Table 4.

Potential strategies to increase dialysis facility reimbursement and/or decrease costs

Strategy	Rationale	Barriers	Comparative Effect on Margin	Recommendations
Greater use of home dialysis modalities	Lower costs than in-center HD or PD; costs for home HD variable; recent increase in home training fees	Lack of physician champions; payments for the extra HD txs on the basis of medical justification vary by the MACs; if payment for extra txs is denied, there is a loss; some home programs are freestanding, and the in-center HD facility does not get any benefit of the cost-savings, only a loss of new referrals and/or loss of current pts, resulting in empty in-center HD stations until pts switched to home modalities can be replaced; increases the overhead per tx; lack of pt incentive to go home; no family support; loss of support system from staff and other pts in center	Could be significant as the number of home pts grow and in-center census decreases	Need a national coverage decision that provides consistent reimbursement guidelines for extra HD txs; allow providers to educate pts with CKD about modalities; nephrology training programs need more emphasis on home dialysis options to develop more physician champions; provide more education for current nephrologists
Greater use of more frequent HD	Pts have trouble with 3-d interdialytic period; may decrease morbidity and mortality from fluid overload and/or hyperkalemia	Providing adequate medical justification to MAC; finding stations to accommodate extra txs	Small; it might increase costs if a Sunday shift was added and not fully used	Should be on the basis of medical need; need a national coverage decision to assure consistent criteria for medical justification
Use of SC ESA	Increased efficacy of SC versus IV epoetin	Pt discomfort and decreased satisfaction; applicable only to short-acting ESAs; effect on margin will be lost with next rebasing	Variable; anecdotal evidence does not show percentage dose decreases as large as once thought; doses have decreased because of the Black Box Warning	Not as much a potential cost-saver as when ESA doses were much higher; cost-savings will decrease further when biosimilar ESAs available
Decreasing hospital admissions and readmissions	Decreased system costs; fewer empty stations; better pt outcomes	Costs of infrastructure for CM and MTM needed to decrease lost hospital days not covered in payment to dialysis facilities; current staffing is insufficient to provide the oversight to offer better integrated care and manage all transitions	Fewer missed txs will reduce average per tx cost of staff and overhead; cost of additional resources will be greater than the savings	Worth pursuing with whatever funds are available, because it is the right thing to do; the best solution will come with a shared savings model so that resources can be used to provide additional services
Innovating operating procedures to increase efficiency	How dialysis providers have responded to reimbursement decreases over the past 40 yr	With less fat in the system, there may be less opportunity without jeopardizing quality and pt safety; staffing productivity is decreasing as the pt tx times increase	Will depend on the degree of process innovation, new technology, vendor competition, and productivity of personnel	QAPI is not just for pt outcomes; it also applies to system processes

HD, hemodialysis; SC, subcutaneous; ESA, erythropoiesis-stimulating agent; PD, peritoneal dialysis; pt, patient; IV, intravenous; tx, treatment; MAC, Medicare administrative contractor; CM, care manager; MTM, medication therapy management; QAPI, quality assessment and performance improvement.