Buyer Beware! Group Health of Seattle Does Not Cover Frequent Home Hemodialysis

[Hemodoc]

Buyer Beware! Group Health of Seattle Does Not Cover Frequent Home Hemodialysis
By Peter Laird, MD

Mark Pennington is one of the few on hemodialysis that is able to continue work and be productive, but this may all come to an end if his new health care provider has their way in this matter.  Mark has an extensive history of complications while on usual care in-center hemodialysis to include multiple hospitalizations and disability making work impossible. This all changed in 2009 when he trained for home hemodialysis with the NxStage System One.  Since that time, his health has improved dramatically and he is now able to work once again.

Insurance Company Will Not Support Home Hemodialysis
(Comment #40 from Home Dialysis Central - used with permission from Mark Pennington)

For several years, I have suffered from Kidney Disease. In July of 2006, I was placed on in-center hemodialysis. This treatment was a mixed blessing. On the positive side, my overall health greatly improved. On the minus side, I suffered numerous infections – including a bout with osteomyelitis of the spine that almost claimed my life and left me disabled. Additionally, the 3 time per week, in-center dialysis would frequently leave me feeling tired and wrung out. This caused difficulty on my job and added stress to my family.

In December of 2009, my wife and I attended training and became certified to perform home hemodialysis.  This 5 time per week schedule allowed for more gentle cleansing of my blood and greatly reduced the side-effects I’d felt in-center. My employer was delighted as dialysis no longer controlled my schedule and I could even work during dialysis. Also, since the machine is portable, we took the first long vacation in years last summer, camping in the Olympic Peninsula in our travel-trailer. . .

In January of 2o11, various concerns prompted me to change my employer-provided health insurance to Group Health. The Dialysis support staff at DaVita warned me that Group Health did not cover this treatment. However, that seemed contrary to the Group Health reputation as an innovator in the medical care field. Additionally, I was in great need of the managed care for my diabetes that Group Health could provide.

On January 23’rd, I received notice that my request for Group Health coverage of my frequent home hemodialysis was denied and that I would have to switch back to 3 day per week in-center dialysis.

I have appealed this decision, but doctors at Group Health have told me that it will not be overturned.

Mark R. Pennington

This is the second case of Group Health denying an optimal dialysis strategy for a patient that I am personally aware.  Last year, my nephrologist in Spokane, WA asked me if I could help him with one of his nocturnal in-center patients that was doing well on the thrice weekly regimen, but Group Health decided to withdraw payment and return her to a different dialysis center for usual care.  I contacted a noted dialysis researcher from Seattle who agreed to write a letter of support for this patient as well as a leading dialysis advocacy group who also offered support for this patient.  Group Health has a stated policy on their website against any of the frequent dialysis strategies many simply call optimal dialysis. 

Clinical Review Criteria

Frequent (Greater Than 3 Days a Week) Home Dialysis, Nocturnal or Short Daily

Conclusions:

Objective 1:

 There is insufficient evidence that home nocturnal dialysis improves important health outcomes compared to in-center dialysis. An RCT found improvement in LV mass and phosphate level, intermediate outcomes, and mixed findings in QOL. There is weak evidence from a single cohort study that nocturnal dialysis lowers the rate of dialysis-related or cardiovascular- related hospitalizations. In this cohort study, all-cause hospitalizations did not decrease significantly.   

 There is insufficient evidence that home short-daily dialysis improves health outcomes compared to in-center dialysis. One statistical analysis found a lower mortality rate with short daily dialysis compared to national rates, but patients may have differed in ways that affect outcomes, and there was potential financial bias. 

Objective 2: 

 There is insufficient evidence that home nocturnal dialysis 6 nights a week improves important health outcomes compared to home hemodialysis 3 times a week.

 There is insufficient evidence that home short-daily dialysis 5 or more times a week improves important health outcomes compared to home hemodialysis 3 times a week.

For questions or comments contact: Clinical Criteria Documentation Team

The conclusions of the Group Health Clinical Review on frequent hemodialysis are simply false in my opinion as shown by the outcomes of the FHN and Group Health has yet to update these guidelines even though they cited the FHN in their 2008 review.  In such, the denial by Group Health of Seattle of home hemodialysis  to Mark Pennington is based on out of date data. Last week, I attempted to contact Group Health at the email provided on the Clinical Review page for frequent dialysis asking them if they have any plans to review this issue again since the publication of the Frequent Hemodialysis Network Trial Group results last November, but to date, I have not received a reply.

Perhaps others will have more results than I did should some of you choose to also ask Group Health when they shall recognize the results of the randomized and controlled, IOM sponsored FHN trial that definitively proved the benefits of frequent hemodialysis. If Group Health has their own peer reviewed randomized and controlled trial disputing the FHN results, let them bring them forth now. If not, it is time for them to stop denying life saving home hemodialysis to any of their patients.

Since Group Health is my default health care provider through my Kaiser policy when I am in the Pacific Northwest, it is an important issue to me as well and is one of the reasons I have not yet moved to Idaho permanently. In my own personal opinion, Group Health is not in the same league as Southern California Kaiser that does provide and does recommend frequent home hemodialysis according to the physician in charge of the Kaiser renal care program, Dr. Peter Crooks. 

Home Dialysis Revives Patients Lives While Saving Substantial Costs

There are compelling reasons for a shift to home treatment, pointed out Dr. Peter Crooks, medical director of the renal program at Kaiser Permanente Southern California, which has taken a leading role in analyzing home hemodialysis outcomes for the HMO.

"Most nephrologists would like to get their patients on home dialysis," said Crooks. (Nephrologists specialize in treating kidney diseases.) "You have a way to improve patient outcomes, and it's more cost-effective."

Crooks said that not only do patients report feeling significantly better with the regular dialysis home treatment allows, but hospitalizations due to complications from kidney failure, even while on dialysis, were halved for Kaiser patients on the home regimen _ from 14 to 7 days of hospitalization a year. Most of these hospitalizations are due to heart conditions linked to or worsened by kidney failure.

Crooks described the overall cost savings of home treatment versus dialysis center care as "substantial."

Nevertheless, Group Health is a Kaiser network affiliated provider for visiting Kaiser members. For me to move permanently to Idaho, I would have to give up control of my health care to Group Health which would deny my own coverage of home dialysis under their stated policies.  In such, Group Health is having a profound impact on my own personal and health care decisions.  Both my wife and I would move immediately to Idaho today if we could only continue the same exact coverage I now enjoy with Kaiser, but the story of Mark Pennington brings home to both my wife and I how precarious it would be to depend on Group Health for my care. For the near future, we will have to limit our visiting time to summer and fall only.

The irony that a patient in Seattle where home hemodialysis was the standard of care 40 years ago is now denied home hemodialysis that gives him his life back declares to all that the false dichotomy of health plan clinical review criteria failing to recognize the benefits of frequent hemodialysis must end. Until that time, buyer beware, Group Health of Seattle does not cover home hemodialysis and they continue to ignore the overwhelmingly positive results of the FHN as well as nearly 50 years of positive observational data. It is time for Group Health of Seattle and many other health care insurers across America to recognize the life saving benefits of longer duration and more frequent hemodialysis. This is all just my humble and honest opinion.

http://www.hemodoc.com/2011/02/buyer-beware-group-health-of-seattle-does-not-cover-home-hemodialysis.html

[paul.karen]

Sad and sickening.

[Sax-O-Trix]

Scary, very scary.  I hope he is able to convince Group Health to change their policy.

[silverhead]

This is rather surprising to me, but possibly the policies have changed recently at Group Health.
We have been members of GHC (Group Health Cooperative) for about 12 years, About 6 years ago Sharon started down the CKD path and started Dialysis  a little over 5 years ago, first 2 years in center and then with our insistence and prodding of our center, Puget sound Kidney Centers, chose us as their first patients to undergo NxStage training, we completed the training and for over 3 years did it at home, had much improved results and well-being until non dialysis problems resulted in her passing away last September.
All the time we were on the regimen we never once heard a single word or concern from GHC about costs of any kind, we did 6 days a week at 25 liters, 450 pump speed. She was not interested in nocturnal and was satisfied with the daily routine.
As far as medical care, I have dealt with some health problems lately and the ability to deal with my personal Physician via email and over the phone has been wonderful, in fact my Doctor phoned me today to see how I was doing and was willing to talk as long as I wanted, You just don't find that level of care very often (by the way, no charges for email or phone services) they have some of the lowest prescription prices and free shipping is provided. My insurance premium is less than $20 per month, pretty hard to beat......
Tom

[tyefly]

Thx  Peter...the information is great.....   I too am a member with Kaiser..... and am injoying home dialysis....  I have thought about relocation to another area and was wondering what coverage would or could be like....thx for the information on Idaho and Group Health of Seattle would be like.....  No home Dialysis..... back to incenter......   NO WAY....   I am not going to a insurance company that will affect my health...... I would like to write to them and ask them about reviewing their policy.....  Hard to beleive in this day and age that we still have these problems with stupid policies that dont make since.....  I am glad you wrote about this......

     Lets all try to get this changed...... who know's.....maybe your own insurance policy might change their policy for the worst......

[noahvale]

**

[Hemodoc]

@Hemodoc:  I'm somewhat confused, why does Mark have to go back in-center?  Is the insurance company denying payment for ALL home modalities or just nocturnal and NXStage (see mention of home hemo in Objective 2)?  Even x3 weekly at home gives him more freedom than in-center - can still dialyze at night, Sundays, longer than 4 hours, etc. if he wishes.  A better alternative until his appeal is decided.

Also, although you state Dr. Crooks "has taken a leading role in analyzing home hemodialysis outcomes for the HMO," his quotes that you use only state "home dialysis/home treatment."  This does not necessarily include NXStage and nocturnal, especially since his article was written in 2008 (I could not retrieve a full version of his paper, "Home Dialysis Revives Patients Lives While Saving Substantial Costs."  Could you provide it?)

Seems to me this might be boiling down to a pi$$ing match between DaVita and GHS on a negotiated payment rate.

Dear Noahvale,

Going back to the Group Health policy, 2008, they do not at all support or fund frequent hemodialysis and the other patient that I am aware of was on thrice weekly nocturnal in-center and they took her off of that with their justification that it was not proven more effective than usual care.

I am sure that the contract issues are part of it, but Group Health denies ANY benefit by their 2008 policy to frequent hemodialysis which in my opinion is just plain wrong.