Hi,
1) What are the various various treatment options for an ESRD patient
requiring dialysis?
Dialysis types and other treatments:
Hemodialysis in a dialysis center:
“The most common treatment modality for ESRD in the United States is
hemodialysis in a dialysis center setting, accounting for about
200,000 patients in 1997. Patients undergoing such treatment lead a
very restrictive and dependent lifestyle: typical treatment schedules
require the patient to be at the center for upwards of five hours,
three times per week. Opportunities for travel are limited because
many dialysis centers in the United States are operating at or near
capacity and are unable to accept a temporary patient. Social and
economic prospects for patients are also limited: the total time
involved in center hemodialysis precludes many opportunities available
to those whose lifestyle is not so restricted.”
http://www.pitt.edu/~patzer/dialysis/ESRD.htm
Ambulatory peritoneal dialysis (CAPD)
“The rise in the use of chronic ambulatory peritoneal dialysis (CAPD)
attests to the desirability and acceptance of portable dialysis
apparatus or, perhaps, the aversion to center dialysis with its
inconvenience and alteration of lifestyle. Over the years, since its
inception, the rate of increase in CAPD has tapered. While CAPD is a
significant advance, there are many patients who are not able to
receive its benefits, to which the modest rate of increase may be
attributed, and who must remain on conventional hemodialysis. The
development of complications causes many others to eventually return
to hemodialysis.”
http://www.pitt.edu/~patzer/dialysis/ESRD.htm
Transplants:
“Kidney transplantation is another alternative that frees the patient
from the restrictive lifestyle imposed by hemodialysis. However,
kidney transplantation is limited by the number of donor organs
available in any given year, currently about 8,000. Kidney
transplantation also has other considerations, such as lifelong need
for immunosuppression drugs to prevent rejection, that potential
transplant recipients need to consider.”
http://www.pitt.edu/~patzer/dialysis/ESRD.htm
A good summary of everything you need to know about Center
hemodialysis, Center self hemodialysis, Home hemodialysis, CAPD &
CCPD, IPD and transplants can be found at:
http://www.kidneydoctor.com/esrd.htm
Home hemodialysis :
This page offers an excellent overview of both the advantages and
disadvantages of home hemodialysis with concise explanations:
http://www.kidney.org/general/atoz/content/homehemo.html
CAPD & CCPD
http://www.kidney.org/general/atoz/content/dialysisinfo.html
http://www.kidney.org/general/atoz/content/peritoneal.html
“There are several kinds of peritoneal dialysis but two major ones
are: Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous
Cycling Peritoneal Dialysis (CCPD).
Continuous Ambulatory Peritoneal Dialysis (CAPD) is the only type of
peritoneal dialysis that is done without machines. You do this
yourself, usually four or five times a day at home and/or at work. You
put a bag of dialysate (about two quarts) into your peritoneal cavity
through the catheter. The dialysate stays there for about four or five
hours before it is drained back into the bag and thrown away. This is
called an exchange. You use a new bag of dialysate each time you do an
exchange. While the dialysate is in your peritoneal cavity, you can go
about your usual activities at work, at school or at home.
Continuous Cycling Peritoneal Dialysis (CCPD) usually is done at home
using a special machine called a cycler. This is similar to CAPD
except that a number of cycles (exchanges) occur. Each cycle usually
lasts 1-1/2 hours and exchanges are done throughout the night while
you sleep.”
(2) What percentage of ESRD patients use each treatment option?
I have found a comprehensive study of the treatment modalities located
here: <a href=“http://www.usrds.org/2001pdf/d.pdf”>
http://www.usrds.org/2001pdf/d.pdf</a>
(This information is from the US Renal Data System).
Treatment Status Two Years after First ESRD Service
Incident patients by gender, age at first service, & modality at 90
days, 1995-1997 combined (% of patients).
Male and female confounded
From 0-19 years old
Center Home CAPD & Oth/Unk Patient
Hemo Hemo CCPD Dialysis Transplant Death Count
21.3 0.8 14.7 3.8 54.3 5.1 2,674
From 20-44 years old
Center Home CAPD & Oth/Unk Patient
Hemo Hemo CCPD Dialysis Transplant Death Count
46.8 1.0 11.5 2.3 24.9 13.5 31,757
From 45-64 years old
Center Home CAPD & Oth/Unk Patient
Hemo Hemo CCPD Dialysis Transplant Death Count
53.8 1.0 9.5 1.7 9.6 24.5 68,017
From 65+ years old
Center Home CAPD & Oth/Unk Patient
Hemo Hemo CCPD Dialysis Transplant Death Count
46.8 0.6 4.6 1.1 0.9 46.1 91,078
You may find an international comparison of treatment options in this
PDF document (warning: large file):
http://www.usrds.org/2001pdf/13.pdf
(3) What percentage of ESRD patients are reimbursed via the various
reimbursement options? Medicare, private insurance, others?
Your question has two separate parts which are tightly interwoven. If
a person is eligible for Medicare, they are assured that 80% of the
cost of their treatment will be covered by it.
“Among all patients receiving care for ESRD, approximately 92.5% have
Medicare as the primary payor, and about 7.5% have some other private
insurance as their primary payor.”
http://www.transweb.org/qa/asktw/answers/answers9702/fundingofkidneytransplants.html
For the 92.5% of patients that are covered by Medicare, the following
criteria apply:
“Medicare will pay 80 percent of the cost of home dialysis for all
patients who are eligible for Medicare. The cost of home dialysis for
each approved dialysis center is determined by Medicare. The remaining
20 percent of the cost is usually paid by either the patient's
insurance company or Medicaid. Many states have programs to assist
patients in paying for this 20 percent if the patient has no insurance
company and/or is not eligible for Medicaid.”
http://www.kidney.org/general/atoz/content/homehemo.html
“Medicare pays for 80 percent of the cost of your dialysis treatments
or transplant, no matter how old you are. To qualify, you must have
worked long enough to be insured under Social Security (or be the
child of someone who has) or you already must be receiving Social
Security benefits.”
http://www.kidneydoctor.com/esrd.htm
“The average annual per capita cost of treatment was $52,200, for an
aggregate total of $16.6 billion, in 1997 (the latest year for which
statistics are available). Fortunately for those under Medicare, the
program pays for approximately 80% of the treatment cost, which
amounted to $11.8 billion in 1997. This, however, still leaves the
patient with about $10,400 in costs which must be paid out-of-pocket
or by private insurers.”
http://www.pitt.edu/~patzer/dialysis/ESRD.htm
The remaining 20% of the cost of treatment for those covered by
Medicare is divided amongst the following payors:
Private Insurance:
“Private insurance often pays for the entire cost of treatment. Or it
may pay for the 20 percent that Medicare does not cover. Private
insurance also may pay for your prescription drugs.”
http://www.ikidney.com/lifestyle_tips/anitem.cfm?AnnID=57
Medicaid can pay the 20%:
“Medicaid is a state program. Your income must be below a certain
level to receive Medicaid funds. Medicaid may pay for your treatments
if you cannot receive Medicare. In some states, it also pays the 20
percent that Medicare does not cover. It also may pay for some of your
medicines. To apply for Medicaid, talk with your social worker or
contact your local health department.”
Veterans Administration:
“Veterans Administration (VA) Benefits
If you are a veteran, the VA can help pay for treatment. Contact your
local VA office for more information.”
Employee or Retiree Coverage:
“Employee or Retiree Coverage From an Employer or Union
This type of group health coverage is for current employees or
retirees. Generally, employer plans have better rates than you can get
if you buy a policy yourself, and employers pay part of the cost. Call
your benefits administrator to find out if you have or can get health
care coverage based on your or your spouse’s past or current
employment, or your parents’ current employment.
In some cases, employer group health plans will have to pay before
Medicare pays”
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
The 7.5% of patients that are not covered by Medicare are covered
entirely by private insurance.
But, the Medicare coverage is complicated:
“If you are eligible for Medicare only because of permanent kidney
failure, your Medicare coverage usually will not start until the
fourth month of dialysis (see page 12). Medicare will not pay anything
during your first 3 months of dialysis unless you already have
Medicare because of age or disability.
Therefore, your employer group health plan is the only payer for the
first 3 months of dialysis.
When you are able to get Medicare because of kidney failure (usually
the fourth month of dialysis), there is a period of time when your
employer group health plan will pay first on your health care bills
and Medicare will pay second. This period of time is called a 30-month
coordination period. This means that if your employer plan doesn’t pay
100% of your health care bills during the 30-month coordination
period, Medicare may pay for the remaining costs. Medicare is called
the secondary payer during this coordination period.”
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
“The 30-month coordination period starts the first month you are able
to get Medicare because of kidney failure (usually the fourth month of
dialysis), even if you are not enrolled in Medicare yet. For example,
if you start dialysis in June, the 30-month coordination period will
start September 1, the fourth month of dialysis.
If you take a course in self-dialysis training or get a kidney
transplant during the 3-month waiting period, the 30-month
coordination period will start with the first month of dialysis or
kidney transplant. During this time, Medicare will be the secondary
payer.”
“At the end of the 30-month coordination period, Medicare will pay
first for all Medicare-covered services. Your employer group health
plan coverage may pay for services not covered by Medicare. Check with
your plan’s benefits administrator.”
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
It is important to understand that Medicare will pay 80% of the fees
only while it is the PRIMARY provider.
(4) What are the general reimbursement guidelines for each type of
reimbursement and each type of treatment?
The first thing I would recommend you do is read this pamphlet
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
published by medicare. It gives a very good explanation of how the
costs are distributed between private insurance, Medicare and you. It
has some price examples too. (I recommend reading page 29, 51 and 52)
It is almost impossible to come up with such a repartition matrix for
the costs. The costs depend on the type of treatment (drugs given,
duration, etc). At the end of this section I have put all the
information I could find in a table, but I am not sure everything you
want is there.
The limits of Medicare payment are percentage based. The cost
breakdown is relative to the frequency of use of said services, and
whether they fall in the category A or B of Medicare coverage. The two
categories have different guidelines for determining where the line is
drawn in terms of what you pay and what Medicare pays.
“Medicare coverage is divided into two parts. Medicare Part A pays
for inpatient hospital care by qualified hospitals (room and board,
drugs, use of special equipment), except for a deductible. You must
pay the deductible amount, each benefit period. If you have a long
hospital stay, you may have to pay the deductible plus a daily charge.
You must pay another deductible if you need to go back to the hospital
60 days or more after your last admission. Part A also covers
transplant testing and surgery. Most people qualify for Medicare Part
A benefits with no premium (regular payment). If you don't qualify for
free Medicare Part A benefits, you may be able to pay a premium to
receive Part A benefits. For information, contact your local Social
Security office or call (800)772-1213.
Medicare Part B pays for other medical and outpatient services-like
dialysis and doctors' fees-after you meet your deductible for the
year. Medicare Part B pays 80% of the rate allowed for dialysis, at
home or in a unit. You must pay a monthly premium for Part B benefits.
For the current Part A or Part B deductibles or monthly premiums, call
the Social Security Administration at (800)772-1213. You may also view
this information on the Health Care Financing Administration
(Medicare) website at www.hcfa.gov/stats/mdedco01.htm, or talk with
your dialysis social worker. “
http://www.lifeoptions.org/employ/employ15.html
The breakdown of costs you ask for is extremely hard to get because of
the complexity of the situation. For example:
“According to one survey of ESRD patients, 42% of new hemodialysis
patients take some form of vitamin D hormone. Interviews of physicians
and nurses experienced in treating ESRD patients suggest that the
actual percentage of patients taking a vitamin D hormone may be as
high as 60% to 70% of all hemodialysis patients.”
We know the costs of the drugs (per patient per year):
Vitamin D hormones
Hectorol $453.44
Calcijex $2,169.96
Zemplar$4,130.88
But depending on the drug taken, it is either covered by Medicare
(because the drug is injected by a nurse) or not covered (because the
drug is self-administered by the patient in oral form). The results I
have gathered in the table at the bottom below will not reflect these
peculiarities. I will present already compiled numbers, cited from
many studies.
“According to the Health Care Financing Administration, the average
cost of dialysis treatment -- including drug therapy, transportation,
in-patient care, etc. -- exceeds $32,000 per year. A kidney transplant
can cost from $30,000 to $70,000, although annual follow-up care is
much less costly than dialysis, averaging about $8,000.”
http://www.muhealth.org/~mokpwww/docs/dirast.html
This is a breakdown of which part of the Medicare program covers which
services. The services covered will be reimbursed to 80% of the cost.
“Service or Supply Medicare
Medicare Part A
Inpatient dialysis treatments (if you are admitted to a hospital for
special care)
Medicare Part B
Outpatient dialysis treatments (when you get treatments in any
Medicare-approved dialysis facility)
Medicare Part B
Self-dialysis training (includes instruction for you and for the
person helping you with your home dialysis treatments)
Medicare Part B
Home dialysis equipment and supplies (like alcohol, wipes, sterile
drapes, rubber gloves, and scissors)
Medicare Part B
Certain home support services (may include visits by trained hospital
or dialysis facility workers to check on your home dialysis, to help
in emergencies when needed, and check your dialysis equipment and
water supply)
Medicare Part B
Certain drugs for home dialysis
Medicare Part B
Outpatient doctors’ services
Medicare Part B
Most other services and supplies that are a part of dialysis, like
laboratory tests
Medicare Part B”
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
Medicare does not cover:
“Paid dialysis aides to help with home dialysis
Any lost pay to you and the person who may be helping you during
self-dialysis training A place to stay during your treatment
Blood or packed red blood cells for home self dialysis unless part of
a doctors’ service or is needed to prime the dialysis equipment
Transportation to the dialysis facility”
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
Primary Payor Medicare Private Insurance
Percentage of patients 92.5% 7.5%
% Covered by primary payor 80% 100%
The table data above is compiled from the following sources:
http://www.transweb.org/qa/asktw/answers/answers9702/fundingofkidneytransplants.html
http://www.kidney.org/general/atoz/content/homehemo.html
http://www.ikidney.com/lifestyle_tips/anitem.cfm?AnnID=57
I have found no mention of a 20 000$ limit in any of the Medicare
documentation. Pages 51 and 52 of this document:
http://www.medicare.gov/Publications/Pubs/pdf/esrdCoverage.pdf
give an excellent roundup of the coverage for all types of treatment
(in home and in centers). It gives the percentage of the cost that
Medicare pays for (with no limit) and what you and your insurance have
to pay for when staying in a hospital or receiving health care at home
from a nurse or family member.
This document http://www.usrds.org/2001pdf/12.pdf gives the total
expenditure for supplies, both in house and in facilities, of Medicare
for the years 1995-1999. It also gives the number of patients in each
category. So by dividing the cost by the number of patients, you will
be able to get the numbers you want. You know that those figures will
represent 80% of the total cost, so you can then deduce the total cost
by dividing by 8 and multiplying by 10. Figures 12.5 to 12.9 and Table
12.7 contain the data you are looking for.
Additional information:
To get your free copy of these booklets, call 1-800-MEDICARE
(1-800-633-4227, TTY/TDD: 1-877-486-2048 for the hearing and speech
impaired). You can also look at or print a copy of these booklets at
www.medicare.gov on the Internet. Select “Publications.”
Important Phone Numbers
ESRD Networks and State Health Insurance
Assistance Program phone numbers are on pages 50-
51. At the time of printing, these phone numbers were correct. Phone
numbers sometimes change. To get the most updated phone numbers, call
1-800-MEDICARE (1-800-633-4227, TTY/TDD: 1-877-486-2048 for the
hearing and speech impaired) or look on the Internet at
www.medicare.gov and select “Helpful Contacts.”
There are special organizations that can give you more information
about kidney dialysis and kidney transplants. Some of these
organizations have members who are on dialysis or have had kidney
transplants who can give you support.
American Association of Kidney Patients
100 S. Ashley Dr. Suite 280
Tampa, Florida 33602
1-800-749-2257
www.aakp.org (on the Internet)
American Kidney Fund
6110 Executive Blvd, Suite 1010
Rockville, MD 20852-3903
1-800-638-8299
www.akfinc.org (on the Internet)
National Kidney Foundation, Inc.
30 E. 33rd Street, 11th Floor
New York, NY 10016
1-800-622-9010
www.kidney.org (on the Internet)
National Kidney and Urologic Diseases
Information Clearinghouse
3 Information Way
Bethesda, Maryland 20892
301-654-4415
www.niddk.nih.gov (on the Internet)
Thank you for using Google
l33t |
