Nephrology News & Issues - Spotlight Archive
New report unveils more barriers to expanding the home dialysis pool
By Mark E. Neumann
Mr. Neumann is Editor-In-Chief of Nephrology News & Issues magazine.
Last November, the Government Accountability Office outlined in a report the failings of government policy to help kidney patients choose home dialysis. A new report, issued March 3, echoes many of the same claims.
The 18-page report, “Economic benefits of increased home dialysis utilization and innovation,” and written by Alex Brill, the former chief economist for the House Ways & Means Committee and now with Matrix Global Advisors (MGA), says policy barriers are preventing a key segment of patients who have end-stage renal disease (ESRD) from gaining access to health and lifestyle benefits of home dialysis.
According to Brill, the barriers that preclude many patients from accessing home dialysis include the lack of sufficient provider education about home dialysis, insufficient reimbursement, limited patient awareness of the home modality, and potentially burdensome requirements for care partner support.
Brill recommends that policymakers alleviate these burdens by focusing on telehealth, reimbursement, patient education, and caregiver issues. He finds that both Congress and federal regulators can do more to help patients receive the benefits of home dialysis by, among other things:
Better reimbursement for the cost of home dialysis therapy
Allowing physicians to leverage evolving telehealth and remote monitoring technology for their patients
Funding more patient and physician education on home dialysis options
Clarifying and simplifying care partner requirements that may confuse patients or otherwise limit home dialysis utilization.
In 2015, the House introduced H.R. 2948, the Medicare Telehealth Parity Act, to make it easier for home dialysis patients to use telemedicine connections and remote patient monitoring to connect with their physicians. “It is incumbent on policymakers to support policies to achieve greater access to home dialysis,” Brill said in the report. “Not only could we see better health outcomes, but with greater uptake, the market can reach a tipping point toward accelerated growth, which can offer incentives for technological innovation that can further benefit patients.”
“Home dialysis can offer certain patients tremendous clinical and quality of life benefits,” said Rebecca Schmidt, MD, Chief of the West Virginia University Section of Nephrology and president of the Renal Physicians Association. “Patients deserve to have choices in their medical care and the option to dialyze at home, when safe and appropriate, is especially key in rural states like mine where many patients live distant to a dialysis center. Home dialysis allows for greater independence and our patients have been able to continue or return to work because they feel better and are not tied to an in-center hemodialysis schedule.”
Barriers to home dialysis were part of the discussions in late February at the Annual Dialysis Conference held in Seattle, Wash. Separate, all-day programs for peritoneal dialysis therapy and home hemodialysis therapy reviewed ways to increase the 12% rate for patients on home therapy in the U.S., which lags behind many other countries. Key issues that were cited, and add credence to both the GAO report and the Brill report include:
• Medical residency programs in nephrology that offer students little exposure to modality options. Few fellows have seen a peritoneal dialysis exchange or visited with a home hemodialysis patient, speakers noted. Residency programs in other countries includes rounds with home dialysis patients.
• Debate continued on whether nephrologists should get equal pay for taking care of a home patient as they do for an inpatient, even though visits are fewer.
• Food & Drug Administration requirements indicate that home hemodialysis patients need either a partner or a telehealth monitoring system in order to perform home hemodialysis. Not all patients agree it is necessary.
• There remains a very high dropout rate for home therapies, particularly home hemodialysis. Some ADC presenters argued that it was important to identify the causes of the dropout rate first before more patients are offered home therapies.
Patient choice on modality options, more so than expanding the home dialysis patient pool for the sake of boosting numbers, is of most importance. Patients who select a therapy – whether it is home or in-center – should have the support of their nephrologist and their kidney care team to obtain the best therapy possible. But options––and choices––should always be revisited.