Dialysis from the sharp end of the needle

Offering an EOD schedule is the best response to patients skipping treatments

By Bill Peckham

At the risk of becoming The Bruce Dikinson of the dialysis industry, when I read the JASN abstract that connects skipping dialysis with URRs below 65%, and thus a 1% payment withhold under the QIP, I think the only prescription is more cowbell! dialysis! Offering Every Other Day (EOD) schedules is the best response to control the cost of skipping.

The JASN paper only addresses the costs associated with being subject to a 1% withhold under the QIP, this understates the cost to the unit of skipping.

Think of a person who comes every treatment, who dialyzes 156 times a year, who we'll call G ... compared to someone who tends to skip twice a month and at the end of the year has dialyzed 130 times, who we'll call D.

First, one reason a person may skip regularly is that they don't feel very well when they do dialyze three times a week; if you're going to feel unwell if you do or you do not go to dialysis, you'll be more likely to not go. EOD schedules, when followed, would increase the person's chance to feel well, thus their ability and willingness to accommodate regular dialysis. But we're talking money, skipping and costs.

On the cost front, consider G's financial impact. Each dialysis payment under the expanded bundle is made up of fractional payments. Lab tests are in the bundle; each one of G's 156 reimbursements include some amount intended to cover lab tests. If G dialyzes 13 times in the month it means that the unit received 13 fractional payments intended to cover the cost of labs.

In addition with each payment the center received fractional payments to cover other monthly services and fractional payments for services that are delivered quarterly or yearly. All sorts of services required by the Conditions for Coverage are paid for a little at a time out of each individual, treatment, reimbursement e.g. the cost of care planning, iron, social worker support, PTH tests, Hepatitis tests, nutritionist support are all paid for a little at a time, by each treatment even though they don't necessarily happen each treatment.

Now consider D's financial impact. Labs still need to be done each month but at the end of the month there are only 11 fractional payments available to pay the cost of running the tests. D, just through skipping, generates 16% less revenue to pay for services delivered at frequencies less than each treatment.

The biggest financial effect may be D's EPO profile before and after skipping. In general let's assume D will need the same yearly dose of EPO whether dialyzing 156 times a year or 130, D will need 624,000 units of EPO (likely D would need a higher yearly dose due to skipping). If D runs 156 times the EPO dose will be 4,000 units per treatment. If D runs 130 times the EPO dose will need to be 4,800 units per treatment. D's skipping makes each treatment less lucrative, over and above any QIP withhold.

EOD schedules fix the financial side of this problem. Skipping in and of itself is a clinical problem, and as the JASN authors note there are as many reasons for skipping as the mind can imagine. But skipping shouldn't mean not having access to dialysis and units shouldn't be trapped into a needless financial drain. I don't think D is thinking: I only need to dialyze 11 times this month, more likely, about twice a month, D has a sense that: I need a break.

With an EOD schedule D would receive the 13/month medical minimum number of treatments - enough dialysis to avoid expensive hospitalizations and keep URRs above 65%; the unit would have received the number of payments anticipated by the bundle to pay for formerly separately billable services; and D would have had two breaks during the monthly grind. Win. Win. Win.

D should be given an EOD schedule and expected to call the unit as soon as the intention to skip is known.

Every Other Day (EOD) incenter dialysis schedules can be done (Part I); EOD schedules would improve clinical outcomes and support patient choice (Part II); EOD schedules are implicitly supported by MAC/FIs (Part III); EOD schedules would improve the clinic's finances and may lower overall Medicare costs per person, per year (Part IV); EOD schedules would increase the clinic's value (Part V). And, EOD schedules are a sensible clinical and financial response to patients who routinely skip treatments.

Shareholders should demand patient access to Every Other Day incenter dialysis schedules

By Bill Peckham

This is Part Five, the last in a five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs [edit] per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).

Let me say from the outset that I don't usually spend a lot of time on dialysis industry equity prices and the concerns of shareholders. I own no stock related to the provision of dialysis. However, as Peter's comment today nicely illustrated, the owners of the capital need to be part of the discussion. I think the case that the seventh treatment would be financially lucrative, is strong. But that is not quite the same thing as value. Today's shareholder is most interested in value.

Would EOD schedules increase the clinic's value? Certainly. Shareholders should be EOD schedules' biggest proponents.

It is easy to think that value to a shareholder relies entirely on net income and ultimately it is true an equity share price has to correlate to net income. But it is net income as it is expected for that industry, for that business, for that business at this point in its life cycle. Dialysis as an industry is at the mature stage of its business life cycle. Most of the dialysis in the United States is provided by two large dialysis organizations that are for profit companies with equity shares available to the public and are generally understood to be at the mature stage of their business life cycles. 

Being at the mature stage leads investors to have expectations of what it means to serve X number of patients or operate X number of facilities. This is why changes in insurance reimbursement are such a big deal to the dialysis industry - whether it is regular inflation adjustments to Medicare's payment (+), or two percent cuts to per treatment funding (-), or the new role of the exchanges (+/-?) it's a big deal because it changes the value of the companies. If average reimbursement goes down, for whatever reason, 100,000 patients are not going to be worth what 100,000 patients were worth the day before. In the world of equity traders what a patient is worth ultimately determines what a dialysis provider is worth.

The good news is we're worth quite a bit to these equity traders, over $85,000 a piece if recent sales are our guide (here, here). We're being sold not as people but as dialyzors. Buying/valuing an established dialysis provider would be like buying/valuing an airline. Sure you pay something for the planes but mostly you're paying for the right to the routes and the airline's frequent fliers. The units are the routes and dialyzors are the frequent fliers. To a shareholder the fact that dialyzors, unlike most frequent fliers, are largely captive of their proximate service provider is a feature not a bug. Providing dialysis and being in position to provide dialysis in the future, has equity value.

EOD schedules increase that value. If patients are worth $85,000 dialyzing six days every two weeks, they're worth more dialyzing seven. EOD schedules increase the value of the provider because they increase the expected value of serving a patient. EOD schedules advance shareholder interests.

Providing every other day incenter dialysis schedules would increase the value of the provider.

Do EOD schedules offer financial benefits to Payers and Providers?

By Bill Peckham

This is Part Four of the unheralded five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs [edit] per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).

At their simplest clinic finances are the average reimbursement per treatment vs the average cost per treatment. EOD schedules manifest as one extra treatment every two weeks and compared to the conventional treatments, that treatment would have a higher average per treatment reimbursement and a lower average per treatment cost. 

The seventh treatment, the extra treatment of an EOD schedule, would have higher average reimbursement per patient because use of EOD schedules would skew towards people who drive themselves to dialysis, and as a group, people who drive themselves to dialysis have better insurance than people who rely on funded transportation. 

The seventh treatment would also have lower non-labor costs. Services such as EPO, iron and labs are fully funded after 6 treatments, meaning in effect the seventh treatment would carry a ~$70 premium. This gain would have to be weighed against the wage premium and possible tenant costs associated with opening on Sunday, but the higher average reimbursement and lower non-labor costs suggests EOD schedules would be viable with relatively few patients.

Beyond the straight revenue/cost analysis EOD schedules would be a financial plus if it keeps patients out of the hospital. Dialysis units pay a price when their patients are hospitalized, and they will benefit if EOD schedules keep their patients in their chairs, dialyzing. Thus, it is an important, fundamental question - will EOD schedules keep patients out of the hospital?

The answer is yes. Would the decrease in hospitalization cover the added cost of EOD schedules? I think so but, on reflection (hence the edits to the position statement) I can't make a very solid case. It is not a simple question to answer. The added cost for Medicare of EOD schedules would be about $5,000 (80% allowed $ x 26) per patient per year and there looks to be $5,000 to be saved in hospitalization cost. On average in 2008 (most recent data year) people who use hemodialysis spent 14.5 days in the hospital, at a cost to Medicare north of $30,000. 

However, the people who choose EOD schedules might not have average hospitalization profiles, if they are healthier than average it means there is less hospitalization costs to save. And if EOD schedules improve survival, if EOD schedules extend people's lives, that will increase total Medicare spending.

And, it does give one pause that incenter EOD schedules are provided no where on Earth. All routine incenter schedules include the dialysis weekend, no matter if the dialysis is being provided through a for profit system or a centrally planned, state owned hospital, . You would think that if EOD schedules saved their cost that systems that fully paid for both the dialysis and the hospitalization would offer EOD schedules. They don't, so maybe EOD schedules wouldn't lower total spending (though I am not convinced, groupthink would be an alternative explanation), but even if EOD schedules don't lower total Medicare healthcare spending they should still be offered.

The dialysis weekend represents a cost shift of sorts. Not getting regular dialysis is risky but patients are instructed in how to decrease the risks through strict dietary control. The added dietary restrictions are a cost. The dialysis weekend increases risk and increases the cost of care to the patient. That doesn't sound like a system that is up to our standards. 

EOD schedules would improve the clinic's finances. EOD schedules lower overall Medicare costs EOD schedules may lower the overall Medicare costs per person, per year.

 

Would Medicare routinely reimburse EOD dialysis schedules?

By Bill Peckham

This is Part Three of a five part DSEN series making the case that incenter Every Other Day (EOD) dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs [edit] per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).

The question has to be asked - would EOD schedules receive routine reimbursement from Medicare, in the same way that conventional schedules receive routine reimbursement? My review of the documents online leaves me to conclude that Medicare support of EOD schedules is implied though not plainly expressed. It is possible that, short of a National Coverage Decision (that anyone can initiate) it may be necessary to fight for routine EOD dialysis reimbursement but that is a fight worth having and on this ground it is a fight dialysis unit administrators can win. 

Medicare Administrative Contractors (MACs) are entities, created by 2003 legislation, that are contracted to pay claims on behalf of Medicare. The country is divided into 15 regions and each region has a MAC (I think there will eventually be 5 MACs, possibly 10 but it is confusing; current list here (PDF LINK)). When a dialysis unit submits a claim, that claim is submitted to their MAC, who then rejects, or authorizes and pays, the claim.

The Medicare Benefit Policy Manual has little, but not nothing, to say about coverage related to hemodialysis treatment frequency, Chapter 11 - End Stage Renal Disease (ESRD), (PDF LINK):

30.1 - Frequency of Dialysis Sessions
(Rev. 1, 10-01-03) A3-3112.6, A3-3166.2
Hemodialysis and peritoneal dialysis are covered at the frequencies shown below under the composite rate. Additional composite rate payments may be made when they are medically justified.

A) Hemodialysis
The usual pattern of hemodialysis consists of three sessions weekly, and these may be covered routinely. If the ESRD facility bills for any sessions in excess of this frequency, the intermediary shall consider requiring medical justification 

MACs are guided by the Medicare Benefit Policy Manual when making claim decisions. According to the claims manual additional dialysis treatments can be reimbursed when they are medically justified but if additional hemodialysis treatments are provided it is up to the MAC whether medical justification is required.

One way MACs communicate their understanding of what is and is not covered or required for coverage, is through Local Coverage Determinations (LCD). As published in CMS IOM 100-08, Section 13.5.1 (PDF LINK), to be covered under Medicare, a service shall be reasonable and necessary. It is the MACs job to ensure LCDs for the service in question is considered reasonable and necessary under Section 1862(a)(1)(A) of the Social Security Act. Basically, MACs will consider a service to be reasonable and necessary if the MAC determines that the service is (my emphasis):

• Safe and effective.
• Not experimental or investigational (with exception).
• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
  • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
  • Furnished in a setting appropriate to the patient’s medical needs and condition.
  • Ordered and furnished by qualified personnel.
  • One that meets, but does not exceed, the patient’s medical need.
  • At least as beneficial as an existing and available medically appropriate alternative.

Two of the current MACs have LCDs regarding hemodialysis treatment frequency: First Coast (FL, PR, VI) and Trailblazer (CO, NM, OK, TX). First Choice directs that:

HEMODIALYSIS sessions which exceed the frequency of three sessions per week must be medically reasonable and necessary.

Trailblazer directs that:

Hemodialysis and peritoneal dialysis performed or billed more than three times per week is reasonable and medically necessary for hyperkalemia, pregnancy, fluid overload, acute pericarditis, congestive heart failure, pulmonary edema or severe catabolic state when these conditions are refractory to dialysis three times per week.

The Trailblazer LCD doesn't preclude payment under other circumstances, but it does suggest that payment for four or more treatments in a week would not be routinely granted. But what about three and half treatments a week? 

An EOD schedule (3.5 treatments per week) uniquely meets the directive that duration and frequency of service be "One that meets, but does not exceed, the patient’s medical need."

There is very good research, most recently a NEJM paper, but the data has been consistent since the 1960s: routinely taking two days off from dialysis increases the risk of mortality and hospitalization. The NEJM paper found that the incidence of death increased during two days off from dialysis vs during the remainder of the week when treatment is every other day :

all-cause mortality (22.1 vs. 18.0 deaths per 100 person-years, P<0.001), mortality from cardiac causes (10.2 vs. 7.5, P<0.001), infection-related mortality (2.5 vs. 2.1, P=0.007), mortality from cardiac arrest (1.3 vs. 1.0, P=0.004), mortality from myocardial infarction (6.3 vs. 4.4, P<0.001), and admissions for myocardial infarction (6.3 vs. 3.9, P<0.001), congestive heart failure (29.9 vs. 16.9, P<0.001), stroke (4.7 vs. 3.1, P<0.001), dysrhythmia (20.9 vs. 11.0, P<0.001), and any cardiovascular event (44.2 vs. 19.7, P<0.001).

In order to meet a patient's need, in order to have 18.0 deaths per 100 person-years, instead of 22.1, patients have to adhere to an EOD schedule. Dialysis on an EOD schedule is reasonable and necessary.

EOD schedules are implicitly supported by MAC/FIs.

EOD schedules would improve clinical outcomes, and support patient choice

By Bill Peckham

This is Part Two of a five part DSEN series making the case that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three) EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs [edit] per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).

I haven't seen, compared to a conventional schedule, the clinical benefits of an EOD schedule disputed. That the dialysis weekend is risky is well known. Most recently a NEJM paper reviewed the evidence but the data has been consistent since the 1960s. Routinely avoiding the weekend should routinely lead to better clinical outcomes.

The tougher questions to answer are concerns that patients would not want to switch from conventional three day a week schedules to EOD schedules, that patients prefer three day a week schedules.

Unless there is a choice it can not be said that there is a preference. For patients who want to dialyze incenter there is little access to higher frequency dialysis. Incenter patients do not have agency to decide their dialysis frequency. I believe that if there was a choice and the risks that are inherent in the dialysis weekend were well understood a significant number of patients would choose the safer schedule.

Some patients due to transportation issues would not be able to use an EOD schedule. Some patients would prefer the set weekly schedule allowed by conventional three day a week dialysis. Some patients seeing EOD schedules as requiring more from them would feel like they are doing all they can and they just aren't able, at this time, to do any more. This is all to be expected and accommodated.

However, some number of patients would want to use the safer schedule and would choose to dialyze EOD. How many is not a number I can give. Each patient would have to make their own personal cost benefit analysis but I think there is reason to believe that most patients would reckon EOD schedules to be a good value.

We're not use to thinking in terms of weekly dose of dialysis, let alone the biweekly dose of dialysis, but I think we should. Talking about treatment duration alone obscures dangerous anomalies like the dialysis weekend. One way to quantify the impact of the weekly dose of dialysis is the HemoDialysis Product (HDP). The HDP assigns an impact value to various weekly dialysis schedules (D&T just republished the Scribner classic) using a simple formula: HDP = (hrs/dialysis session) x (sessions/wk)².

My experience supports using HDP as a way to understand the impact of various schedules; how various schedule would make me feel as compared to other schedule options. In order to decide if I would use an EOD schedule I would want to weigh the benefits against the cost. Would I feel better, would the burden of CKD5 be less vs. spending more time dialyzing and taking into account the net effect of additional time getting to and from the clinic and the time spent recovering from the dialysis treatment. The costs are easier to reckon then the benefits, the HDP provides a way to quantify the expected benefits.

A conventional three day a week, four hours per treatment schedule has a HDP=36; keeping treatment length the same but dialyzing once more every two weeks, i.e. going to an EOD schedule, brings the HDP up to 49. Thus, increasing the amount of time dialyzing by 16.6% - from 6 days every two weeks to seven days evey two weeks - will increase the impact of therapy by over 36% - from 36 to 49.

Another way to say it is that going from 12 to 14 hours of treatment per week, in effect, in this way, through frequency, increases the HDP 13 points. If instead you increased your weekly time to 14 hours while keeping frequency the same, i.e. doing four hour forty minute runs three times a week, your HDP would be 41.94, a six point gain.  Frequency gives more dialysis 'bang' for a dialyzor's 'buck', paid in time.

The EOD schedule is the better value. There is every reason to believe that if EOD schedules were offered, EOD schedules would be a popular choice.

Think of the very good financial advise to pay your mortgage every two weeks instead of every month. If you pay every month you will make the 12 payments and four times during the year you get an extra week of income between payments. Having an extra paycheck between mortgage payments is pretty great. But if you pay every two weeks you end up taking years off of your mortgage, saving lots of money and you don't really notice that you made a 13th monthly payment during the year. An EOD schedule would be like agreeing to pay your mortgage every two weeks instead of every month. It's the smart move.

Offering EOD schedules improves clinical outcomes. Offering EOD schedules supports patient choice.

The Every Other Day Dialysis Clinic

By Bill Peckham

My contribution to the excellent discussion taking place on The Kidney Doctor (spring boarding off the Atlantic article) puts forward incenter every other day dialysis schedules as one of the solutions needed to improve the clinical outcomes of those who use dialysis. I am an advocate for incenter every other day dialysis (e.g. the petition, here, here), I have not heard anyone dispute that this would be better clinically but some might question this, the push back I have heard has been that it is impractical. Not that it shouldn't be done, but that it can't be done. Or it can only be done at too high a financial cost. 

I say that Every Other Day (EOD) incenter dialysis schedules can be done (Part One); EOD schedules would improve clinical outcomes and support patient choice (Part Two); EOD schedules are implicitly supported by MAC/FIs (Part Three); EOD schedules would improve the clinic's finances and [edit; equivocation] may lower overall Medicare costs [edit] per person, per year (Part Four); EOD schedules would increase the clinic's value (Part Five).

I will make my case in five parts. Part I -

EOD incenter dialysis schedules can be done along side conventional schedules

The most specific concern that I have read is that you couldn't do EOD dialysis schedules for some patients but not others. "You can't be a little bit pregnant" the skeptics remind, contending that a unit would have to go entirely to an EOD schedule to offer anyone an EOD schedule. "They'd have to be 100% in or 100% out", "What clinic can accommodate its entire pt population for an additional treatment day?".

I would not advocate switching entire incenter populations over to EOD schedules but I think all patients should be offered EOD schedules. Transportation to the unit, specifically funded transportation, is an issue outside the control of units and represents a real barrier to EOD schedule access. I don't see EOD schedules being used by a majority of patients but I do believe it would be a popular choice if it was widely available.

What follows is an example of how a unit could operate with some patients using an EOD schedule, while other patients, the majority of patients continue to use a conventional three day a week schedule.

Consider a 24 station unit - operating six shifts Monday through Saturday at 80% capacity, a unit with 115 patients dialyzing 3x/week on average for 3.5 hours.

The unit would have to have in mind the minimum number of patients they would need to have dialyzing on Sunday to open the unit (the unit conventionally runs Mon to Sat). And then double that number to find how many patients the unit would need to start EOD schedules. It's a question of staffing.

Staffing a Sunday shift would be more costly than an average conventional shift but the treatments provided would carry more reimbursement. There would be different staffing requirements for different units, depending on case mix among other factors. For ours the number is 12, the unit would need 12 patients to make opening the unit on Sunday viable. Thus, the unit needs 24 patients to want EOD schedules for it to make sense to start their EOD program.

36 patients have agreed to switch to EOD schedules (there will need to be another post on how it might come to pass that a third of a unit's census would agree to switch but it would start with buy in from the patient's MCP physicians).

The first step to make this work is to divide the EODers into two groups of 18 (a number well over the 12 patient threshold). Instead of calling them MWF and TTS we'll call them Group 1 (G1) and Group 2 (G2). At this unit the interest in EOD skewed to the evening shift.

To accommodate the EODer's shift preferences the unit manager has to have 8 stations on the evening shift (16 wanted EOD) and 5 stations on both the morning and mid day shifts (10 patients on each wanted EOD schedules). As the EOD census grows or contracts G1 and G2 have to stay in balance, just as the shifts generally have to remain in balance. However, unlike MWF & TTS, G1 & G2 are indistinguishable from the dialyzor's point of view so switching between the groups should not represent a problem but it will mean that there will be times when patients have to shift from G1 to G2 or vise versa - as long as the number of patients on G1 and G2 is greater than 24 (12+12) the program remains viable at this unit.

Day One
It's Monday and G1's turn to dialyze. The patients get themselves to treatment and arrive at their appointed times, receiving their treatments normally. If they use ESAs they receive their dose. This continues through the day. From an operational stand point it should look like any other Monday even as this tectonic shift in the provision of dialysis is taking place.

Day Two
G2 comes in for their dialysis. As with G1 this looks like any other Tuesday from an operational stand point. Unless you looked at their charts you wouldn't be able to tell G2 patients from the conventional TTS patients. But as a group they do skew towards the units younger and healthier patients. Many of the unit's older and sicker patients rely on funded transportation to get to and from dialysis and it has not yet been worked out how to make funded transportation compatible with EOD schedules. This reality does mean that as a group the EODers are younger, healthier and have better insurance than the unit's patients generally.

Day Three to Six
The unit would continue to operate per usual, without any unique staffing requirements. In gathering supplies and preparing stations, staff would know they were getting ready for Wednesday and G1 or Thursday and G2. If it was time for labs they'd be drawn, iron would be given, visits with doctors and staff, nutritionists and social workers would take place normally.

Day Seven
On Sunday G1 would come in for dialysis. From the patient's point of view Sundays would be different. On every other day of the week you'd come in at your normal time but if dialysis fell on a Sunday you'd come in, most likely, at a different time. Having a special Sunday time for dialysis, different from dialysis on conventional days, is what allows EOD schedules to embed in a unit with a majority of patients using conventional schedules. 

It might be that on Sunday G1 and G2's dialysis is always during a window from 8AM to 2PM or it could be that G1's Sunday is from 10AM to 6PM and G2's is from 8AM to 2PM. The options would need to be evaluated based on patient and staff preferences and availability but ultimately most patients would need to accommodate a time outside their conventional time. Until the EOD census grows it will be necessary to operate the unit for just part of the day on Sunday. Additionally by operating the unit for only six or eight hours the unit would still be available for maintenance tasks typically done during off hours.

It's 10AM, G1 arrives in waves of four, 20 minutes apart. The four techs and one nurse get 18 patients dialyzing by noon. At the height of operation the unit operates 18 stations at once with a slightly higher staff/patient ratio then their conventional standard, since no medications, labs or ongoing education is taking place and there are no deliveries and few phone calls. The patients have event free treatments, they are generally healthier than the average unit patient and they have not had two days off. Note that no formerly separately billable services are provided on Sunday but payment is the same, resulting in the ~$70 included in the bundle for formerly separately billable services to be available for increased staffing costs.

Day Eight
G2 comes in for dialysis. From an operational perspective it should look the same, setting up treatments based on a patient's prescription. Staff would know to set up for Monday and G2. The only difference I would expect to be apparent is that G2 would not show the effects of taking two days off while the conventional Monday patients would continue to show the symptoms associated with the break in their routine renal replacement.

Day Nine to thirteen
Lather, rinse, repeat.

Incenter every other day dialysis can be done along side conventional dialysis schedules.