Mythbusting! Do Nephrologists Really Make Less Money Seeing Home Dialysis Patients?
In 2010, an MEI study found that while 92% of patients did in-center hemodialysis (HD), just 6% of nephrologists would choose that option if their own kidneys failed.1 So, why doesn’t every nephrologist screen every patient for home dialysis – PD or home HD? And, why don’t more patients choose a home option? What barriers do nephrologists perceive—and is reimbursement one of them? Let’s look at some of the myths and perceptions and find out.
Myth 1: Patients are Not Willing to do Home Dialysis Tasks
A 2016 survey of 250 in-center patients found a much higher percentage said they would be willing to do home HD dialysis tasks than 51 nephrologists—also surveyed—assumed: 2
- Weighing themselves: 98% of patients were willing vs. 69% MD assumption
- Disinfecting chair/machine: 84% of patients were willing vs. 34% MD assumption
- Addressing alarms: 53% of patients were willing vs. 31% MD assumption
- Taking vitals: 46% of patients were willing vs. 20% MD assumption
- Self-cannulating: 41% of patients were willing vs. 16% MD assumption
One way to overcome erroneous assumptions is to help patients understand as much as they can about their treatment options. MEI’s patient presentations How to Have a Good Future with Kidney Disease meet the criteria for Medicare’s paid (MIPPA) kidney disease education benefit. Kidney School Module 2 can teach patients about treatment options and provide an action plan. The My Life, My Dialysis Choice decision aid can help patients review options in light of what they value for their health and lifestyle—and serves as a shared decision-making tool that can make the toughest part of nephrologists’ jobs easier. The book Help, I Need Dialysis! can help patients learn what to expect with each dialysis option. Using tools like these can help patients make a better and more informed treatment choices.
Myth 2: Dialysis is “Too Complex” for Patients with No Medical Background to Learn
This cannot be the case, since many patient care technicians (PCTs) with no medical background are hired by clinics and trained to do most of the direct patient care, with supervision and oversight from a licensed nurse. Home patients receive training and supervision as well.
In fact, to offer home dialysis, the ESRD Conditions for Coverage3 at 42 CFR 494.100(a) requires:
- Clinics to be approved to provide PD and/or HHD
- The interdisciplinary team to oversee home patients’ care
- A qualified home training RN to provide most of the training, which must:
“(3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas:
(i) The nature and management of ESRD.
(ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician’s prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient’s plan of care.
(iii) How to detect, report, and manage potential dialysis complications, including water treatment problems.
(iv) Availability of support resources and how to access and use resources.
(v) How to self-monitor health status and record and report health status information.
(vi) How to handle medical and non-medical emergencies.
(vii) Infection control precautions.
(viii) Proper waste storage and disposal procedures.
Further, 42 CFR 494.100(b) requires dialysis clinics to assure that the home patient/partner demonstrates comprehension of what s/he was taught. So, when a clinic complies with the regulation, there should be no question about whether any home trained patient—even with no medical background—is competent to do PD or HHD as well as a PCT could. An often overlooked consideration about home dialysis is that the patient and/or his/her care partner is highly motivated to provide the best care possible because the patient’s health and life depends on it.
Myth 3: Home Dialysis Patients Won’t Complete Their Prescribed Treatments
Research has found that skipping and/or shortening HD treatments predicts a higher risk of hospitalization and death. In 2004, the Dialysis Outcomes and Practice Patterns Study (DOPPS) reported that 7.9% of U.S. (in-center HD) patients skipped at least one treatment/month and 19.6% shortened at least one treatment by 10 minutes/month—more than in other countries. Patient characteristics linked with skipping included younger age, depression, smoking, and race (African American vs. non-African-American). Patient characteristics associated with shortening treatments included younger age, depression, employment status, race (same as above), and more years on dialysis. Larger clinics had higher rates of skipping (>60 patients) and shortening treatments (>75 patients).4 Might smaller clinics allow staff to get to know and educate patients better, which could contribute to reducing skipping and shortening?
We don’t have a lot of research that compares skipping and/or shortening treatments in home vs. in-center dialysis patients. However, home patients have greater flexibility and can adjust their treatment schedules to meet their needs and don't have the same transportation needs as in-center patients. So, they may be less prone to skip and/or shorten treatments, especially when they are taught about the higher risk of death and hospitalization if they do. Contrary to what I’ve heard from in-center patients, I’ve never heard a home patient report feeling like they’re on an assembly line.
Myth 4: Nephrologists Make Less Money Caring for Home Dialysis Patients
Medicare reimburses nephrologists who see in-center patients with a monthly capitation payment (MCP) based on the number of visits, with a maximum of 4 visits per month. They may see in-center patients weekly themselves, or have an advance practice RN (APRN) or physician assistant (PA) see them for 3 of the 4 weeks, but must have at least one face-to-face visit each month to assess the vascular access.
In most cases, a nephrologist has a face-to-face visit with home patients once a month, too. Some home patients choose not to come to clinic appointments monthly. In those cases, the Medicare Administrative Contractor (MAC) can waive the face-to-face visit on a case-by-case basis and pay the home dialysis MCP if the doctor’s notes indicate that s/he “actively and adequately managed the care of the home dialysis patient throughout the month.”5
Let’s look at the difference in nephrologist revenue from in-center and home dialysis. We will assume a dialysis clinic with 20 in-center stations and a home dialysis program:
- The clinic runs 3 shifts a day, 6 days a week and provides in-center HD to 120 patients
- The clinic has 20 trained home dialysis patients (a mix of PD and home HD)
- A nephrologist (or APRN or PA) sees in-center patients once a week for the Medicare monthly capitated payment (MCP) of $284 per patient.
- A nephrologist sees home patients once a month for the Medicare MCP of $239 per patient.
At first glance, it would seem that in-center patients would drive more nephrologist revenue, because there are more of them.
- Let’s say a nephrologist sees 120 in-center HD patients each week, and spends 6 minutes (for ease of calculation) on each, or 0.1 hour/patient/week. This would be 120 x 0.1 = 12 hours per week, or 48 hours/month. The in-center monthly MCP of $284 x 120 patients = $34,080: $710 per hour.
- A physician who sees 20 home patients monthly for 20 minutes each (.33 hour) could bill for .33 x 20 or 6.7 hours per month; $239 x 20 would be $4,780: $713 per hour.
The hourly rate is nearly identical.
While total physician revenue is higher due to volume, the time commitment is also more than seven times higher, just for patient visits. Thus, growing a clinic’s home program could result in more experienced staff—and higher Medicare revenues, too. If patients on home dialysis can keep their jobs or return to work, they may have higher income, which can make it easier to follow treatment plans. And, if working brings them employer health plan coverage, clinic and nephrologist revenues would be higher still.
In addition, an experienced home training RN can supervise approximately 20 home dialysis patients—at least twice the number an in-center RN can supervise. The home training RN can answer most questions, troubleshoot most problems, review treatment sheets, address issues with the company that provides the equipment/supplies as needed, and only consult with the nephrologist as needed. A good home training RN can save a busy nephrologist time.
Let’s share these mythbusters and overcome our assumptions and stereotypes about which patients can do home dialysis successfully. We can make 2018 the year where more U.S. patients can live fuller lives by doing dialysis at home.
Merighi JR, Schatell DR, Bragg-Gresham JL, Witten B, Mehrotra R. Insights into nephrologist training, clinical practice, and dialysis choice. Hemodial Int. 2012 Apr;16(2):242-51. https://www.ncbi.nlm.nih.gov/pubmed/22151183. (Accessed 12/22/2017)↩
Yau M, Carver M, Alvarez L, Block GA, Chertow GM. Understanding barriers to home-based and self-care in-center hemodialysis. Hemodial Int. 2016 Apr;20(2):235-41. https://www.ncbi.nlm.nih.gov/pubmed/26415746. (Accessed 12/22/2017)↩
Centers for Medicare & Medicaid Services. 42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities; Final Rule. April 15, 2008. https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Downloads/ESRDfinalrule0415.pdf. (Accessed 12/22/2017)↩
Saran R, Bragg-Gresham JL, Rayner HC, Goodkin DA, Keen ML, Van Dijk PC, Kurokawa K, Piera L, Saito A, Fukuhara S, Young EW, Held PJ, Port FK. Nonadherence in hemodialysis: associations with mortality, hospitalization, and practice patterns in the DOPPS. Kidney Int. 2003 Jul;64(1):254-62. http://www.kidney-international.theisn.org/article/S0085-2538(15)49314-7/pdf. (Accessed 12/22/2017)↩
Medicare Claims Processing Manual Chapter 8 - Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims. Section 140. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c08.pdf. (Accessed 12/22/2017)↩