Report Title:

Appropriation; Reimbursements; Nursing Dialysis Patients


Appropriates funds to DHS for necessary reimbursements to providers.


S.B. NO.









relating to health care.



SECTION 1. The legislature finds that it is in the best interests of the State to ensure that the people of Hawaii receive the best possible health care.

Current statistics indicate there are approximately one thousand eight hundred renal dialysis patients in Hawaii. End stage renal disease (ERSD) cases continue to increase statewide at approximately five to seven per cent annually. The life span for dialysis patients also increases as technology and treatment programs improve. However, medical complications associated with renal disease require special, additional care in skilled nursing facilities. The additional skilled care required for renal disease patients during these stays are not covered by current inpatient, sub-acute, or skilled nursing payor reimbursement formulas.

As medical knowledge and technology have evolved, the lifespan for patients with end stage renal disease has increased dramatically. Patients may live twenty-five to thirty years and more with regular dialysis treatments. Consequently, many of these patients suffer episodes of other acute illnesses associated with the aging process such as heart surgery, respiratory distress, hip and knee deterioration, etc. The added complication of renal disease then causes extended hospital stays during acute treatment and frequently requires continued care in a skilled nursing or intermediate care setting. Due to financial constraints, added care in a skilled nursing setting are generally lacking. However, in order to provide service, facility providers limit admissions to only one or two patients. The lack of "critical mass" of patients with renal disease results in a deterioration of staff skill levels which then causes more and probably misdirected admissions to acute facilities. Then the cycle begins again for these renal patients who must occupy an acute care bed well past their acute stay while waiting for placement in a long-term care facility.

In an effort to better serve renal patients requiring episodic hospitalization, physicians over the past years have conducted research on renal disease complications and alternative treatment methodologies toward this end. One finding indicates the staggering need in Hawaii for sub-acute/skilled nursing facilities and especially a need for those to focus on the care of patients with end stage renal disease. A facility focused on patients of this type would afford staff the ability to keep skill levels current, thereby improving the quality of care and significantly reducing readmission to acute hospitals. In addition, such facilities would offer all acute providers in the State a placement opportunity for their most difficult to place patients, thereby freeing up acute hospital care capacity. Costs would also be reduced due to the onsite availability of dialysis treatment.

Recent studies in Hawaii have found that a licensed nurse (either LPN or RN) must deliver much of the care required for renal skilled nursing patients as each patient requires a pre-and post-dialysis assessment. The pre-dialysis assessment typically takes approximately fifteen minutes. The post-dialysis assessment takes approximately ninety minutes since the treatment can be quite physically draining for the patients and this is typically the period when side effects might occur. The practitioner must also devote additional time to document findings from the assessment in the patientís chart. All these required additional activities occur three times per week, which is the typical frequency for dialysis treatments. Other practitioner duties include conducting a skin assessment and corresponding documentation in the chart three times per day. In addition, a registered dietitian must be called in to evaluate weight and nutrition at least once per week.

These additional activities over and above the regular care required for a skilled nursing level patient require approximately thirty-five additional staff hours per week, per patient -- many of them in the more highly compensated, licensed staff categories. The total additional cost to providers for these services for each patient is approximately $280 per day.

The purpose of this Act is to ensure that there are cost reports for payments to providers and to appropriate funds to the department of human services for necessary reimbursements to providers.

SECTION 2. The department of human services shall ensure establishment of cost reports necessary for payments to healthcare providers.

SECTION 3. There is appropriated out of the general revenues of the State of Hawaii the sum of $2,500,000, or so much thereof as may be necessary for fiscal year 2004-2005, for reimbursements for skilled nursing services for dialysis patients.

SECTION 4. The sum appropriated shall be expended by the department of human services for the purposes of this Act.

SECTION 5. This Act shall take effect on July 1, 2004.