September 03, 2019
3 min read
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Buy-in needed from nephrologists, providers to meet home dialysis goal

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Editor’s note: HHS has set a goal of having 80% of the incident dialysis patient population treated by home dialysis or have a functioning transplant by 2025. Nephrology News & Issues asked Brent W. Miller, MD, the Michael A. Kraus Professor of Medicine and clinical chief of nephrology at Indiana University School of Medicine, as well as a Nephrology News & Issues Editorial Advisory Board Member, whether the plan can be successful.

Nephrology News & Issues: Do you believe most, if not all, patients are candidates for dialyzing at home?

Brent W. Miller, MD: ESKD is a tough disease in so many ways. I think 30% of patients right now should be undergoing dialysis at home. To get above 30%, we will need multiple changes in dialysis care. Then, I do think 60% to 70% of patients can dialyze at home.

Nephrology News & Issues: What do you see as the pros and cons of the proposed ESRD Treatment Choices (ETC) model? Are financial incentives going to make a difference in significantly increasing new starts on home therapy?

Miller: The old adage “Every system is perfectly designed to get the results it achieves” applies here. Kidney disease is hard to address, but we also have a profession that is struggling because of a complex web of mediocre fellowship training in home therapies, indifferent [chronic kidney disease] CKD care, an unwieldy model for innovation, skewed compensation of nephrologists and the inertia of a profitable thrice-weekly outpatient HD model.

Brent W. Miller

I think HHS has it correct with the ETC model. First, they have created a clear, visible target. Second, the most powerful lever they have is the reimbursement for providing care. It appears they are willing to use this.

However, I am not sure the 6% increase in financial incentives over 3 years as proposed for nephrologists and providers will be enough. No one has done a good time-motion study in nephrology. My analysis indicates that the physician monthly capitated payment for home dialysis would need to be almost double the in-center payment to equalize reimbursement per unit of time (ie, change nephrologist behavior).

On the transplant side, I am leery about how the final program will work. The two worst discrepancies have already been corrected: listing time now dates to dialysis date and kidney allocation matches expected lifespan. Rewarding or penalizing providers for actions they have no control over is not a good idea.

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Nephrology News & Issues: Is the HHS target realistic?

Miller: It is aspirational. There are practices that have over half their patients on home therapies and a high transplant rate (15%). I am not sure everyone can get there, but I think now we have general acknowledgement that we can do better than the current status.

Nephrology News & Issues: Do we need further improvements in technology — more patient-friendly home dialysis machines, established telehealth systems — to not only broadening the home census but improve retention?

Miller: We need all of the above and more. The innovation being discussed at Kidney X and elsewhere shows that there are ideas out there; think of moving from a rotary phone to a smartphone.

Nephrology News & Issues: You successfully expanded the home dialysis program at the University of Washington in St. Louis.

Miller: First, home programs need to be given adequate resources to succeed. I am continually amazed at the underinvestment or misallocation of resources in home programs across the country. If you want to point to why the United States lags in home dialysis, this would be the place to start, including the lack of adequate resources in training nephrologists in home dialysis.

Second, both kidney transplant and home dialysis only succeed in the long term if the entire group functions as a team. We would not have succeeded without enormous effort from the nurse practitioner, the nurse manager, our home dialysis nurses, our social worker and dietitians. Our program was also blessed with many medical assistants and others who acted as the glue of the program. Several physicians stepped in and helped manage the program even though they were not the medical directors. Our long-time business administrator had a nursing background and was supportive of investing and growing home therapies, and our nephrology division chief and department chair were willing to let me try innovative approaches.

Third, engaged medical leadership is key. As the medical director, I tried to be a physical presence in the program as much as possible and be involved in the planning, finances, quality improvement and other areas. Communicating often to the other physicians in the program is critical.

Lastly, the program has to be financially viable. Ultimately, this is what led to our success. Because our program was a small independent program that was geographically land-locked, home dialysis was the only way we could compete geographically and with the payer-mix conundrum of dialysis.

I am proud of the fact that millions of dollars of revenue generated from my home dialysis program funded some of the basic nephrology research that has been done in St. Louis during the last 2 decades and will continue to do so for the foreseeable future. If home dialysis becomes financially attractive to all constituents, it will flourish. – by Mark E. Neumann

Disclosure: Miller reports no relevant financial disclosures.

To read further Viewpoints on this subject, click here and here.