National Kidney Month: Support Home
Dialysis
From: The Honorable Jim McDermott
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 Andrew.Adair@mail.house.gov or Peter Mihalick in Rep. Marino’s office at
peter.mihalick@mail.house.gov. The deadline to sign is Monday, March 18, 2013.
Sincerely,
Rep. Jim McDermott
Co-chair, Congressional Kidney Caucus
Rep. Tom Marino
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.
Sincerely,
Rep. Jim McDermott
Co-chair, Congressional Kidney Caucus
Rep. Tom Marino
Co-chair, Congressional Kidney Caucus