Yesterday, we discussed the fact that dialysis costs have been pretty static at around $ 30K a year for decades.  Mostly because of the improvements to technology and therapy that folks like me developed over the years.  And, because the US government pays for it- and sets the price.  A system that often arouses grumbling among those providing the care.

To those of us who know dialysis- we recognize that if we were to have to be so treated, we’d want that therapy to be provided in our homes.  Overnight.  So, we’d have the best shot of maintaining a productive life.  (Some 90% of nephrologists would opt for home therapy- if they were medically suited for such treatment.  But, only 2% of our dialysis census is currently treated via home hemodialysis.)

Right now,  effecting dialysis thrice weekly means ‘on average’ our toxin levels are under control.  But, that’s on average. (See the diagram above.)  During dialysis, our blood is thoroughly cleaned.  And, then the levels of various toxins and by-products creep up until it’s time for our next treatment.  And, that dialysis treatment- removing toxins, excess water, and pumping our blood some 3 times or more per treatment out of and into our bodies- leaves us debilitated.  Unable to get back into the swing of things for a long while.  Couple that with the 3 to 4  hours (minimum) of therapy, the 1 hour or more of traveling and waiting to be hooked up, the resting period after treatment, and being transported home, means three days of the week are shot.

If we were treated at home, things could be less complicated- and if we were treated overnight, we’d sleep during therapy and probably be ready for a normal life in the morning.  (Back in the 1960s and 1970s when this sort of treatment was routinely offered- and the treatment times were 12 hours- that was the fact.)  Nowadays, home hemodialysis could probably be done each night (ok, 6 times a week) and would entail  the administration of much less medicine, plus afford one a better quality of life.  But, don’t get overexcited- only 1 in 8 patients are probably suited for such therapy.  (A trained partner, for one thing, is required.)  However, that still is way more than the 1 in 50 that currently so obtain treatment.

But, as I mentioned yesterday, home dialysis is covered under Medicare part B.  Which means the government deals with those patients differently that conventional dialysis patients .  (Part A is mandatory- everyone participates, Part B is elective.) And, therein lies the problem.  For starters, HHS (Health and Human Services) pays for four physician visits a month for in-center patients.  But, home paitents are only entitled to one visit a month.   And, since this protocol was instittued in 2004, the practice of patient dialysis at home has dropped substantially.

Way back in the 1980’s and 1990’s, there was a company that was efficiently treating patients at home.  It had developed a home treatment protocol (water treatment, transportable delivery systems, trained caregivers, and used my dialysate) which cut preparation time and yielded better therapy for the patient.

But, HHS (the agency that ultimately pays for dialysis) considered this methodology to be an abuse of the system.  Because the firm was charging the government higher rates for dialysis at home than would be charged in center.  (Home Intensive Care [HIC] used both nurses and caregivers for each treatment at home.) And, HHS thought the applicable rates should be lower-much lower.

Judge Stanley Sporkin (Federal District Court, DC) had already thrown out HHS rules to limit patient care to four home visits by caregivers, agreeing with the arguments of Nathan Lewin, a DC lawyer who was HIC’s attorney in this action.  (The terminology:  It would have a “devastating impact” on elderly or ailing people.)  But, then Congress- in the Omnibus Budget Reconciliation Act of 1989 wrote the law to favor HHS- reducing the payments possible for HIC and reducing the impetus for home hemodialysis.

Nowadays, home hemodialysis can still be effected.  But, someone else besides the patient has to be trained (“a caregiver”).  This entails about five hours of training from a nurse or health professional.  But, Part B limits the reimbursement for that training to 90 minutes. Which really means there will be no trained caregiver.

How much money are we talking about?  If every potential home hemodialysis patient had one caregiver, then the costs would be less than $ 10 million a year.  And, currently home hemodialysis costs less than ½ to 1/3 of in-center dialysis.  So, the savings would be substantial.   Except the saving accrue to Part A of Medicare, while  Part B costs would increase.

See the problem?  Actually, neither do I.  Because I deal with overall costs.  But, bureaucrats only look through their doors- not at the whole house.

Don’t you just want to shake somebody silly?

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