Patients, providers struggle with ways to improve dialysis in rural areas

Issue: July 2019

ByMichael Kraus, MD

ByJeffrey Hymes, MD

It is promising to see the U.S. government take interest in improving rural health care and increasing the use of home dialysis. In March, a MedPAC report on outpatient dialysis facilities expressed concern about “the gap in the Medicare margin between urban and rural facilities,” while HHS Secretary Alex Azar separately supported wider adoption of home dialysis and earlier intervention for patients with chronic kidney disease. We believe better awareness of rural disparities, support for technological innovations and changes in reimbursement policies for rural care and home dialysis have the potential to fundamentally improve outcomes for patients in these locations.

In a recent blog discussing the CMS initiative “Rethinking Rural Health,” CMS Administrator Seema Verma noted that approximately 60 million Americans, or roughly one in five, live in rural areas.¹ Among the five leading causes of death, rates are higher for rural communities.² This includes higher mortality for patients with ESRD driven in part due to increased comorbidities.³ A major driver of this disparity, however, is significant variation in available health care resources, especially for those with chronic diseases, which require more intensive and longer-term management.

Rural communities also have higher poverty, underinsurance and transportation issues, and poorer access to high speed internet. There is less availability of nephrologists; access to primary care physicians is reduced by 33% and the average patient travels 2.5-times farther to dialysis than their urban counterpart.^1,2 Complicating matters, rural patients are also at significantly higher risk for obesity, cardiovascular disease and diabetes and subsequent development of CKD.⁴

The struggles of rural ESRD care are real. Finding solutions that work to address these disparities is critical.

Increase access in rural areas

Home dialysis can alleviate many of the transportation and access issues facing rural patients, as well as provide significant medical advantages. These include improved blood pressure control and fewer cardiovascular hospitalizations along with better quality of life.^5,6

In an address to the National Kidney Foundation, Azar noted that, “while peritoneal dialysis or home hemodialysis may not be possible for absolutely everyone, they can often be more convenient, better for patients’ independence and self-sufficiency, and better for their physical health.”⁷ We need to strive to improve access and delivery of home care to rural America.

We recognize patients may still need support from in-center facilities or have other barriers to successful home dialysis. Even with a strong commitment to opening rural facilities, we know these centers face significant challenges due to lower patient populations and availability of staff.

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MedPAC recently noted that low-volume and rural facilities had lower Medicare payment margins and the variance was significant. MedPAC 2017 data showed a rural facility margin of negative 5.5% compared to the urban facilities margin of positive 0.4%. The margin was even worse for the low-volume rural facilities.⁸ Closing this reimbursement gap for rural facilities while further incentivizing the adoption of home dialysis will be significant steps toward increasing access to care and improving the health of rural patients with ESRD.

Barriers remain

After the passage of the Bipartisan Balanced Budget Act of 2018, Verma said the administration had taken several steps to improve rural health by expanding access to telehealth and other virtual services. The steps provided access to telehealth “for complex patients and care for patients experiencing a stroke or with end-stage renal disease,” she wrote in a CMS blog post.

Telehealth can connect rural patients with their interdisciplinary team, nephrologist and technical support which should improve quality, timeliness of care and retention on therapy. In addition, telehealth should be able to connect local primary care to more thorough and rapid specialist coverage, improving the ability for the local primary care physician and hospital to provide urgent care as well.

Even with these advances, however, there are concerns that we will not be able to reach the rural patient. Rural and tribal areas continue to lag behind urban areas in mobile broadband deployment. This means access to telehealth video visits may be limited. According to the Federal Communications Center 2018 Broadband Deployment Report, rural communities remain at risk. Approximately 14 million people in rural areas lack adequate LTE service (cellular modem), and more than 10% of rural areas do not have either adequate LTE or fixed terrestrial service.⁹

While expanded use of telehealth creates a new opportunity to advance home dialysis, HHS’s definition of telehealth, which requires video communication, creates a barrier to reaching the same rural patients HHS hopes will benefit most from recent policy changes. Due to the lack of broadband infrastructure, a tiered approach to the monthly capitation payment (MCP) should be considered. For example, a combination of telehealth dialysis records, store and forward imaging, and telephone discussions with the patient could satisfy the requirements of an MCP visit in locations where broadband ability cannot support reliable video conferencing. The remote MCP visit could also help decide whether the patient needs to be seen in person.

Conclusion

Patients should have treatment options that fit best with their lifestyle, health status, social setting and aspirations, and for most people, this means home dialysis. By providing individualized home dialysis training, telemedicine support, social networking, physician training and computer connected health care equipment, patients, especially those in rural settings, could thrive while living with kidney disease.

We applaud the renewed focus by CMS on the struggles often faced by patients in rural settings, both in preventing chronic disease and providing better access to quality care. For patients with ESRD, we must keep working to close this gap between rural and urban care. Heeding the MedPAC recommendations and providing more incentives to accelerate the adoption of home dialysis in rural settings would be an important next step.

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For more information:
Michael Kraus, MD, is associate chief medical officer at Fresenius Kidney Care focusing on home therapies and held a similar role with NxStage Medical Inc. before the company merged with Fresenius earlier this year. He is the former service line chief for IU Health Physicians Kidney Diseases and clinical chief of nephrology at Indiana University School of Medicine.
In his role as chief medical officer for Fresenius Kidney Care and senior vice president of clinical and scientific affairs for Fresenius Medical Care North America, Jeffrey Hymes, MD, leads quality clinical care across the United States for the company’s nationwide network of dialysis clinics.

References:

www.cms.gov/blog/putting-our-rethinking-rural-health-strategy-action
www.ruralhealthinfo.org/topics/rural-health-disparities
Maripuri S, et al. Clin J Am Soc Nephrol. 2012;7:1121-1129.
www.cdc.gov/ruralhealth/about.html
McCullough PA et al. Am J Kidney Dis. 2016;68:S5-S14.
Jaber BL, et al. Am J Kidney Dis. 2010;56:531-539.
www.medpac.gov/docs/default-source/reports/mar19_medpac_ch6_sec.pdf?sfvrsn=0
Azar, Alex M. Remarks to the National Kidney Foundation, Washington. March 4, 2019.
2018 Broadband Deployment Report – Federal Communications. Reports & Research Reports, Feb 2, 2018. Accessed on May 13, 2019.

Disclosures: Kraus and Hymes report no relevant financial disclosures.