Cost of Dialysis
The US Renal Data System (USRDS) recently found that the cost of dialysis has risen over the years and now accounts for six percent of total Medicare expenditures. According to federal statistics, there were around 636,905 prevalent cases of end stage renal disease on December 31st, 2012. Of these, 402,514 people were receiving treatment through peritoneal dialysis or an established graft. At present, Medicare spends between $28 and $30 billion each and every year for treatment relating to chronic kidney disease.
Prior to October 1972, there was no formal legislation that extended coverage to ESRD patients through Medicare. In the 1960s, the use of dialysis for the treatment of kidney failure became apparent and the need for coverage through governmental offices was realized due to the prohibitively high cost of dialysis. In 1972, Congress addressed this issue through Social Security Amendments that included coverage for individuals who were under 65 years of age and were the spouse or dependent of an individual who had worked long enough to qualify for Social Security. The policies that were adopted limited payments to $138 per treatment of which the government covered 80% of the cost. In time, Congress adopted laws that changed the reimbursement rate. In 2012, the Quality Incentive Program (QIP) went into effect which was Medicare’s first pay-for-performance program that requires providers to meet specific quality metrics.
Medicare Coverage
In general, most people who require treatment for chronic kidney disease will have the cost of dialysis covered by Medicare. This program is not part of the Health Insurance Marketplace and does not require Marketplace participation. Medicare was established to provide insurance for individuals who are 65 years of age or older, are under 65 with specific disabilities, and those who suffer from end stage renal disease. Medicare Part A is referred to as Hospital Insurance due to the fact that it covers inpatient, hospice, and home health care. Medicare Part B is known as Medical Insurance because it helps with provider services, outpatient care, home health care, and certain types of preventive services. To qualify for Medicare coverage as an ESRD patient, an applicant must have worked the required length under Social Security, the Railroad Retirement Board, or as a government employee; be receiving benefits under Social Security or the Retirement Board; or be the spouse or dependent of someone who meets the requirements. Those who do not qualify may be able to receive assistance through state programs.
Premiums and Deductibles
Although the total cost of dialysis can easily exceed $25,000 each year, most patients will be responsible for paying a small portion of the expense depending on the coverage they have and the services they utilize. The ESRD patient who is new to the Medicare system will typically qualify for coverage under the type of plan known as Original Medicare and will be able to receive treatment from nearly all providers and healthcare facilities that do accept Medicare and that offer treatment for kidney failure.
The monthly premium for Medicare coverage can range anywhere from $100 to $500 each month depending on the plan and often comes with a deductible of $100 or more. Because the costs vary from one individual to the next, it is important to contact the Centers for Medicare and Medicaid Services (CMS) directly to find out how much the applicant will be responsible for. Those who qualify for Medicare as an ESRD patient can expect their benefits to begin on the first day of the fourth month following the onset of treatment. Coverage might begin sooner for those who successfully complete a home dialysis training program administered by approved facility and who intend to perform their own treatment.
Special Considerations
It is important to understand that the government may not be willing to cover surgical procedures that are performed in order to prepare for treatment. Those who receive coverage due to renal failure will lose their benefits 12 months after the treatments end or 36 months after a transplant unless treatment is resumed within 12 months or there is the need for another transplant within 36 months. Individuals who are covered through an employer will need to inquire about their benefits and the associated cost of dialysis with the administrator of their plan.
Self-Administered Home Treatment
Individuals who have the option of receiving treatment in a clinic or performing their own therapy at home should carefully consider the positives and negatives associated with each option. The main downsides associated with treatment at a clinic include a restricted schedule, travel to and from the facility, and variations in providers. Self-administered therapy gives patients more flexibility to dialyze when it is convenient for them and saves them a significant amount of travel. Most facilities offer training courses for those who plan to administer treatment at home and will help to monitor supplies as well as provide guidance on proper technique and sterility. Many of the items that contribute to the high cost of dialysis are covered by Medicare regardless of whether or not treatment is performed at a clinic or in the home.
There are a couple of requirements that must be met in order to perform treatment at home and that might not be covered by insurance or the treatment facility. These include the installation of a back flow prevention device, waste line connections, and a 20 ampere ground fault interrupter circuit. The costs of having this work done can be a few thousand dollars and it is important to find out from Medicare and the treatment clinic if the patient is responsible for these costs or if there are stipend programs in place that can help offset the expense. Other costs result from increased utility usage, supply storage, waste creation, furniture needs, and in-home assistance if necessary. Again, it is a good idea to find out if programs exist that can help offset some or all of the cost of dialysis.
Kidney disease is a major medical concern in the United States that has created significant costs for both the federal government and patients. While most of the costs associated with long-term treatment are covered by the taxpayers, the fact that demand for dialysis is increasing is a sign that there is a need for better public education initiatives. Most new cases of end stage renal failure are the result of poor diets and little exercise and could be prevented through an awareness of positive lifestyle behaviors.