Kidney Dialysis Palliative Care Program Bridging a Gap to Hospice

Washington-based Providence Hospice of Seattle and the Northwest Kidney Center recently partnered to develop a palliative care program that allows patients with renal diseases to continue receiving dialysis after they transition to hospice. With most of these patients having to forgo dialysis in order to be eligible for the Medicare Hospice Benefit, the program could provide greater access to care for people with these diagnoses, Kaiser Health News (KHN) reported.

The partners received a $180,000 grant from the Cambia Health Foundation to partly finance the program.

Patients with advanced chronic kidney disease and end-stage renal disease represent an underserved population in hospice. Only 2.3% of Medicare decedents who received hospice care in 2018 had a kidney condition as their principal diagnosis, according to the National Hospice & Palliative Care Organization (NHPCO).

As these patients near the end of life, they face a tough choice between ceasing dialysis that can minimize symptoms and pain associated with kidney disease. The six-month terminal prognosis requirement for the Medicare benefit is among the barriers that dissuade kidney patients from electing hospice.

Only a fraction of dialysis patients receive specialized palliative care that can effectively target their issues, indicated Daniel Lam, M.D., clinical associate professor at the Kidney Research Institute and palliative care medical advisor for the Northwest Kidney Centers, in a recent Kaiser Health News report.

“There are a lot of palliative care needs among the dialysis patient population. We think expanding hospice access is the right thing to do for a population that experiences such disparities in this important service,” Lam told Hospice News. “Asking patients to stop something that is still helping them achieve an acceptable quality of life in order to obtain other needed services puts an undue emotional and physical burden on patients and their families. We want patients and their families to know that the entire health care team is with them, even in the most challenging of circumstances.”

Lam, who is also medical director of Harborview Medical Center Palliative Care Services, helped to launch the program.

A Medicare report found that in 2013 a mere 4% of patients receiving prevalent dialysis also received palliative care services, with only half of those receiving care from a physician with specialty training in these services.

While considered life-sustaining curative care, dialysis treatments could have palliative benefits, according to a 2011 American Journal of Hospice & Palliative Care study.

“Dialysis patients are often denied hospice benefits unless they forego dialysis treatments,” the study’s authors found. “However, many of those patients might benefit from as-needed dialysis treatments to palliate symptoms of uremia, fluid overload, etc. The current Medicare payment system precludes this ‘palliative dialysis’ except in those few cases where the terminal diagnosis is unrelated to renal failure.”

Nearly 500,000 patients in the United States with kidney failure or end-stage renal disease require dialysis, according to Kidney Care Partners. Roughly 25% of the nation’s dialysis patients receive hospice care, compared to 50% of the general Medicare population, according to a study published earlier this year in the Clinical Journal of the American Society of Nephrology. Kidney dialysis patients spend an average of roughly five days on hospice care, according to researchers. This falls short of the general population estimated average of more than 17 days.

Hospice utilization among Medicare decedents in Washington state reached 46% in 2018, just below the national average of 50.7%, according to NHPCO.

Through the palliative care program, patients receiving dialysis at the Northwest Kidney Centers are candidates to simultaneously receive hospice services from Providence Hospice of Seattle if they have a six-month terminal prognosis. Referrals to the program come from several sources, Lam told Hospice News. These include Northwest Kidney Center staff, or patients’ primary nephrologists. Patients may also self-refer.

Providence Hospice of Seattle is a nonprofit, community-based hospice provider that serves seriously and terminally ill patients and their families throughout King County in Washington, including Vashon Island. In addition to hospice, the organization offers adult and pediatric palliative care.

The kidney palliative care program began at Northwest Kidney Centers in 2017, providing services to roughly 450 patients over time. Since partnering with Providence in 2019, 22 patients have received dialysis and hospice services concurrently, Lam told Hospice News. Partnering with Providence Hospice was an important consideration in launching the program further, according to Lam.

“Recognizing a significant gap in dialysis patient access to hospice services as compared to those with other serious illnesses, we sought out a partner who would help us provide a soft landing for our patients with a limited life expectancy,” said Lam. “Providence Hospice was willing to partner with us on a service that ultimately benefits patients and families, and allows them to focus on what is most important — each other. Providence’s track record of providing hospice services for other vulnerable populations demonstrated to us that they aligned with Northwest Kidney Centers.”

Established in 1962, the Northwest Kidney Centers is the eighth largest dialysis provider nationwide. The nonprofit organization also focuses on public health education and research into the causes and treatments of chronic kidney disease.

Currently, Medicare does not reimburse simultaneously for both dialysis treatments and hospice services. New models of care and associated policies that make the provision of interdisciplinary palliative care with or without dialysis financially possible are needed to counterbalance significant financial incentives, according to researchers of a 2018 report from the American Journal of Kidney Diseases.

The current health delivery model for advanced chronic kidney and end-stage renal disease is “ill-equipped to address many of the needs of seriously ill patients,” according to researchers, who indicated that palliative care “may address some of these gaps in care.” Barriers include uneven access nationwide to palliative services and under-developed models of care for these patients.

Medicare beneficiaries with chronic kidney disease accounted for $79 billion in Medicare spending during 2016, while those with end-stage renal disease accounted for $34 billion, adding up to roughly $114 billion in total expenditures, according to the study.

Reform may be on the horizon that would expand access to hospice for these patients. Taking effect next year, the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) will roll out a Kidney Care Choices Model (KCC) that allows certain patients to receive concurrent care, including dialysis and hospice care for patients with a terminal diagnosis of kidney failure.

Implementation of the KCC Model began in 2020, with the performance period running from Jan. 1 of this year through Dec. 23, 2023. Through KCC, CMS and CMMI will assess payment adjustments and accountability for care provided to aligned beneficiaries under the model. Participating providers focus on building necessary care relationships and infrastructure to support care.

Many stakeholders in the hospice space, as well as some policymakers, are advocating for the establishment of a community-based palliative care benefit within Medicare that would allow for concurrent curative services as well as palliation.

“Unless hospice providers are reimbursed privately, they can’t provide much in the way of services for patients with renal disease,” said Suzanne Watnick, M.D., chief medical officer at Northwest Kidney Centers. “Chronic dialysis patients whose only diagnosis is end stage kidney disease and who want to go on hospice must either stop dialysis or forgo hospice. The new Kidney Care Choices Models, which are voluntary, allow for a waiver so those patients can access hospice care.”