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  1. #1
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    My insurance and Davita

    I started dialysis on October 1, 2013. On that same very day Davita became non-participating with my carrier (UnitedHealthcare). If I had started one day sooner, I would have been grandfathered in as an exception. Thanks to a grant my social worker got for me though, most of my bill will now be paid for so I don't have to change doctors. Thankfully.

  2. #2
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    I started with DaVita At Home back in July 2012 for HHD training and ongoing support. Receiving the letters in September from my employers insurance provider, United Health Care regarding dropping DaVita as an in-network provider was disturbing, to say the least. I wisely elected to take (and pay for) Medicare Part B starting 1-1-2013, which got my $3500 In-Network Provider out of pocket max paid.

    Disturbingly, the dropping of DaVita as an in-network provider exposes me to another $3500 out of pocket max (additional deductible of $1600) at a copay of 60% versus in-network of 85%. I have been assured by my social worker and the DaVita regional insurance specialist that I am grandfathered through a continuation of coverage clause in the agreement between DaVita and United Health Care.

    I've been checking my United Health Care dialysis claims and getting assurances from my social worker each month during my clinics, but the prospects of taking on the additional out of network provider costs or going to the only other HHD provider (Fresenius) in my city that is served by my nephrologist does not make for for comforting feelings for the short and long term future of the situation that I've come to rely upon.

  3. #3
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    Quote Originally Posted by stumpr54 View Post
    I started with DaVita At Home back in July 2012 for HHD training and ongoing support. Receiving the letters in September from my employers insurance provider, United Health Care regarding dropping DaVita as an in-network provider was disturbing, to say the least. I wisely elected to take (and pay for) Medicare Part B starting 1-1-2013, which got my $3500 In-Network Provider out of pocket max paid.

    Disturbingly, the dropping of DaVita as an in-network provider exposes me to another $3500 out of pocket max (additional deductible of $1600) at a copay of 60% versus in-network of 85%. I have been assured by my social worker and the DaVita regional insurance specialist that I am grandfathered through a continuation of coverage clause in the agreement between DaVita and United Health Care.

    I've been checking my United Health Care dialysis claims and getting assurances from my social worker each month during my clinics, but the prospects of taking on the additional out of network provider costs or going to the only other HHD provider (Fresenius) in my city that is served by my nephrologist does not make for for comforting feelings for the short and long term future of the situation that I've come to rely upon.
    I know how you feel. From what I'm told (I also work for United) they are still negotiating, though my contact has since left the company so I am not sure what the current status is.. In CT, Davita does 75% of the dialysis so to go non-par, that really is affecting too many people.

  4. #4
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    Hello rickster12,

    I just had my monthly HHD clinic and my social worker had me sign another "Continuation of Coverage" document that will be sent to United Health Care to assure continued coverage of my DaVita HHD services as an in-network provider. Fresenius just assimilated Midwest Dialysis, who had/has several clinics in the Milwaukee area - none of which offers HHD. This is in addtional to an assortment of Fresenius Medical Care Dialysis centers also in the area, and as noted previously, only one of which offers HHD services.

    I noted from an earlier post that you are receiving in-center hemodialysis and are progressing slowly through the needle sizes 17 ga to 16 gag to 15 ga as well as the amount of dialysate processed to minimize the trauma and stress on your fistula. While my fistula and button holes (4 ea. - self developed) are well "dialed in" I didn't get there overnight and had my share of issues. I got through these relatively quicky owed to starting hemodialyis directed in an HHD clinic whilst training for same. The skill and experience levels of the dialysis nurses and their respective innovations made a huge difference over what you would normally experience in-center.

    I've been at home with my care partner/spouse since September 2012, conducting 5X weekly treatments and in doing so have gained an extraordinary amount of knowledge about all things hemodialyis - especially home hemodialysis. I put that knowledge to work everytime I put together a weekly treatment plan and conduct a short daily or nocturnal treatment. I've learned a great deal about fistulas, the development and maintenance of buttonholes. I've learned almost more through my own experiences than I did during the 5 weeks of training.

    It looks like your in for a long slog until you have working buttonholes. Once your fistula has reached that level of maturity and is working adequately, it opens up a whole new world of vascular access and one that I've leveraged heavily in my favor.

    I developed three new buttonhole sites in about 4 weeks, each taking five or six days of sticks and treatment with sharp needles. I've come to learn that these sites can require period "tune ups", as the buttonhole tract in the arm tissue can get out of alignment with the flap cut in the fistula vessel beneath, making needle placement via soft touch cannulation anything but a no brainer. The fistula vessel behaves much like a muscle, which develops/strenghens with use and that can produce the physical changes that cause once great working button holes to cease to work or cease to work with the same level of ease as when originally developed. Having an "arsenal" of techniques to manage the normal changes in vascular access is much like having an awesome set of tools - you can handle nearly any job.

    I've worked a demanding full time job during all of this and have had the treatment flexibility through HHD to engage in periodic bouts of repeated short notice multi-night business travel. I have resorted to some in-center after work hours treatments in order to extend my business trips and stay on my 5X weekly treatment schedule. There are folks like you who work full time and receive in-center dialysis 3X weekly, but as you are discovering with the associated energy drain, they are few and far between.

    The treatment schedule flexibilty of home-hemodialysis along with the less demanding on the body 5 or 6 per week short daily dialysis treatments, make the modality quite appropriate for hemodialysis patients that wish to work - full or part time. I've got at least 15 years on you and my plan is to continue working up to full retirement age if not beyond while on HHD and/or with a transplanted kidney. I've been on two transplant program lists since January 2011 and November 2012, but I'm in no hurry to assimilate foreign tissue as I've been making a very good go of HHD thanks to a great medical staff and my remarkably dedicated and capably care partner/spouse of 36 years.

    If you've got an individual willing to train and serve as your care partner, you should aggressively pursue home hemodialysis as your preferred dialysis modality.

  5. #5
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    Hi, unfortunately no health partner for me. I most likely will be sticking to the in center dialysis. I have been on the large (15) needles for about a month now. I am told about mid winter for the button holes so not that far off. So far the uncomfortable part is my tailbone from sitting so long. Even the cushion isn't enough.

  6. #6
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    I am almost ready for the 15 needles and the buttonhole. The fistula top needle is so deep that the button hole is the only way for others to access it. Only one person can place needles right now. I want to do home dialysis as soon as my blood work gets where it needs to be. So far, they are giving me lots of medication to build the cells and straighten the red and white blood cells. With all the trouble I have had my husband is in no hurry for me be my health partner. He wants to make sure everything is right first. Praying you have a good Thanksgiving.

  7. #7
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    Hello rickster12,

    I'm not sure why the long wait to start buttonholes. Generally it is anywhere from 5 to 10 sticks with a sharp 15 GA needle in the same site at the same angle. It is best to have the same person placing the needles to assure the same angle and needle position with the successvie needle placements.

    I have found that placing the needles myself is not only a great way to assure the angle is the same but it takes away the element of "surprise" and sometimes discomfort that comes at the hand of someone else. Even when I have started a new site for the development of a buttonhole I really don't feel much of anything because I am doing the sticking, which eliminates any surprise and permits me to adjust if there is any discomfort. I think of it as removing a splinter in reverse and a needle is far more uniform with less drag on the tissue than any splinter.

    Each sucessive stick with a sharp needle in the same site becomes easier as the tract is already cut into the tissue leading to the fistula. The fistula has no sensitivity other than a feeling of presssure when it is poked. The developing tract in the tissue acts as a guide/tunnel for the sharp needle and then of course the blunt needle when the tract and flap in the fistula can be navigated successfully with a blunt.

    The mechanics of buttonholes never cease to amaze me and with it the relative ease at which I am able to access my blood in a purely bloodless manner. Sure, the blood goes into the needle and tube but it otherwise is never exposed to the air. I endeavor to "spill no blood" during the course of a treatment, accessing my blood, connecting and disconnecting lines, removing needles and holding pressure. A great pressure hold results in a mere spotting on the gauze that is just a bit larger than the button hole itself.

    The 15 GA sharp and blunt needles that looked so large when I started HHD training now seem small. I'm fortunate to have rather a prominent fistula with run off vessels in my lower arm that are just under the skin, e.g. very little tissue between the skin and the vessel. As a result, I get a near immediate flash in the needle tube the moment I place the blunt needle in the button hole, which is the visual feedback that the needle is in the right place and barring any flow issues, hemodialysis can begin shortly thereafter.

  8. #8
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    Reason given by my center is each needle is for three weeks to build the fistula since" it is just not mature enough." After the fistula gram they went back up to the 17 (which if you have been following my journey, you know the top of my fistula is too deep for it to reach and a 16 long is needed) After they just got one of the 17 in, they had to use the catheter again for the other. I was then told not to move my arm because the 17" lower level needle could slip out). The next treatment was with the 16 long again. Now three weeks down the road they are telling me they are ready to use the 15. I hope they come in long too. I am the only one using the 16 long in our center.

  9. #9
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    Hello kcramer,

    The whole purpose of creating an arteriovenous fistula is to produce a vessel capable of the high blood volume flow that is required for hemodialysis and to provide easy access to that vessel. Certainly there is variation in individual patients, but it sounds like your exceptions, if they persist, are going to make it difficult if not impossible to perform home hemodialysis.

    The fistullogram will "revise" a fistula and thus set the vessel's development back to the start, regardless of when it was created and the general rule of thumb of 3 months from creation to maturity.

    After my fistullogram, one of the new vessels that was created in the process was used for the venous site. We progressed from 17 ga to 15 ga and with it increased run times (dialysate processed) and blood flow rates as well as using the same site contnuously to develop a buttonhole. The venous site and associated vessel could not pass the transonic flow test but that did not prevent using the site successfully for dialysis at a 550 ml/min blood flow rate, provided it was in "push", e.g. return of blood.

    Properly placed needles in a properly formed and functioning fistula that is near the skin, should not "slip out". The 1" long 15 ga blunt dialysis needles that I place are at least 3/4" into my combined tract and fistula flap, aka the button hole site. Combined with the taper of the needle and associated friction between needle and tract, the needles need to be pulled out to be removed - they cannot "slip out". The advantage of this condition is that I can lay or remove securing tape with my free hand and not have to worry about dislodging a needle. Once a needle is taped down, it isn't going anywhere, regardless of what I do with my fistula arm, e.g. I have complete freedom of motion.

    Perhaps I've come to accept my situation as the norm, but certainly being unable to move your arm during treatment had better be a short term condition as well as the need for special long dialysis needles or these requirements are going to make dialysis treatments very confining and limiting in-center and moreso at home - if at all possible at home.

    If your final objective is home hemodialysis, I would have your medical team assure you that you or your care partner will be able to consistently place your needles with the fistula as is. If that is not the case, some form of fistula revision is needed that will enable the use of standard needles and permit enough needle engagement in the fistula to minimize the chance of a needle slipping out.
    Last edited by stumpr54; 03-17-2014 at 04:47 PM.

  10. #10
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    OMG this info about Davita and United Health Care is very helpful.We have United Health care but it doesnt carry any renal resources coverage! I will have to get medicare to cover my dialysis.Even then its a 80/20 copay plus premiums so I hope I can go the PD route nocturnal at home to cut costs.The money part of this is scaring me as we are a one income couple.The only Davita center here is a 25 mile drive.Guess I wont have to worry about that now since they dont even take my insurance.Do they take medicare or send you to the hosp for care?

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