Staff-Assisted Home Hemodialysis: An Option for Some Patients

Occasionally patients or their loved ones post in the Home Dialysis Central Facebook group or Home Dialysis Central Forums asking where to find staff to help with home dialysis:

• Some have physical or mental challenges that keep them from doing all the PD or home HD tasks without help. They may be cognitively impaired, too frail to lift heavy bags or move supplies, or limited use of their hands or eyes may prevent self-cannulation.

• Others may be willing and able to dialyze solo, but use a machine that is not FDA-approved for solo or are treated by a doctor or clinic that requires patients to have a care partner.

• Many do not have family or friends they can ask to help them do home dialysis. They may think they have no choice but to do in-center HD or choose conservative management and face certain death.

This blog discusses another option for some, if financial barriers can be overcome.

Medicare Coverage for Dialysis

In 1965, President Lyndon B. Johnson signed legislation establishing Medicare and Medicaid and in 1972, President Richard Nixon signed the law extending Medicare to people with disabilities and those with ESRD requiring dialysis or transplant.

In 1974, the first full year Medicare covered dialysis, about 40% of patients were doing home hemodialysis (HD).¹ By 1978 the number of home dialysis patients had declined so much that the Health Care Financing Administration (HCFA; now Centers for Medicare & Medicaid Services or CMS) began encouraging home dialysis by:

• Waiving the 3-month qualifying period for Medicare as an incentive to patients

• Paying the same for home dialysis as in-center to incentivize facilities (home cost less)

• Paying physicians an add-on for each home-trained patient to incentivize them to refer for home dialysis

These incentives remain in place today. Medicare did not then and does not now pay for home dialysis aides. The expectation has always been that patients would have volunteer family or friends to help with home dialysis as they did prior to Medicare coverage.

History of Payment for Dialysis

When Medicare first started to pay for dialysis, clinics could bill for dialysis and drugs separately. Independent dialysis clinics were reimbursed $138 per treatment and hospital-based clinics $156 per treatment.

With declining use, HCFA established “target rate reimbursement” for home dialysis. This was “an optional reimbursement method for providers and renal dialysis facilities that execute an agreement with HCFA to furnish all necessary home dialysis medical supplies, equipment, and supportive services (including the services of qualified home dialysis aides) that are medically necessary to enable patients to continue dialyzing in the home setting.”²

HCFA published target rate reimbursement notices in 1980³ and 1981,⁴ noting, “The law establishing the target rate clearly states that the maximum rate payable is 70% of the national average payment for in-facility dialysis.” The rate varied from $90-$120 per treatment based on location, less than the rate for in-center dialysis. It’s no wonder that of the 1,200 facilities HCFA contracted with, just 30 accepted the target rate reimbursement.⁵

Other Medicare payment methods included the 1983 composite rate reimbursement that bundled treatment and supplies; hospital-based clinics were paid $131 and freestanding ones $127 (with some geographic variation).

Home dialysis patients had to select a “method” they wanted to use:

• Under Method I, dialysis clinics billed the same amount for home patients as in-center ones.

• Under Method II, dialysis facilities billed only for support services (RN, RD, and MSW) while durable medical equipment suppliers billed Medicare for everything else for home dialysis.

Some facilities steered patients toward Method II that Medicare reimbursed at a higher rate.

As Method II costs were rising, in 1988, Congress asked Medicare to investigate why. The GAO looked at 1987-1988 and found that one supplier, Home Intensive Care (HIC), was providing home dialysis aides for home patients and billing Medicare $252 per treatment, about twice what clinics could bill under Method I. Northwest Kidney Centers, with five facilities and 200 home patients, was paying for home dialysis aides for about 2/3 of its home patients and could afford to do that under Method I.

When HCFA proposed capping Method II payment, HIC sued, claiming that providing aides reduced inpatient costs. The GAO found this to not be true and reported all of this to Congress, including that HIC was being reimbursed $67 per treatment of its “reasonable charge for dialysis” for home dialysis aides and other services—even though Medicare didn’t cover those and the extra cost for aides was not offset by inpatient savings. Based on its investigation, the GAO report supported a proposed new payment mechanism for home dialysis.⁶

In 2011 Medicare established a bundled payment system called the “ESRD prospective payment system (ESRD PPS).” . The PPS bundled dialysis treatment and supplies for home and in-center patients and added ESRD-related drugs and ESRD-related labs.⁷ Having been burned by HIC’s higher charges and a growing percentage of home patients choosing Metod II, this led Medicare to plan a study of costs and benefits of staff-assisted home dialysis.

Medicare paid separately for erythropoietin for 20 years after FDA-approval until 2011, when the prospective payment rate was established, adding ESRD-related drugs and ESRD-related labs into the bundle.⁸ Medicare did not change its policy about staff-assisted home dialysis.

The Government Plan for a Home Dialysis Demonstration

By 1989, just 2% of patients were on home HD. Patients who required ambulance transportation were doing in-center HD and ambulance transportation cost Medicare more than dialysis.

The Omnibus Budget Reconciliation Act of 1990 mandated that HCFA conduct a 3-year demonstration to see if Medicare coverage of staff-assisted home HD would be safe and cost effective for patients who met rigid criteria. Congress provided funding to include up to 800 patients. For eligibility, the law required patients to:

• Be bed or wheelchair-bound and unable to transfer; or

• Be eligible for ambulance transportation to a dialysis facility for at least 6 months; or

• Have a medical condition that worsened by having to travel to a dialysis facility; or

• Have no family member available to be a care partner/caregiver; or

• Not be a resident of a skilled nursing facility

HCFA developed the Scope of Work for a Staff-Assisted Home Dialysis Demonstration⁹ and in 1991 signed contracts with Abt Associates and the Urban Institute to implement and evaluate the project. HCFA set the per session payment. The mean rate was $48.42 for outpatient clinics and $50.66 for hospital-based, in addition to the Medicare composite rate payment. In addition, dialysis clinics received $200 for training each aide/patient pair plus the $20 payment that Medicare paid for training unpaid helpers at that time.

HCFA contracted with the 18 ESRD Networks to review patient eligibility, assure care quality, and collect project data. In January 1992, Abt sent a letter about the demonstration to all 2,137 U.S. certified dialysis facilities. Of those:

• 13% said they had eligible patients and were interested

• 37% said they were interested but didn’t have eligible patients

• Half said they weren’t interested. Of these, 29% said the eligibility criteria would make patients too sick to do home dialysis, 29% said the reimbursement was too low, and 24% said it would be too hard to recruit staff.

Abt sent applications to the 144 interested facilities that had eligible patients.

The Staff-Assisted Home Dialysis Demonstration 1992-1995

The demonstration project started in May, 1992. Patients were randomized, with half assigned to staff-assisted home HD and half getting in-center dialysis as usual. HCFA expected fewer than 200 patients to be referred to evaluate these hypotheses:

1. Would staff-assisted home HD cost less than conventional treatment?

2. Would the treatment be as safe as in-center dialysis?

3. Would patients receiving staff-assisted home HD be more satisfied and have better quality of life than those receiving in-center dialysis treatment?

The 1997 Report to Congress¹⁰

By the end of recruitment, 45 new clinics had opened and were informed of the demonstration. About 52% of the 2,182 facilities responded to the letter. However, even with multiple outreach efforts, only 91 patients at 38 facilities participated. Half (45 patients) were controls and the other 46 were assigned to the experimental (paid aides) group. By the time the study started several patients had died or withdrew, leaving just 21 patients receiving staff-assisted home HD. Two more patients were still awaiting an aide when it was time to analyze the data. Some of the findings were:

• Clinics willing to participate were larger with more patients on home dialysis.

• Rural clinics that may have had less transportation were not more willing to participate.

• In the Medicare database, 46% of clinics had home HD programs, but a “substantial number” of these were not active in 1992 when the demonstration started.

• Nearly half of participating clinics were from Networks 4 and 5 (mid-Atlantic). One home HD MD from Network 4 referred 13% of the patients. Networks 1 (New England), 6 (GA, NC, SC), 9 (IL, KY, OH) and 17 (Northern California) referred no patients and only 2% of facilities participated with 98% of dialysis facilities not participating.

• An average of 10 monthly claims were filed with an average charge for the aide of $643 per month after facilities with fewer than 3 months of home aide claims were not counted.

Conclusions (Copied from the Report)

“The demonstration had too few enrollees to support statistical analysis, and the data can only be regarded as suggestive. However, the following conclusions can be tentatively drawn:

• The vast majority of patients in this demonstration were not distressed with their pre demonstration dialysis arrangements – 93% (14 of 15) of those who had home hemodialysis aides paid by insurers other than Medicare, and 88% (21 of 24) of those who had in-center dialysis, reported being somewhat or very satisfied.

• The eligibility criteria that were Congressionally-mandated for this demonstration, in

general, characterize patients who are too ill for home hemodialysis. Thus, a home

hemodialysis aide is not likely to be an alternative for most patients for whom an

ambulance is medically necessary.

• The patients who were enrolled in the demonstration were somewhat older and much

sicker than the ESRD population in general, with far more comorbid conditions documented m medical records. During the 2 year and 9 month period studied, 78% of the enrollees died. This is nearly twice the mortality rate than among the general ESRD population, which had a 40% mortality rate over a comparable period.

• The rate-setting formula that was Congressionally-mandated yielded rates that were

probably low, relative to the care requirements of many of these patients. The majority

of the aides used in this demonstration had dialysis experience, but carried little in the

way of health care credentials.

• Although the numbers are small and do not permit conclusions about quality of care,

demonstration patients who dialyzed at home with the assistance of aides had better

dialysis outcomes and a lower mortality rate than control and experimental patients who did not have demonstration aides for home dialysis.”

My Experience with HCFA’s Home Dialysis Demonstration

I started working as a social worker with dialysis and transplant patients in 1978. I heard that Jewish Hospital in St. Louis, Missouri, paid home dialysis aides. I don’t know if that program used target rate reimbursement, but saw an interesting article that stated the hospital applied to the Missouri Kidney Foundation for funds to pay for home dialysis aides.¹¹

In my Network (IA, KS, MO, NE), there were three clinics and four patients who participated in staff-assisted home dialysis demonstration. One of my patients had been paying out of pocket for a home aide. He transferred to my clinic to participate in this demonstration when his facility chose not to due to the reimbursement amount. My facility re-trained his aide and billed Medicare for that home training and for the monthly aide services in addition to the composite rate. When it received the payment for the aide, it sent the patient a check for that exact amount. It was a win-win for everyone. By the law that established the demonstration, Medicare had to continue paying for home aides for patients who had an aide under the demonstration after the demonstration ended.

Staff-Assisted Home Dialysis Today

Medicare covers PD and home HD equipment, supplies, medications, labs, and support services. The support services Medicare covers includes clinic visits and/or contacts between visits with the home training nurse, dietitian, and social worker. It does not include home dialysis aides.

Medicare certified dialysis providers may provide in-center dialysis or on-site home HD to residents of skilled nursing facilities (SNFs) or nursing facilities (NFs). Two large Medicare-certified providers—Dialyze Direct and Concerto Renal Services—use trained staff to perform on-site dialysis in SNFs/NFs. When home HD is provided on-site in a SNF or NF, it may be provided in a patient’s room or in a “den-like” setting where one or more trained nurses or technicians treat one or more residents. CMS published guidance to help dialysis providers that oversee nursing home residents’ care and personnel from state survey agencies and Medicare- approved accreditation organizations assure that home HD provided on-site in a SNF/NF is in compliance with federal and state (if applicable) regulations.¹²

Some insurers cover staff-assisted home HD for eligible patients. The CPT code they expect to see is 99512 – Home visit for hemodialysis. The following information on eligibility was copied from three of the largest insurers’ websites.

You Can Advocate for Staff-Assisted Home Dialysis

In April of 2023, H.R. 2853—Expanding Care in the Home Act¹³ was introduced in the House of Representatives. This bill would have required Medicare to cover staff-assisted home dialysis as well as other home care services. Unfortunately, the legislation died when that session of Congress ended.

The National Kidney Foundation is drafting legislation called The Improving Access to Home Dialysis Act of 2025 that would provide short-term Medicare coverage for staff-assisted home dialysis for patients with a temporary need and long-term coverage for patients who are blind, have cognitive or neurological impairments, or other illnesses that reduce mobility. Check out information on NKF’s Advocacy site that shares NKF’s legislative priorities, regulatory advocacy, resources for advocates, state resources, learn about what kidney advocates are up to, and consider joining NKF’s Voices for Kidney Health.