Removing barriers to home dialysis: An interview with economist Alex Brill of Matrix Global Advisors

Economist Alex Brill of Matrix Global Advisors released a report March 3 demonstrating how federal policies limit patient access to home dialysis. Brill discussed the report in more detail, and included some steps to overcome the barriers to home dialysis care. -by Rebecca Zumoff

NN&I: In the report you say, “Enabling home dialysis to flourish does not require that all of these barriers be removed simultaneously. Rather, reaching the tipping point that yields increased utilization of and investment in this modality will help knock down remaining barriers. This momentum will not only help more patients receive the clinical, economic, and psychosocial benefits that home dialysis currently offers, but also open up possibilities for potentially unforeseen innovation in home dialysis.” What do you think are good first steps to reach this tipping point?

Brill: In terms of removing barriers to home dialysis utilization, all efforts—from improving patient education and awareness to facilitating certification of more facilities to provide home dialysis services—should be pursued simultaneously. But, recognizing that advocates and policymakers alike often need to prioritize their efforts, I would suggest that tackling provider-related barriers is a particularly useful initial step, as physicians and nurses play such an important role in patients’ decision to pursue home dialysis.

NN&I: You mention patient education as being a crucial step to increasing home dialysis use. Do you think a patient's fear of dialyzing at home is related to their health care providers’ lack of knowledge and hesitancy to have patients play a more active role in their care? Do you think an individual health care provider’s bias towards in-center care can be overcome with more education?

Brill: Yes to both. As a general matter, patients rely heavily on the advice and preferences of their physicians. Patients may be more self-informed today than a generation ago, but for many, many patients their trusted doctors are very influential in the decisions they make.

NN&I: It is often cited that most nephrologists would chose home dialysis for themselves, but are not recommending it for their patients. Do you think their medical training and expertise leads them to feel more comfortable dialyzing at home?

Brill: I suspect that this is true. It is certainly true, as I wrote in my recent paper, that home dialysis would be a beneficial modality for many more people than are currently using it. While 12% of U.S. dialysis patients are deemed to be well suited for home hemodialysis and 33% for peritoneal dialysis, only 2% and 10% of dialysis patients, respectively, use these home modalities. This underutilization of home dialysis needs to be addressed.

NN&I: Do you think financial incentives are causing facilities to lead their patients towards in-center care? Do you think dialysis facility affiliation is influencing nephrologists in their role to recommend home dialysis? If so, how do you think this can be rectified?

Brill: I do believe that dialysis facilities can be responsive to financial incentives and disincentives, in part as a necessity given the low margins under which they operate. For example, there is evidence that the Centers for Medicare & Medicaid Services add-on payment for home dialysis training does not cover the actual cost of training, and this discrepancy is a disincentive for facilities to train home dialysis patients. Working to saturate the market with good information, bolster patient education, and improve provider training will complement the pursuit of fairer reimbursement, and these efforts combined can raise the share of patients opting for home dialysis.

NN&I: What steps can the Centers for Medicare & Medicaid Services take to increase home dialysis use? Do you think there is the potential for CMS to save money if more patients used home dialysis?

Brill: Given the outsized role that CMS plays in reimbursement for dialysis services, there is clearly a role for the agency to play in ensuring a level playing field and encouraging patient education. The question of saving money is harder to answer in the abstract and will depend on the specific details of the policies pursued by CMS. Quality of life can be improved, perhaps at no additional cost. If so, that would be a huge win for patients.

NN&I: In the report you say, “On average, Hispanic patients are 13% less likely to receive PD and 37% less likely to receive HHD, while black patients are 29% less likely to receive PD and 17% less likely to receive HHD.” What do you think are the causes of the racial disparities in home dialysis use? How can they be rectified?

Brill: In my research I did not identify any of the causes of these disparities, but they are significant and worthy of further investigation. It should be noted that the disparities in home dialysis utilization are consistent with evidence elsewhere in the research literature indicating that minority populations have worse access to care.

NN&I: Is there a take away message you think is important for renal professionals?

Brill: Home dialysis is not for every ESRD patient, but there are tangible benefits to home dialysis for those who are well suited for it, and there is evidence that a suboptimal share of the ESRD population is dialyzing at home. If the health care system broadly—from patient advocates to payors, and all the providers in between—can work to level the playing field between home and in-center dialysis, the U.S. market for peritoneal dialysis and home hemodialysis can get an important boost and patients can realize a meaningful gain in quality of life.