Cheaper Kidney Care
Vs.
Redesigning kidney services to improve patient
choice, shared decision making and deliver NHS
costing savings
Impact of economic climate on pricing
•
PD patient numbers have fallen consistently during a period of increased economic
pressures without price increases
•
Price decreases linked to initiatives to increase PD patient numbers have failed to drive
growth in PD and have lead to regional price variations and differences in equity of
access to advanced PD solutions
•
List prices for Baxter PD solutions have not increased to reflect increased cost of
manufacture and distribution
•
Therapy prices include fluids, machines, Baxter and 3rd party ancillary products,
technical and customer service support
•
The cost of APD to the NHS (staff, disposables and overheads) is still 35% less than in
centre HD
Baxter’s response to the National PD tender
• Baxter’s response has been based on the tender specification and also
the market evolution of Peritoneal Dialysis therapy in England over the
past several years.
– Over the past 5 years Baxter has endeavoured to hold or reduce prices whilst there has
been a continual decline in the number of peritoneal dialysis patients.
– Due to the high level of service support required to maintain patients at home we have
been unable to leverage our costs and in real terms over the last 5 years we have
experienced year on year increases in the costs of infrastructure and of the operation
necessary to maintain a high level of patient and renal unit support.
– Baxter’s response reflects what we believe is a fair cost of providing PD.
• Redesigning kidney services to improve patient choice, shared decision
making and deliver NHS costing savings – what is the role of PD as a
clinical and cost effective therapy?
Shared decision making: what does good look like?
“Shared decision making is the key to good outcomes for people with advanced
kidney disease. The work of NHS Kidney Care is making that a reality for more
people and my goal is that 100 percent of people have choice”. 1
Open patient choice should be a key step as part of shared decision making. If a
patient chooses home therapies, focus on how to make that work, rather than on
obstacles. 2
At least 50% of patients starting on dialysis will be eligible for home treatment, 60%
of patients eligible for home treatment will choose a home treatment if they are
given appropriate education. 3
In the partnership or shared decision making approach, the practitioner
genuinely does not disapprove of the decision the patient eventually chooses - it
is the discussion that is important
1.
2.
3.
Dr O’Donoghue PRESS RELEASE 24 May 2010 NHS Kidney Care welcomes Secretary of State’s commitment to home dialysis
Improving Choice for Kidney Patients: Five STEPS toolkit to Home Haemodialysis NHS Kidney Care February 2010
Renal Association Working Party on Peritoneal Dialysis Final Report 18.11.09
The patient pathway
Established Renal Failure
(ERF)
Conservative Care
Renal Replacement Therapy
(RRT)
Benefits of PD as an
initial modality?
1. Initial survival
advantage
2. Preservation of
vascular access
3. Preservation of RRF
Transplant
If PD is no longer
possible, a switch to
Home Haemodialysis
(HHD) would be a logical
treatment option for
patients preferring
home- based care
Home
PD
HHD
In - centre
5
Costs and reimbursement
•
The treatment of Established Renal Failure (ERF) is disproportionately costly using up to 2% of
the NHS budget for less than 0.5% of the population1.
Annual cost of dialysis modalities2
HD main unit
HD Satellite
APD
CAPD
HHD
£35,000
£32,500
£21,600
£15,500
£20,700
Annual cost of
dialysis
•
•
•
Non-mandatory tariff 2010/11
Aim to move to a mandatory “best practice” tariff in 2011/12.
Best Practice Tariffs are specifically priced and structured in order to promote quality of
care and value for money
Code
Description
Tariff (£)
per session
Tariff (£)
per day
LC01A
Haemodialysis/Filtration on patient with Hepatitis B 19 years and over
152
LC02A
Haemodialysis/Filtration 19 years and over
144
LC03A
Peritoneal Dialysis on patient with Hepatitis B 19 years and over
48
LC04A
Peritoneal Dialysis 19 years and over [1]
48
Erythropoiesis Stimulating Agents (ESAs) and Patient Transport Services (PTS)/Healthcare Travel Scheme (HTCS) costs excluded
1. National Service Framework for Renal Services: Part One – Dialysis and Transplantation. Department of Health. 2004
2. Baboolal K et al The cost of renal dialysis in a UK setting—a multi centre study Nephrol Dial Transplant (2008) 23: 1982–1989
Costs of treating dialysis patients in the UK
£1,050,000
If just 30% of
dialysis
patients
were treated
at home it
could save
the NHS over
£100 million
£1,000,000
£950,000
Cost treating ERF £k
£900,000
£850,000
£800,000
£750,000
£944,211
£1,047,832
£919,795
£1,004,059
£894,875
£960,290
£869,467
£916,579
£843,563
£872,931
£817,805
£831,584
£785,461
£650,000
£785,461
£700,000
£600,000
2007
2008
2009
2010
2011
Maintain status quo - use of home dialysis falls to 13% by 2013
Increased provision of home dialysis to 30% by 2013
Joseph, J and Laplante, S. NDT Plus (2010) 3 (suppl 3) iii91 (Sa182)
Data projected forward to 2013 from 2008 Renal Registry Report
2012
2013
Modelling the impact of dialysis modality mix on the cost to the Renal
Unit of providing Renal Replacement Therapy (RRT)
Using patient numbers and modality mix from Renal Units in London
190,000,000
Increasing the number
of dialysis patients
treated at home from
15% in 2010 to 40% in
2014 could result in an
annual cost saving of
£12,459,644
in 2014
and cumulative cost
savings of £31,370,101
over the 4 years
Cost of RRT provision (£)
185,000,000
180,000,000
175,000,000
170,000,000
165,000,000
160,000,000
2010
2011
2012
2013
Maintain status quo with 15% of dialysis patients treated at home
Increase the number of dialysis patients treated at home to 40% by 2014
2014
Home Dialysis
Modality
HHD
CAPD
APD
Data on file using costs adapted from Baboolal K et al (2008) The cost of renal dialysis in a UK setting—a multicentre study Nephrol Dial Transplant 23: 1982–1989
2010
1.2%
5%
8.8%
2014
10%
11%
19%
Impact of dialysis modality mix and reimbursement on Renal Unit contribution for
provision of Renal Replacement Therapy
Using patient numbers and modality mix from Renal Units in London
Contribution under
current
reimbursement
Contribution under Best
Practice Tariff
6,000,000
4,000,000
Contribution (£)
2,000,000
0
2010
2011
2012
2013
2014
-2,000,000
-4,000,000
-6,000,000
-8,000,000
Maintain status quo with 15% of dialysis patients treated at home
Increase the number of dialysis patients treated at home to 40% by 2014
Data on file using costs adapted from Baboolal K et al (2008) The cost of renal dialysis in a UK setting—a multicentre study Nephrol Dial Transplant 23: 1982–1989
If there are no changes in
modality mix over the next 5
years the introduction of the
Best Practice Tariff may lead
to substantial losses in
contribution.
Increasing the number of
dialysis patients treated at
home to 40% by 2014 could
lead to a continuation of
positive contribution for the
Renal Unit
National PD tender
Incentivising PD growth through Clinical KPI’s
• Clinical KPI’s developed by the Clinical Procurement team to support the PD
commissioning pathway
• Sliding scale discount linked to quality
• Reported via monthly commissioners report
KPI
Measurement
Incident take on to PD
% of incident dialysis patients choosing PD
Prevalent growth of PD
programme
% of patients remaining on PD at day 90
Demonstrate funding and
infrastructure for aAPD
Commissioning for Quality and Innovation (CQUIN) targets:
Incentivising home dialysis
• Example of a recent business case
– Unit has CQUIN to grow PD patient numbers by 10 by end of 2011
– The PD service is run by one full time PD nurse (Band 7), resulting in a nurse to
patient ratio of 1:33
– Risk of forfeiting associated CQUIN payment as current PD staffing levels
insufficient to support growth in the PD programme
– The National Renal Workforce Planning Group (2002) recommended 1 whole
time equivalent per 20 community dialysis patients with a skill mix of 5 nurses:
1 HCA
– Increasing % dialysis patients treated with PD from 16% to 26% would save
the trust £230,639
– Following presentation of business care the trust identified budget to
recruitment of one additional nurse to enable the PD programme to expand
Summary
•
PD patient numbers have fallen consistently during a period of increased economic pressures
without price increases
•
Price decreases linked to initiatives to increase PD patient numbers have failed to drive growth in
PD
•
PD offers a number of benefits as an initial modality?
• Initial survival advantage
• Preservation of vascular access
• Preservation of RRF
•
If PD is no longer possible, a switch to Home Haemodialysis (HHD) would be a logical treatment
option for patients preferring home- based care
•
Incentivising PD growth
• Cost saving to the NHS
• Commissioning for Quality and Innovation (CQUIN) targets
• Clinical KPI’s linked to NPDT
•
Excel model and App available to model local impact of modality mix and reimbursement