardship. Dialysis providers and surgeons who insert PD catheters (and vascular accesses) need to know that there is no need to put a patient with limited insurance on in-center dialysis and wait 3 months for them to get Medicare. Social Security policy states that Medicare can start the first day of the month dialysis starts if someone who qualifies for Medicare STARTS PD or home hemodialysis training before the end of the 3 month qualifying period. The Social Security Administration’s Your Social Security Statement provides proof of whether an individual qualifies for Medicare. Individuals can download their personal Statement from the Social Security Administration’s website if they set up a My Social Security account. Anyone who is 18 or older and has a valid email address, Social Security number, and mailing address can set up an account. Social Security currently mails statements to those 60 and older who aren’t collecting Social Security benefits and don’t have a My Social Security account. Sample statements for people of different ages can be found here.

NOTE: Social Security policy provides definitions for who is “fully or currently insured” (has enough work credits) and states that spouses and children of workers can qualify for ESRD Medicare under the worker’s record. Home Dialysis Central has a Medicare Start Date Calculator that can tell you when Medicare will start based on the date of first dialysis and the modality or planned modality.

When you have CKD patients who are progressing to kidney failure who have no unmodifiable contraindication(s) for home dialysis, encourage them to consider that option, especially those who have limited insurance and could benefit from getting Medicare sooner. To make sure that a patient can get Medicare sooner:

• Download, copy, and keep in a safe place the two Social Security policies listed in this blog.
• Encourage your patients to annually download the Social Security Statement from their My Social Security account or ask Social Security for a printed copy and share it with you so you can see whether the patient qualifies for Medicare.
• If your patient doesn’t yet have Medicare, but the SSA Statement says he/she qualifies, keep a copy of the Statement.
• Educate surgeons who place PD and HD accesses that the 3 month qualifying period can be waived if:

1. A patient gets his/her PD or HD access the same month he/she starts dialysis and
2. The patient starts a home training program before end of the qualifying period

• With the patient’s permission, share his/her SSA Statement with the surgeon confirming his/her Medicare eligibility.
• Prioritize those with limited insurance coverage on your dialysis clinic’s training schedule so those with limited coverage start home training before the end of the 3 month qualifying period. (Refer to the Medicare Start Date Calculator, above, to see when Medicare starts for an in-center patient.)

Following the steps above could:

• Assure that your patients with limited insurance get Medicare as soon as possible and that surgeons and hospitals or dialysis access centers get paid by Medicare for dialysis access they place.
• Provide patients the opportunity to self-manage and take more control over their kidney disease treatment and have fuller and more satisfying lives.
• Grow your cost-effective PD and/or HHD program, which may reduce the costs to Medicare for treating dialysis patients.