Support Home Dialysis — We Need Greater Reimbursement for Training

It’s the right time to send a strong message to the Center for Medicare and Medicaid to increase the reimbursement for training home hemodialysis patients.  Nurses spend anywhere from 4 – 6 hours per training session with a patient, but the clinic receives a mere one hour credit at an approximate $36.  No wonder only 24% of dialysis centers are certified for home hemodialysis,  No wonder less than 2% of dialysis patients are doing home dialysis, living longer and enjoying a better quality of life.

We now have our best opportunity to make an essential change.  Now we can help the scores of patients who desire home hemodialysis, but have faced barriers none of which they created.  It’s time to challenge CMS to finally make a change which will have a positive effect on dialysis patients’ lives.

The leadership of the Congressional Kidney Caucus have now made the issue of home training their cause.  They have prepared the following Dear Colleague Letter to drum up congressional support.  It’s up to us to drop what we’re doing and immediately contact our own representatives to urge them to sign on to the letter.


National Kidney Month: Support Home Dialysis

From: The Honorable Jim McDermott
Sent By:
Date: 3/11/2013

Dear Colleague:

March is National Kidney Month.  We write to urge you to join us in asking Medicare to incentivize home hemodialysis (HHD)—a form of treatment that allows patients with end-stage renal disease to live longer and more fulfilling lives.

As you know, when kidneys fail, patients face a long and difficult road.  The overwhelming majority of dialysis patients travel to facilities three times a week for this treatment.  While these facilities keep patients alive, the travel required to get to and from these facilities greatly restricts their lives.  Many patients are greatly weakened by the treatments.  Outpatient dialysis centers will continue to remain an option that end-stage renal disease (ESRD) patients have when choosing a treatment, but patients must be fully educated on all treatment options.  There is ample evidence that demonstrates this is far from the case today.

Dialysis patients should be aware of and have access to the treatment option that they and their physicians think best. HHD has been proven to offer lower risk of death, more energy, quicker recovery, improved appetite, increased likelihood of transplant, better blood pressure with fewer medications, and less stress on the heart.  In addition, patients travel to a facility monthly rather than three times a week.

Nonetheless, barriers continue to exist for Medicare beneficiaries to access HHD:

  • Despite Medicare regulations that require dialysis      facilities to educate patients on all treatment options, many patients and      even nephrologists are not sufficiently familiar with HHD.
  • Medicare does not sufficiently pay dialysis centers for      the up-front cost of the training patients and their care partners to take      their diaysis home.
  • Medicare does not sufficiently reimburse dialysis      centers for training; the training add-on is only $35 per day, even though      an average training day is 5-6 hours and Medicare regulations require that      a registered nurse provide the training service.

This helps to explain why only one in four dialysis centers even offer HHD, why so few patients are even aware HHD is an option, and why patients have difficulty accessing HHD.

Please join us in asking CMS to update these training payments to encourage a more robust uptake rate of HHD.  To sign on to the following letter or for any questions please contact Andrew Adair in Rep. McDermott’s Office at or Peter Mihalick in Rep. Marino’s office at deadline to sign is Monday, March 18, 2013.


Rep. Jim McDermott                                      Rep. Tom Marino

Co-chair, Congressional Kidney Caucus        Co-chair, Congressional Kidney Caucus


March XX, 2013

Secretary Kathleen Sebelius
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201

RE: FY 2014 Home Hemodialysis Training Payment

Dear Secretary Sebelius:

As you update your payment system for the Medicare end-stage renal disease (ESRD) program for FY 2014, we urge you to pay close attention to home hemodialysis training payments that CMS pays to outpatient dialysis centers.  We are concerned that these payments are set to low, thus discouraging the use of home hemodialysis (HHD)—a treatment modality for patients with ESRD that in many cases enhances patient quality of life and can reduce costs to Medicare and society.

Home dialysis creates substantial benefits for dialysis patients and their families.  Observational studies confirm that patients who dialyze at home generally have better survival rates and a better quality of life.  Home dialyzers often have the freedom to continue working a steady job, creating economic and other benefits to both patient and family.  Because home dialyzers do so more often and for longer periods of time (for example while sleeping) than patients in dialysis centers, they generally report better wellness outcomes.

The FY2013 rate of $33.44 per training session (adjusted based on geography) barely covers the cost for one hour of a nurse’s time in most markets—much less the 4-5 hours required for a nurse to conduct such a training.  Because as many as 25 training sessions are required for patients to be ready to perform HHD, outpatient dialysis centers are in the position of providing dozens of hours of uncompensated care for a single Medicare patient who wishes to get trained for HHD.

According to a study in the American Journal of Kidney Disease, a survey of nephrologists demonstrated that they believe that 11 to 14 percent of patients are fit to be HHD users.  Nonetheless, only 2 percent of ESRD patients currently use HHD, and fewer than a quarter of dialysis centers are certified to offer HHD.  We believe that the training payment plays a role in this imbalance.

As you perform the important work of updating the MIPPA payment bundle for FY 2014 and, in particular, the sensitive task of making reductions to reflect your estimate of the change in the utilization of certain drugs and biologicals, we urge CMS to revisit training payments for HHD with an eye toward adequately reimbursing providers to encourage them to have robust HHD programs for those ESRD patients for whom such treatment is appropriate.


Rep. Jim McDermott                                      Rep. Tom Marino

Co-chair, Congressional Kidney Caucus        Co-chair, Congressional Kidney Caucus

One thought on “Support Home Dialysis — We Need Greater Reimbursement for Training

  1. PLEASE support and provide the necessary training so applicable patients can participate in (home) hemodialysis.
    I have stage III and not a candidate for organ transplant.
    My son is stage IV and is on a transplant list.

    PLEASE find compassion within yourself and your colleagues.


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