A strange, long-standing Medicare policy forces patients with kidney disease to give up dialysis to receive hospice. Medicare was planning to experiment with a reversal to this policy this year, but a recent announcement shows the trial being delayed until January 1, 2022. Will this trial eventually create hope for much needed access to hospice among patients with kidney disease?
Why Would People with Advanced Kidney Disease Want Hospice?
People with advanced kidney disease sometimes have a life expectancy of six months or less, the primary admission criterion for hospice. They get the same benefits from hospice care as people with other diseases. For instance, hospice improves symptom control, emotional support, care coordination, patient/family satisfaction, and quality of life during a very important time. Among dialysis patients specifically, hospice cuts Medicare spending by more than two-thirds, lowers hospitalizations 53%, and lowers intensive care procedures 90%.1
What’s the Problem with Going Off Dialysis to Enroll in Hospice?
Hemodialysis is a life-sustaining treatment for people with end-stage kidney disease. Treatments are usually needed multiple times per week. The process removes excess water, solutes, and toxins from the blood when people’s kidneys can no longer perform these functions adequately. People who have lost 85% or more of their kidney function and who quit dialysis usually have about one week to live. In every other circumstance, hospice does not hasten death. Choosing hospice is never about choosing death – with the exception of people who have end-stage renal disease. In fact, home hospice care most commonly correlates with lives lengthened by days to months, compared to patients who go with other treatment routes.
Why Would Medicare Deny Hospice to Dialysis Patients?
Medicare only pays for hospice when patients no longer have a reasonable option for a cure or when patients no longer want to pursue aggressive treatments. Unfortunately, Medicare continues to categorize dialysis as a cure, making dialysis patients ineligible for the same hospice benefits that people with other diseases receive. Of course, dialysis does not cure kidney failure any more than insulin cures diabetes. Medicare does not force diabetics to give up insulin for hospice. Medicare’s dialysis exclusion to hospice is unique.
What is Medicare Doing About Hospice for Dialysis Patients?
One recent move toward a fix was Medicare’s Kidney Care Choices Model (KCC). Like Medicare’s other disease-specific models before it, the KCC, overall, is designed to test whether certain care improvements reduce Medicare spending and improve the quality and coordination of care for beneficiaries with late stage chronic kidney disease, end-stage renal disease, and kidney transplants. The general thrust of KCC emphasizes increasing the number of home dialysis and transplant cases. Buried in 84 pages of background information and provisions, dialysis providers can find a page allowing for concurrent hospice care and dialysis treatment. The performance period for this experiment was scheduled to begin January 1, 2021. Unfortunately, a recent Medicare announcement shows this being delayed until January 1, 2022. They offered no explanation other than giving providers time to coordinate.
Other Problems with Kidney Care Choice and Hospice
Medicare approved only select providers for the KCC. Therefore, despite the program name “Kidney Care *Choice*,” access and choice in hospice could be severely limited during the performance periods. The aspiration would be that the model would produce even more data about the benefits to Medicare of concurrent hospice and dialysis. This could influence Medicare to simply allow concurrent dialysis at some point in the future – a point that would likely be five years away. However, Jane Schell and Douglas Johnson of the University of Pittsburg School of Medicine, point out an important flaw in the KCC that could scuttle this aspiration.2 KCC does not pay for hospice or allow for direct Medicare reimbursement of hospice costs. Instead, KCC gives approved providers the same lump sum payment for nephrology care whether the patient receives hospice or not. Medicare proposes that if hospice lowers overall costs, then the healthcare provider will be able to reap the benefits. On the other hand, adding hospice services may add to their costs, with no additional reimbursement for the additional services. Schell and Douglas express concern that most nephrology providers will choose to avoid this gamble. Even if Medicare finally begins the KCC implementation period, if their concerns prove valid, patients with kidney disease would continue to be denied hospice. Additionally, the KCC would not be effective at collecting the data that might finally convince Medicare to allow concurrent hospice and dialysis.
The ray of hope offered by KCC seems thin and flickering. For at least a year, and probably longer, Medicare will continue to falsely label dialysis as curative in end-stage renal failure and deny these patients the same opportunities to die in comfort, at home.
- Wachterman MW, Hailpern SM, Keating NL, Tamura MK, O’Hare AM. Association between hospice length of stay, health care utilization, and Medicare costs at the end of life among patients who received maintenance hemodialysis. JAMA Internal Medicine. 2018 June; 178 (6): 792-799.
- Schell JO, Johnson DS. Challenges with Providing Hospice Care for Patients Undergoing Long-Term Dialysis. Clinical Journal of the American Society of Nephrology. 2021 Mar 8;16(3):473-5.