Funding NHHD

Obtaining ongoing commitment to funding from dialysis providers is the cornerstone to a successful, sustainable and progressive program.

When we first decided to set up an NHHD program in Geelong in 1998, I considered two primary options:

1. Applications through the research grants process in Australia – primarily the National Health and Medical Research Council (NH&MRC)

The NH&MRC, though a highly competitive process, seemed to be the more appealing option at first – due to the relative speed (if successful) of a funding stream.

However, grants through the NH&MRC are for a finite period (usually a maximum of 3 years) at the end of which a program, like NHHD, would just be beginning to ‘hit its straps. It would, however, have had little chance to develop ‘stamina’ – outcomes and results – and thus would likely be left high and dry without a longer-term funding ‘buy-in’ by ongoing funding agencies (in Australia – this means government and the public purse).

Though the wheels grind a little more slowly and more frustrations can emerge when dealing with government departments – decision-making can be sometimes slow due to their committee processes – in the longer run, government funding for a pilot project seemed the more secure choice.

If funded by government and then successful – both from a clinical outcome and a financial aspect – then the longer-term aim of achieving ongoing funding seemed more secure. It is difficult for an agency to back away from a program it has funded and which has been proven successful.

It took 2 years – and much effort but, in the end, due to the weight of circumstantial evidence at the time (albeit from relatively small and largely Canadian literature base consisting of cohort and observational studies on small numbers of patients), I achieved support from the Department of Human Services, Victoria (DHSV) for a 3 year pilot study.

I wish to clearly acknowledge here the special contributions of Jan Snell, the Barwon Regional Director, DHSV and Gillian Smith, Project Officer, DHSV for their assistance throughout.

The output of the program, the clinical outcomes and the financial benefits accruing to DHSV – particularly if similar NHHD programs could be achieved by other dialysis services – can be found in the NHHD-related publications from our unit.

Further, the evidence for a subsequent shift in dialysis practice towards longer and more frequent sessions can be seen in the Table and Graphs that follow the reference list.

Agar JWM, Knight RJ, Simmonds RE, Boddington JM, Waldron CM, Somerville CA. Nocturnal Haemodialysis: An Australian cost comparison with conventional satellite haemodialysis. Nephrology (Carlton) 10 (6), 557-570, December 2005

This paper, though long and complex, details the comparative cost advantages in the Australian setting of NHHD when compared to outpatient, community-based facility care.

It is this paper that encouraged DHSV to introduce the incentivization reimbursements detailed below.

By the end of the DHSV pilot project and with generous lectureship support, in particular from Fresenius Medical (Aust), Amgen (Aust), Janssen Cilag (Aust) and Baxter (Aust) for invited lectures (JWMA) given nationally and internationally, the success of the program was disseminated.

Uptake throughout Australia has resulted in the number of patients on longer hour and more frequent dialysis (the majority of whom have switched to overnight therapy) steadily growing.

Unfortunately, the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) has only just begun to ask the question ‘Is this patient on NHHD?’

The current ANZDATA Report (2007) shows clearly the outcome data for NHHD across Australia and New Zealand and the remarkable outcomes generated by this modality.

This is best summarized by Carmel Hawley who, on behalf of ANZDATA, presented the outcomes of extended hour and frequency home HD at the annual scientific meeting of the Australian and New Zealand Society of Nephrology in Newcastle – August 2008.

Her presentation can be seen at …

http://www.anzdata.org.au/ANZSN/2008/HomeHDreport.pdf

This data alone would suggest an interesting and refreshing wind of change is gently sweeping through ANZ dialysis.

From November 2005, a Federal government incentive to home therapies (both HD and PD) was introduced such that through the CMBS reimbursement scheme, physicians now receive a payment incentive for maintaining patients in the home which is not paid if patients remain in facility care.

From February 2006, in the State of Victoria, an annual DHSV incentive for NHHD of $10,000/patient … over and above the standard reimbursement … was introduced and is now paid to renal units for each patient on NHHD.

This Victorian incentive reimbursement decision can be appreciated from visiting the DHSV website at:

These dual steps are reinvigorating home therapies in Australia and, in particular, have renewed enthusiasm for home HD … with NHHD increasingly the preferred and incentivized option.

Other countries must find their own ways forward … but a careful examination (beyond the scope of this website) of the steps taken by government and health department agencies in Australia – and in particular in Victoria – to encourage home-based dialysis therapies and NHHD in particular, may be a good starting point for other regions seeking to embrace this superior form of dialysis.