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.
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