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How Medicare payment changes affected home dialysis use

End-stage renal disease makes up 7.2 percent of Medicare spending, even though those patients represent less than 1 percent of the Medicare population, according to a database that tracks chronic kidney disease.

In an effort to lower health-care costs, Congress established the ESRD Prospective Payment System in 2008, as part of the Medicare Improvement for Patients and Providers Act. It mandated that Medicare patients treat themselves at home if able, and it introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment, and paying for training for patients to give themselves injections and treatment at home.

Now, a study from Stanford researchers shows that home dialysis treatment among Medicare patients increased by 5.8 percent from January 2006 through August 2013. The researchers also found that non-Medicare patients covered by other forms of health insurance also turned to home dialysis by a jump of 4.1 percent.

“These spillover effects suggest that major payment changes in Medicare can affect all patients with end-stage renal disease,” the authors wrote in the study, which appears in the latest edition of the Journal of the American Society of Nephrology. “One of the stated goals of the PPS payment reform was to incentivize an increase in-home dialysis use, and it appears that it has succeeded in this stated goal.”

Eugene Lin, MD, a postdoctoral fellow in nephrology and lead author of the study, told me that most nephrologists believe the trend toward home dialysis is good for the taxpayers and for the patients.

People going through this phase of chronic kidney disease — when dialysis or a kidney transplant are the only chance of survival — cost less to take care of at home and have similar outcomes to in-center hemodialysis patients.

“It’s hard to say if one therapy is definitively better than the other,” Lin said, “though home dialysis generally offers patients more independence and potentially better quality of life.”

Lin explained the difference between in-center hemodialysis and home treatment: At a center, blood is filtered through a machine, whereas home dialysis entails either having a hemodialysis machine at home (and having a caregiver help with the treatments) or performing peritoneal dialysis.

The latter is the most commonly used at-home treatment and involves using the abdominal compartment as a filter. The toxins in the blood get filtered through the abdominal membranes into clean fluid, which is then removed and discarded.

Similar drugs are used both in centers and at home, but they’re easier to give in the hemodialysis setting, and so had a higher likelihood of overuse prior to payment reform. “Once they bundled the drug reimbursement with the treatment, we saw dramatic decreases in the use of these drugs and a concurrent increase in home dialysis use,” Lin said.

Jay Bhattacharya, MD, PhD, of Stanford Health Policy, was senior author of the study.

Previously: Study: Treatment plans for kidney failure should consider cause and circumstances of diseasePhysicians advocate for "more educated and deliberative decision making" about dialysis and Study shows higher Medicaid coverage leads to lower kidney failure rates

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