The Business of Health Care

CMS Misses the Mark on Home Hemodialysis

We are disappointed that CMS’ recently proposed rules again miss a clear opportunity to address home hemodialysis access for Medicare patients.

Recent clinical research demonstrates the significant benefits of more frequent dialysis. Better clinical outcomes, lower mortality, and higher survival – the list goes on.  Recognizing the strength of this data (and heeding the calls of numerous patient advocates), large national commercial insurers, including UnitedHealthcare and Aetna, recently clarified their policies, granting greater access to home, and more frequent, hemodialysis for commercial patients.

In recent weeks, CMS’ proposed rules for both Physician Fee Schedule and ESRD PPS Rule came out.  In the proposed Physician Fee Schedule, physician payment will increase for in-center dialysis, but will remain essentially unchanged for home dialysis.  Physicians are already paid generally 20% less to care for their home dialysis patients, and under the proposed rule for physician payment this disparity would grow.  In the proposed ESRD PPS Rule, there were no mentions of home hemodialysis.  None.  In the rule, CMS proposes a 2.5% increase to the bundled payment rate, representing hundreds of millions dollars of additional money going to the Medicare dialysis program.  None of this increase is going to address the known payment issues impacting access to more frequent home hemodialysis.

It is disappointing to us that the rules would be proposed this way, particularly given the overwhelming clinical data in support of the therapy, the recent movement by private insurers, and the growing recognition of Medicare payment impact on home hemodialysis access.  MedPAC even stated in their March report this year that some of the future monies and/or cost savings from pharmaceutical savings might be applied to address known payment issues with home hemodialysis.

We think that Medicare is again missing a perfect chance to take the lead to improve access to this life-changing therapy.  Doing nothing would be a real injustice to patients, and cannot be in the best interest of the public health particularly in light the USRDS’ own recent commentary.

The Medicare payment system has encouraged the current practice where over 9 of 10 patients are going into the center for their dialysis, which is diametrically opposed to what physicians and nurses would choose for themselves.  This is also in contrast to what patients might choose for themselves with full awareness of and access to the options.  These proposed rules will only perpetuate the way things happen today.  They are inconsistent with the Congressional mandate that Medicare develop reimbursement mechanisms to foster increased use of home therapy, and are also inconsistent with stated goals to maximize rehabilitation.

Clearly, the medical world’s perceptions of the benefits of more frequent home dialysis are catching up with the increasing real-world data available in support of the therapy.  On that note, we were pleased to see the recent study by the Chronic Disease Research Group (CDRG) has concluded that patients receiving more frequent home hemodialysis are more likely to receive transplants – and patients not on the transplant waiting list when they started were nearly twice as likely. Because transplantation is such a wonderful outcome both for patients and the health care system, knowing that more frequent therapy with the NxStage System One™ could lead to increased transplantation for patients is great news.

Earlier this summer, Aetna clarified their coverage policies on more frequent home hemodialysis therapies.  Clearly this is fantastic news.  The Aetna policy update was consistent with the policies updated by UnitedHealthcare, Cigna, and others. Our customers’ experience with private insurance coverage and payment has been consistently positive, but anything that can reduce the anxiety among providers and patients will benefit access.  Also, the direction that commercial insurers take will often influence long term Medicare policies, which as we know are important because nearly 9 of 10 dialyzors are Medicare beneficiaries.

We recently wrote an article for Renal Business Today outlining the complex Medicare payment issues impacting access to more frequent hemodialysis.  In summary, we feel strongly that inadequate payment for the resource intensive up-front training impacts both patient access and, potentially, quality-of-care for home hemodialysis – this initial training episode is critical for the dialyzor’s experience and success at home.  We also feel that a lack of comfort and understanding of payment through the medical justification process for the ongoing more frequent sessions limits providers from fully embracing more frequent home hemodialysis for their Medicare beneficiaries who could benefit, despite the fact that evidence shows that these payments do in fact occur.

Medicare can respond by making two very simple fixes that could materially impact patient access to home hemodialysis — making the training payment consistent and appropriate given the resource requirements and clarifying ongoing coverage, including those for appropriate more frequent sessions as UnitedHealthcare, Aetna, and others have now done on the private insurance side.  This is what Medicare should have done. It’s the only way to send the right message to patients and providers.  In fact, given that the recent MedPac report highlighted these as issues to be evaluated, and because CMS in their 2011 rule-making process stated that they would evaluate the adequacy of training payment in the future, patients should be asking why wasn’t this done.

Like you, we want to help make this right. We’re only just getting started. Luckily we have a way to impact this. Comments to the Proposed Physician Fee Schedule are due to CMS by September 4, and to the Proposed ESRD PPS Rule with QIP by August 31.  We will comment and we hope that you, your friends, colleagues and family will as well.  Together we can do something about this.

Joe Turk is the President of NxStage Medical, North America. NxStage is a medical device company, headquartered in Lawrence, Massachusetts that develops, manufactures and markets products for the treatment of ESRD and acute kidney failure.