Home Dialysis Rate Did Not Increase Despite Financial Incentives

[okarol]

Home Dialysis Rate Did Not Increase Despite Financial Incentives
Natasha Persaud

Financial incentives from Medicare’s End-Stage Renal Disease (ESRD) Treatment Choices (ETC) payment
program did not increase the home dialysis adoption rate in 2021, the first year of the program, a new study
finds.
The mean proportion of patients with any home dialysis in the first 90 days did not differ significantly
between ESRD facilities and managing clinicians who did and did not receive financial incentives for home
dialysis use: 20.72% vs 20.60%, Yunan Ji, PhD, of Georgetown University in Washington, DC, and
colleagues reported in JAMA Health Forum. The percentage of weeks a patient received any home dialysis and the percentage of dialysis sessions performed at home in the first
90 days also did not differ significantly between groups.
In the mandatory ETC trial, investigators randomly assigned 91 hospital referral regions to financial incentives and 211 to no
incentives (control). The home dialysis payment adjustment increased the reimbursement rate for home dialysis for the first 3
years, which was 3% in 2021. The performance payment adjustment increases or decreases the reimbursement rate for home
and facility dialysis depending on whether the rate of home dialysis and transplant improves.
Home dialysis costs less than facility-based dialysis and provides comparable if not better clinical outcomes, Dr Ji’s team pointed
out. Up to 85% of patients may be suitable candidates. The US Department of Health and Human Services wants 80% of new
kidney failure patients to receive home dialysis or a kidney transplant by the year 2025.
According to the investigators, “higher incentives may be necessary to affect behavioral change by dialysis clinicians and
facilities.” This analysis only examined the first year of the program, so continued evaluation is warranted.
The trial involved 12,394 managing clinicians and 18,621 patients with ESRD aged 66 years or older (42.1% women) who
initiated treatment with dialysis in 2021. Of the patient cohort, 65.7% were White, 17.7% Black, 5.2% Asian, 4.3% Hispanic, and
0.9% Native American. Patient characteristics, dialysis facility size, and facility profit status did not affect the study findings.
In an accompanying editorial, Sri Lekha Tummalapalli, MD, MBA, MAS, of the Division of Healthcare Delivery Science and
Innovation at Weill Cornell Medicine in New York, New York, and colleagues argued that more time is needed to properly
evaluate the ETC payment model. The shift to home dialysis is “complex and time-consuming,” they explained. To expand home
dialysis, nephrologists need to grow in their knowledge of the ETC model, and the health care industry needs to provide greater
resources, staffing, and training.
According to Dr Tummalapalli and colleagues, “the ETC model remains a promising, ambitious experiment aiming to improve the
care and outcomes for patients with ESKD. Further evaluation and monitoring will be key to assess US progress in advancing
kidney health.”

Disclosure: Thisresearch wassupported by J-PAL North America Health Care Delivery Initiative.
References
Ji Y, Einav L, Mahoney N, Finkelstein A. Financial incentives to facilities and clinicians treating patients with end-stage kidney
disease and use of home dialysis. JAMA Health Forum. Published online October 7, 2022.
doi:10.1001/jamahealthforum.2022.3503
Tummalapalli SL, Navathe AS, Ibrahim SA. Early findings from Medicare’s end-stage renal disease treatment choices model. JAMA
Health Forum. Published online October 7, 2022. doi:10.1001/jamahealthforum.2022.3500

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[fightingPKD]

After attending the Davita Home Hemo introduction this morning, I can sort of understand why.

Absolutely overwhelming amount of information I got bombed with.  It's a pretty large time commitment to do learning  - you're talking (it appears) 3 to 4 weeks of leave from work (both my wife and I).  Having to put together the machine at home yourself,  find a way to store a month's supplies, and so on.
I'm honestly not sure I could do it, if I were by myself. 

The benefits definitely outweigh the start up stressors in my mind, but there are definitely stressors.

[Simon Dog]

It was two weeks when I did the home hemo thing the first time (Baby K) and I think about a week the second time (NxStage).  They were nice and did not make my wife attend all sessions - plus NxStage is now certified for solo treatment so you don't need to bring a second.   In both cases the clinic (Fresenius) had people deliver and setup the machine, however, certain maintenance is the patient's responsibiliy - for example, if the fluid prep unit fails, they send you a new one and the patient does the switch of the control unit (big, heavy) and packs the failed one up for return shipment.   Once a NxStage eexpires (shuts down after so many hours on the meter), they delivered and set up a new one while I was on the road and a visiting patient at an out of town center.

Well worth it in my opinion.

[fightingPKD]

Oh, I'm not suggesting it isn't worth it.  Just saying I can understand the hesitancy.  I'm already experiencing brain fog and memory lapses and I felt overwhelmed. 
Also, there's absolutely no way I'm trusting myself to do it alone at first.  I'd do in-center if I was alone.  At least, for a while until I got more comfortable with the entire process.  I'm not convinced I can stick myself.

Also, it appears that different dialysis clinics do different degrees of 'help'.   (edit: It'll be a nxstage one device in my case (Davita).)

[Simon Dog]

It would be an improvement if they separated starting the lines from running the machine.   The transition would be easier if one could master self cannulation in the clinic before being cut lose to concurrently become fully comfortable with all of the other tasks involving home hemo.

[kristina]

Oh, I'm not suggesting it isn't worth it.  Just saying I can understand the hesitancy.  I'm already experiencing brain fog and memory lapses and I felt overwhelmed. 
Also, there's absolutely no way I'm trusting myself to do it alone at first.  I'd do in-center if I was alone.  At least, for a while until I got more comfortable with the entire process.  I'm not convinced I can stick myself.

Also, it appears that different dialysis clinics do different degrees of 'help'.   (edit: It'll be a nxstage one device in my case (Davita).)

Hello ... and ... like yourself, I can fully understand some hesitancy to "do dialysis-treatments yourself" because it takes lots of courage and can become a very complicated matter if your kidneys are seriously failing and the blood is not "clean enough" for the dialysis-needy-patient to think clearly and precisely enough to "do it yourself". It is my opinion that a very clear-thinking head is very much needed to "handle" the dialysis-machinery plus everything involved for dialysis-treatments etc. So, "doing it yourself" sounds very good of course, it also sounds very encouraging, and it also has a touch of independence, but I personally would not have dared to "do it myself", especially since I am not at all medically inclined because I am much more an artist ...

During my own dialysis-years I had to travel every time (three times every week) to the same dialysis-center and because of my special requirements needed, I sometimes had to wait in the dialysis-center to "be put on" for up to two hours, on some rare occasions even up to three hours ... just to be "put on" for the next four hours of dialysis-treatments. Of course, it was frustrating on occasions, but I still would not have thought of "doing it myself" because the nurses were always very professionally precise and exacting and for me to do exactly the same procedure, as a non-medical-person, it would have caused too much pressure and most certainly too much stress, which would have "inspired" further ill-health because of stress-related-SLE-flare-ups...

Also, if I would have considered to "do dialysis-treatments" myself at home with the help of my non-medical husband, we would have had to move to a much bigger place to accommodate the necessary dialysis-machinery etc. plus all the equipment etc. and that was certainly totally out of the question in my case...

Take great care and all the best good-luck-wishes from Kristina.

P.S. I was just thinking about what I did write earlier (see above) and feel, that I should also add, how I also did and still do some work towards my survival - as good as possible - not only during my dialysis-years. This I did and still do by checking-up on my weight every morning (increasing weight could be bad news), plus making sure that I am eating every day the same amount (to avoid unexplained weight-increase) of the most dialysis-friendly & kidney-friendly vegetarian diet etc. etc. I also felt that during my dialysis years I always had to make sure to keep as fit and certainly as slim as possible at all times despite my tiring dialysis-treatments to make sure that I could remain as fit and as slim as possible not only whilst on the kidney-transplant-waiting-list, but at all times and, for example, I had to train myself to make sure to go for a walk every single day in all weathers etc. etc. etc. The same discipline has continued to this day after my kidney-transplant in everything (i.e. kidney-friendly diet, weight-check every morning, regular walks etc. and I "got very much used to it" as a lifestyle and there are surely many other points to mention but I only wanted to give "the general idea" from my experiences plus my point of view ...

Good-luck-wishes again from Kristina.