Economic Impact of Home Hemodialysis

Abstract

Home hemodialysis (HD) is growing in the United States, but the economics of the modality are largely unknown, especially considering the unique aspects of home HD in the United States . In this review, I focus on details of Medicare coverage, which directly applies to most patients on dialysis and influences the policies of private insurers. Key details in Medicare comprise the relationship between home dialysis training and initial Medicare eligibility, reimbursement for home HD training, coverage of additional HD treatments (ie., in excess of 3 treatments per week), and monthly capitated payments to nephrologists. The overarching narrative is that frequent home HD directly increases Medicare costs for outpatient dialysis, but these added costs can be mitigated by lower inpatient expenditures if increased HD treatment frequency lowers the risk of cardiovascular hospitalization and infection control is emphasized. I also review recent international literature; conventional home HD exhibits a superior cost profile, whereas frequent home HD is generally cost-effective over multiple treatment years (ie, if early technique failure is avoided). Out-of-pocket expenses for patients should be considered. The future economics of home HD in the United States will be determined by new equipment, new adaptations of the modality, and new payment models.