In January, there might be a lot more people like Mary Prochaska.
Ms Prochaska, 73, a retired social worker from Chapel Hill, NC, has advanced chronic kidney disease and relies on dialysis to filter waste from her blood while waiting for a kidney transplant, her second. But she no longer goes to a dialysis center three times a week, the standard treatment. There, nurses and technicians watched her for four hours while a machine cleaned her blood.
Instead, she opted for home dialysis. “It‘s easier on your body and better for your health,” she says. “And much better than exposing yourself to anything you could get by being in a group of people” in a center during a pandemic.
With the help of her husband, Mrs. Prochaska performs peritoneal dialysis; after a surgeon implants a tube in his side, his abdominal lining acts as a filter. After training for a few weeks, she began using a household machine called a cycler to remove excess fluid and impurities.
“It automatically does the pumping and pumping, five times a night, while you sleep,” she says. “When you get up, you are done. It’s like having a normal life.
So far its only unpleasant side effect is fatigue, sometimes requiring afternoon rest. A company called TruBlu Logistics provides the solution cases, tubes and other supplies, and Medicare covers the costs, which are considerably lower than in-center dialysis.
In 2017, according to the United States Renal Data System, 14.5% of Medicare beneficiaries suffered from chronic kidney disease, from 10.5% of people aged 65 to 74 to almost a quarter of people over the age of. 85 years old. Almost half of the dialysis patients were older. over 65.
For decades, health advocates and many nephrologists have encouraged more patients to consider home dialysis. But that year, of 124,500 patients with newly diagnosed advanced kidney disease (also known as end-stage kidney disease), only 10% started peritoneal dialysis the way Ms. Prochaska did.
Another 2 percent switched to home hemodialysis, removing waste with machines adapted from those used in the centers.
All of the other dialysis beginners have gone to a dialysis center, possibly owned by one of the two industry-leading companies, DaVita or Fresenius.
This fall, however, Medicare announced a mandatory program designed to transform that system, covering about 30% of beneficiaries with advanced chronic kidney disease, or nearly 400,000 people. Starting Jan. 1, it will use payment premiums – and later, penalties – to try to increase the proportion of patients using home dialysis and receiving transplants.
Even experts with no love for outgoing administration have called this approach the most significant change for kidney patients since 1972, when Richard M. Nixon signed a law providing Medicare coverage for people with kidney disease, whatever their age.
“It’s bold,” said Richard Knight, transplant recipient and president of the American Association of Kidney Patients. “There are a lot of incentives for providers to do things they haven’t done traditionally.”
“I think it’s going to have a really profound impact on kidney care,” said Dr. Abhijit Kshirsagar, nephrologist and director of the dialysis program at the University of North Carolina.
Studies have shown that dialysis patients at home report a greater sense of independence and autonomy, with more flexible hours that make work or travel easier. They benefit from a better quality of life. So why do so few choose it?
Some patients start dialysis when a crisis sends them to the emergency room. With little time to explore the decision or take the necessary training for home dialysis, they end up in the centers.
But many don’t seem to know they have alternatives. In a 2016 study, almost half of patients on center hemodialysis said it was not their choice.
“There are some patients who don’t know they might have dialysis at home,” said Dr. Suzanne Watnick, chief medical officer of Northwest Kidney Centers in Seattle. “For me, it’s a parody. Patients who have received training on the different modalities have a significantly higher rate of participation in home dialysis. “
But the training doctors receive may not focus on this option. Also, once patients get used to a center, “where everything is done for you, you probably won’t take the responsibility of doing it at home,” said Knight. Home dialysis can seem daunting or scary, and neither doctor’s offices nor for-profit centers have had much motivation, at least financially, to promote it.
Thirty percent of them will soon. Medicare will increase its monthly payments for each patient who receives dialysis at home, starting at 3% in the first year and then decreasing thereafter. Dialysis practices and clinics will also have their reimbursements adjusted up or down based on their total dialysis and home transplant rates.
Several new voluntary programs will also boost incentives. Beginning in April, Medicare will pay providers a premium of $ 15,000, over three years, when a patient receives a successful kidney transplant. Another measure provides greater support for living kidney donors.
Whether these incentives will significantly increase home dialysis and transplants remains an open question.
Some providers, noting that the penalties might outweigh the bonuses, are not happy to fall into the 30% of covered practices or centers, randomly assigned by zip code. “The average nephrologist is going to have a pay cut,” said Dr. Watnick.
In addition, not all elderly kidney patients can or want to have dialysis at home. “They may have some degree of cognitive impairment” or be too fragile to lift bags of solution, said Dr. Gerald Hladik, chief of nephrology at the University of North Carolina. They need space to store supplies and a clean, private dialysis space.
Even with a lot of discussion and education, it is not clear what proportion might possibly choose home dialysis. Maybe 25 to 50 percent, suggested Dr Watnick – “but we don’t know.”
While the new Medicare model excludes nursing home residents and people with dementia, the choice will otherwise be up to patients. Particularly during a pandemic, “we support that patients have the choice to go home,” said Knight. “But not in favor of pushing people to go home.”
Some older people with multiple illnesses may decide to forgo dialysis altogether. Wherever it is practiced, it is physically and psychologically expensive, and survival decreases in old age.
Dr Hladik’s 75-year-old father, for example, wanted to spend his last days at home with his dog or at the beach. He chose conservative management to control his symptoms and lived comfortably for a year and a half without dialysis.
But home dialysis has worked well for Jorge Moreira, 65, an accountant in Burien, Was. As his kidney disease progressed four years ago, he began dialysis at a clinic in the North West Kidney Centers.
He found it difficult to arrive at 5:30 a.m. three days a week so that he could finish at 9:30 a.m. and get to his office, and he suffered from painful leg cramps. A technician suggested that she look into peritoneal dialysis; his doctors agreed.
The first few months were tough, said Mr Moreira, learning the manual technique, dialysis four times a day. Then, like Ms. Prochaska, he switched to a cycler and now swaps fluids overnight. It’s simpler, he says, and suits his busy life; he walks and rides a mountain bike and serves as a pastor.
“I have more time for myself, my family, my business,” he says. “I have more strength. I sleep very well. I feel good.”
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