More patients take on in-home dialysis due to compensation, yearly savings
Brad Davern could commute for his dialysis treatments, like about 400,000 Americans who depend on clinics to filter their blood.
But going to a clinic would mean less exercise time — and less independence — for Davern, who joined a growing segment of kidney patients receiving dialysis at home, often with help from family members. Scholars say the change encouraged by Medicare, which spends more than $29 billion a year to treat kidney failure, can cut annual health care costs by as much as $20,000 per patient.
“You're more in charge of your health. You're more in charge of everything,” said Davern, 33, of Munhall, who spent six years on clinic-based dialysis before switching to in-home in 2007. “I needed a change.”
About 8 percent to 9 percent of American kidney patients on dialysis receive the treatment at home, up from about 5 percent a decade ago, said Dr. Jeffrey S. Berns, an associate dean in graduate medical education at the University of Pennsylvania in Philadelphia.
He and other observers attribute the shift mostly to changes several years ago in how Medicare compensates health care providers for dialysis. In particular, doctors said the federal program increased reimbursements to cover training for patients who want to administer their own dialysis or have a friend do it.
That made it more lucrative for clinics to suggest the in-home option to patients, for whom clinic-based treatment can run $80,000 a year, doctors said. The cost often drops to $60,000 for those who stay at home for most dialysis sessions, said Dr. Barbara Clark, a nephrologist at Allegheny General Hospital in the North Side and medical director at DaVita Northside Dialysis.
Medicare officials would not comment on the reimbursement changes or savings.
Caring for kidney failure accounts for more than 6 percent of the agency budget, according to the U.S. Renal Data System.
Federal leaders guaranteed Medicare coverage for kidney failure starting in the 1960s, Clark said.
“They never could have foreseen how many health care dollars would be used for taking care of end-stage renal disease,” Clark said, calling the trend a $40 billion strain on the national health care system.
She and other experts estimate that reported incidence rates climbed several hundred percent since the 1980s because of higher rates of obesity, diabetes and hypertension, along with better awareness, better testing and an aging population.
About 31 million people in the United States, or about 10 percent of the population, are thought to have chronic kidney disease, according to the American Kidney Fund. More than 400,000 of them are in the final stage that typically requires dialysis, data system numbers show.
In Western Pennsylvania, the trend means about one in 2,000 people depends on dialysis, Clark said. Doctors said that's slightly higher than national norms because the area skews older and heavier than many others.
Incidence rates tend to be higher among blacks, but researchers said the reasons remain unclear.
Patients with ailing kidneys often use dialysis as a bridge to transplants, relying on the artificial purification to clean their blood several times a week. Those who stay home might use one of two methods: hemodialysis, which involves flowing the blood through external filters, or peritoneal dialysis, which involves a longer-term catheter in the abdominal area.
Infections, the risk of complications and ultimate outcomes do not appear substantially different for in-home patients or those who use clinics, though doctors say some patients should stay in professionally monitored settings.
“This is not rocket science. People can learn how to do this,” said Dr. Beth Piraino, the National Kidney Foundation president and a UPMC kidney specialist. “I like to say it's home dialysis, but it's not alone dialysis.”
She said home dialysis patients tend to receive kidney transplants faster than those in clinical settings, perhaps because those at home are more motivated.
Home patients often have more control over their schedules and an easier time holding jobs, experts said.
Still, many patients prefer the social element of going to a clinic, or might lack home support to do dialysis comfortably on their own, said Dr. Leslie Spry, an NKF spokesman and dialysis center director in Lincoln, Neb.
“I have a few patients who like that social situation. Even though we try to get them home, they come back to the center,” Spry said.
About 30 percent of his center's patients, many of them spread across rural areas, undergo dialysis at home. Spry said rural areas “have probably been the leaders in this area just because it's hard to build dialysis units in every small area.”
Home treatment was a new concept to Betty Zilch, 80, of Shaler when she began dialysis about a decade ago. She stuck to convention, undergoing treatments in Allegheny General — four hours a day, three times a week — for more than two years before undergoing a successful kidney transplant.
“I would've felt safer in the hospital with the technicians and my doctor there,” Zilch said.
Adam Smeltz is a Trib Total Media staff writer. Reach him at 412-380-5676 or firstname.lastname@example.org.
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