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Over the years, there have been federal efforts in the U.S. to shift dialysis for kidney care patients into the home. Meanwhile, home-focused kidney care companies have cemented their spot as part of the broader health care landscape.
In this environment, the question that lingers is if there’s a place for home health providers in the home-based kidney care space.
Roughly 37 million Americans live with chronic kidney disease and almost 700,000 have end-stage renal disease (ESRD), according to the United States Renal Data System (USRDS). Despite this, at-home dialysis has been largely underutilized in the U.S., especially in comparison to other countries.
“There are two types of dialysis — peritoneal dialysis and home hemodialysis,” Adam Boehler, CEO of Rubicon Founders, told Home Health Care News. “One of the interesting things about our country versus other countries is that our levels of home dialysis are much lower. We’re looking at home dialysis rates in our country that are around 15%.”
Rubicon Founders is a Nashville, Tennessee-based investment firm that aims to build and grow transformational health care companies.
Boehler is also the former director of the Center for Medicare and Medicaid Innovation (CMMI).
He noted that Hong Kong, for example, had a home dialysis rate closer to 90%, while Guatemala checked in at roughly 50%.
In 2019, 45% of Medicare-certified dialysis facilities were not certified to offer home dialysis, according to the USRDS.
But in recent years, home-based kidney care has begun to pick up steam.
“This is because of regulatory reform,” Boehler said. “Now we have pay parity for home dialysis and for in-center dialysis. A lot of the new models that came out of CMMI and the president’s kidney care initiative really create incentives for our country to move toward more appropriate transplants and more dialysis at home.”
Along these lines, companies working in this space have received significant attention from financial investors.
Last year, Rubicon Founders launched Evergreen Nephrology. The company forms partnerships with nephrologists in local markets to address kidney care.
“A major component of what we’ll do for these nephrology groups is provide care in the home, including home dialysis support,” Boehler said. “It’s something we believe in, so we’ve created a company to do it. We thought there was a huge opportunity to make a difference.”
Additionally, the value-based, home-focused kidney care company Somatus locked down more than $325 million in oversubscribed Series E financing in February. The kidney care management company Monogram Health also raised $160 million in its Series B funding round last year.
Monogram Health, in particular, is growing fast. Though the company currently operates in 28 states, its expansion plans will bring that number up to 34 by the end of 2022, Mike Uchrin, the CEO of Monogram Health, told HHCN.
In Uchrin’s view, Monogram Health’s ability to be “dialysis provider agnostic” is one of its greatest value-adds.
“What that means is we’re able to take that patient-centric approach,” he said. “Whichever modality is best for that patient is what we’re going to promote with them. We can ensure individuals are on home dialysis, when appropriate, versus in-center or palliative. And dialysis is just one treatment option — it’s not the end-all be-all. By being dialysis provider agnostic, we can take that independent approach to what’s most appropriate for the care of our patients.”
Currently, almost 90% of the dialysis patients that Monogram Health provides care for are on permanent access. This is significant in terms of reducing a patient’s risk for hospitalization.
Uchrin also noted that the company sees about a third fewer hospitalizations for individuals that are receiving at-home dialysis.
Where home health providers fit in
With companies like Monogram Health making waves in the home-based kidney care space, one could wonder where home health providers fit in.
Uchrin sees room for potential partnerships between home health providers and organizations like Monogram Health.
“We need clinically integrated partnerships with home health companies,” he said. “For instance, at any given time, an individual with a late-stage chronic kidney disease will have a wound. About 10% of our population at any given time has an active wound. We need effective home health companies to come in and deliver that wound care. We need those skilled nurses to come into the home and deliver that immediate care.”
Boehler believes that home health care providers will be useful on the preventative care side as well.
“If you’re in the home, you’re going to notice things, the symptoms of developing kidney disease,” he said. “You’re going to be able to intervene to stop the patient from progressing or at least slow progression. I think that’s a huge area.”
Boehler also noted that home health workers could assist patients with peritoneal dialysis.
“This dialysis is something that somebody can do for themselves,” he said. “It doesn’t need to be clinically assisted. That said, sometimes people need help, or they need somebody just to make sure that there’s a nice transition.”
On their end, some home health providers also see room for themselves in this area of care but are still working through what that might look like.
“I have a lot of interest in home-based dialysis and the increased use of peritoneal dialysis,” Dr. Anna Loengard, AccentCare’s chief medical officer, told HHCN in an email. “I am guessing part of the question which would need to be answered is if there is overlap in what CMS or other payers are paying for in each of these service reimbursements. Nonetheless, could we have a population of nurses that are skilled in this area to support patients going home on home dialysis? And then being contracted for home health services, or being a subcontractor to the dialysis provider?”
Dave Davis, the vice president of clinical solutions and integrity at AccentCare, points out that home health providers are somewhat limited by how the ESRD benefits pay for services right now, however.
“In general, dialysis facilities are paid by CMS and insurances to manage the services and supplies associated with the care related to ESRD,” he told HHCN. “What we have seen as an industry, in the past, was that the dialysis facility would contract with the home health agency to provide teaching and training for administering peritoneal dialysis in the home environment.”
Looking ahead, patient choice will likely continue to drive the larger shift towards home-based kidney care.
“If you go to a center [for dialysis], your life is tethered around that center,” Boehler said. “You always have to be close.”
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