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Launching a Successful Nursing Home Dialysis Program
Curt Anliker Chief Operating Officer
McGuireWoods | 2 CONFIDENTIAL
An Under-Served, Significant Market
• 430,000 ESRD patients in U.S. • 5,500 Home dialysis patients in U.S. (2011 USRDS)
• We estimate 12% of ESRD reside in skilled nursing
facilities
51,000 Patients $2.0+ Billion market
McGuireWoods | 3 CONFIDENTIAL
Benefits of Nursing Home Dialysis
Stakeholder Benefits
Patient Survival Convenience & lifestyle Consistency of meds, meals & therapy
Nursing Home Marketing tool & census builder Acuity drives in overall reimbursement Eliminate transportation costs & logistics Daily dialysis can therapy minutes
Payors Cost (fewer meds & hospitalizations) Zero transportation costs
Physician Improved care for patients & their families Potential source of new patients
Hospitals Ability to discharge patients Discharge destination becoming a more data-driven event. Quality home dialysis is a factor. Think ACOs.
ESRD Provider Growth opportunity in a slow-growth industry
McGuireWoods | 4 CONFIDENTIAL
There is One Loser
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There is One Loser
Transportation Companies
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Basic Business Model & Requirements
• ESRD Provider certified for Home Hemodialysis Training & Support
• Skilled nursing facility considered patient’s home - even the resident on a 100-day Part A rehabilitation stay
• Billed as home dialysis • Coordination agreement b/t ESRD Provider and SNF
outline the responsibilities and the economic terms • Ensuring caregiver staffing costs are covered is the key to
a program’s financial viability • Understand both your Fiscal Intermediary and your state’s
Medicaid policy for reimbursement of additional treatments
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Regulatory Environment
• ESRD Conditions of Coverage (CMS 2008)
• 2004 Survey Guidance Letters – S&C 04-24 (March 19, 2004) – S&C 04-37 (July 8, 2004) – Issued to State Survey Agencies – Defined the relationship b/t the ESRD provider and the SNF – Defined the staffing requirements
• States retain right to impose more stringent regulations than the CMS’ Conditions of Coverage or Guidance Letters
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The Go / No Go Decision to Launch
• Quantify the market need with market analysis
• Is your ESRD provider certified for Home Dialysis? If not, what investment is required?
• What is the reimbursement policy of both your fiscal intermediary (Medicare) and your state (Medicaid) vis á vis > 3 treatments per week?
• Are there any additional state regulations?
• Don’t underestimate the sales, management requirement & resources, and the added level of operational complexity
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The Go / No Go Decision to Launch
• Clarify your business objective 1. Add the service as an incremental offering for patient-
centered modality?
A Noble Goal
The Right Thing To Do
Go For It
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The Go / No Go Decision to Launch
• Clarify Your Business Objective 1. Add the service as an incremental offering for patient-
centered modality?
A Noble Goal
The Right Thing To Do
Go For It
2. Create a business with a standalone enterprise value?
Go Big or Go Home
Multiple SNF locations
50-100 patients minimum
McGuireWoods | 11 CONFIDENTIAL
Viable Operational Models
NxStage Daily Dialysis
Conventional Thrice Weekly
Bedside
YES
NO
Den
YES
YES
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Which Business Model To Use?
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Which Business Model To Use?
It Depends
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Which Business Model To Use?
It Depends
Factors Include: • SNF empty bed capacity • SNF footprint • State regulatory environment • Staffing availability • ESRD Provider resources
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Program Responsibilities
ESRD Provider SNF
Patient caregivers OR Patient caregivers
Caregiver Training & Skills Verification Physical space build-out (Treatment & storage)
Dialysis equipment & supplies Dialysis chairs
Dialysis related drugs Digital scale
Medical oversight (Med Director & Qualified Home Training RN)
On-site licensed RN (trained by ESRD provider)
Labs Medical waste disposal
Regular in-servicing of SNF staff Cleaning & utilities
Social worker & dietician Medication administration
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Other Operational Considerations
• Remember, the ESRD provider is a guest in the SNF • Align goals with the SNF and be aware of the potential
tension of operating within their facility • Exceptional communication needed for effective
coordination of care • Continual in-servicing is required due to high staff
turnover in SNFs • On-site QAPI meetings • Bio-medical staff support • Nephrologist credentialing: open or closed unit?
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Given the most recent 10 years of focused effort serving this niche market, compelling clinical outcome data is starting to emerge.
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Recent Data Studies Demonstrate Proven Patient Benefits for Nursing Home Dialysis
• Affiliated Dialysis Centers recent data releases: – Annual Dialysis Conference (Atlanta - Feb 2014) – National Kidney Foundation (Las Vegas - April 2014)
• Analyzed outcomes of nearly 4,000 patients over 6 years • P < .001
McGuireWoods | 19 CONFIDENTIAL
Recent Data Studies Demonstrate Proven Patient Benefits for Nursing Home Dialysis
• Affiliated Dialysis Centers recent data releases: – Annual Dialysis Conference (Atlanta - Feb 2014) – National Kidney Foundation (Las Vegas - April 2014)
• Analyzed outcomes of nearly 4,000 patients over 6 years • P < .001 • Key results released to date:
1. Clinical outcomes at 3 months were consistent with the trend and quality of care to the general ESRD population
2. Daily dialysis improves mortality rate. Median survival increases from 30 months to 50 months.
McGuireWoods | 20 CONFIDENTIAL
Nursing Home Patients – Mortality Comparisons
Source 3 month
6 month
12 month
USRDS 50% 26% 14%
Tamura et al 39% 13%
Affiliated Dialysis 86% 80% 71%
Nursing Home ESRD Patient Survival Probability - Incident
USRDS 2010 Annual Data Report Tamura et al NEJM 2009
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Daily Dialysis Shows Improved Survival Rates
Patients on Daily Dialysis vs. Conventional Demonstrated: 1. Improved health status 1. Lower monthly mortality rates 1. Significantly longer median survival
(50 mo vs. 30 mo)
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Summary
• Nursing home dialysis is a growing segment and patients are worthy to be served by quality home dialysis programs
• The nursing home dialysis niche plays perfectly into the developing ACO model of care and the need for cost controls in our national health care system
• Affiliated Dialysis is committed to serving, promoting, and educating the industry on this critical service
• Access our website for additional information, including our recent data study press releases
McGuireWoods | 23 CONFIDENTIAL
Questions?
www.affiliateddialysis.com
Curt Anliker Chief Operating Officer