Of the nearly 500,000 end-stage renal disease (ESRD) patients undergoing dialysis, only 12 percent receive dialysis in-home despite it being cost-effective and preferred by both patients and payers.[i] In a recent speech to kidney disease patients and advocates, Health and Human Services (HHS) Secretary, Alex Azar, stated that Medicare was making a concerted effort to expand the utilization of At-Home Dialysis, including expanding telehealth services.
Policy and Reimbursement Changes
Last year, Congress passed the Bipartisan Budget Act of 2018 (BBA) which included the expansion of reimbursement for telehealth and remote patient monitoring services. As well, the BBA increased reimbursement for dialysis services and eliminated the “originating site” requirement for telehealth services for ESCOs (ESRD Seamless Care Organizations).
Previously, telehealth services were only available to patients in rural areas or those qualified by Medicare as physician shortage areas. With the passing of the BBA, dialysis centers and patient homes will now qualify as originating sites, allowing patients to receive virtual check-ins and monthly assessments via video conferencing from the comfort of their home.
What is Home Dialysis?
A mere 12 percent of patients receive dialysis at home; however, those that do overwhelming receive Peritoneal Dialysis (PD). Peritoneal Dialysis uses the lining about a patient’s abdomen, the peritoneum, and a cleaning solution, dialysate, to clean their blood. Dialysate contains sugars that absorb fluids and waste from their blood and filters through the peritoneum.
The time necessary for dialysate to sit in a patient’s peritoneum and absorb waste varies, known as the dwell time, varies for individual patients. Following the dwell time, dialysate is removed from the body, and the new dosage is injected into the peritoneum through a catheter in the patient’s abdomen or chest.
There are two main types of PD treatment: cycler-assisted peritoneal dialysis (CCPD) and continuous ambulatory peritoneal dialysis (CAPD). Both types can be done at home and by the patient following several weeks of training. Home dialysis has many benefits for patients, providers, and payers alike.
Benefits of Expanding Home Dialysis
As HHS Secretary, Alex Azar, recently stated, HHS and Medicare are working to overhaul Medicare’s payment system to facilitate the movement of dialysis treatments from clinics to homes. Providers of dialysis services, such as Fresenius and DaVita, have praised the move announcing that they intend to provide a quarter of dialysis services in-home by 2022 and 2025, respectively.[i]
For providers, home dialysis enables them to cut clinician time in half and decrease the cost of care. As well, since 2011, dialysis providers have received the same reimbursement for home dialysis as for in-center dialysis.[ii]
Research has long suggested that patients prefer home dialysis, particularly PD, to receiving in-center hemodialysis. Benefits to patients of home, peritoneal dialysis include greater lifestyle flexibility, great dietary flexibility, more stable blood chemistry, and blood hydration, and in some cases, longer lasting residual kidney function.[iii]
Despite patient preference, provider cost efficiency, and improved clinical outcomes, the growth of home dialysis has been stagnant – increasing only .5 percent from 2013 to 2016. However, CMS’ expansion of reimbursable telehealth services sets up the industry to rapidly accelerate the utilization of home dialysis.
Telehealth's Impact on Home Dialysis
Several theories exist to explain the slow uptake of home dialysis services: the perception that care is substandard to in-center dialysis and the fear of receiving care without medical oversight are two common arguments. However, the utilization of telehealth rebukes both these arguments while also addressing the shortcomings of in-center dialysis.
The Bipartisan Budget Act of 2018, as stated previously, expanded telehealth services to allow for monthly evaluations and virtual check-ins via video conferencing through providing waivers to ESCOs and including patient homes as originating sites.
New virtual check-in CPT codes (G2012) provides patients and their family with a piece of mind, having the ability to reach out to clinicians to see if the require in-person care; also creating a strong patient-clinician relationship. The BBA expansion also allows for monthly assessments by clinicians through video conferencing. This again contributes to building a patient-clinician relationship and allows for substantial medical oversight as clinicians can observe (via video) a patients dialysis area in their home and provide feedback and recommendations.
While much research remains to be done of the efficacy of telehealth specifically for treatment of dialysis, patients and providers alike are embracing CMS’ new, progressive telehealth regulations to improve dialysis care and services to ESRD patients.