Reactions to The Atlantic (ProPublica) Dialysis Article…

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Robin Fields published a report concerned with dialysis in The Atlantic and on ProPublica (longer version). Her report accurately reflects the opinions of various patients and professionals- but not necessarily all the facts.  (You can read my impressions developed over the past half-century via “Dialysis”  index found in the page header).

Her basic premise is that dialysis costs more in the US than elsewhere, without greater patient outcomes.  However, that is IDENTICAL to our health care system, as a whole.  She states that 100,000 patients start dialysis annually and ¼ die within the first twelve months.  (After that, the death rate drops to 1 in 6.  She compares that to Italy, which has a death rate of 1 in 9, where cardiovascular and diabetic complications are extremely less frequent that among American patients.  She also tries to tie this to more frequent physician contact, with no data.) What she does NOT say is that private health insurance pays for the first twelve months; it’s not till almost year 3 when Medicare picks up the tab.  (It used to be by the end of year one- that changed long ago.)

Ms. Fields points out that we pay $20 billion a year for the 275,000 federally funded dialysis patients (375K overall census).  However, a good portion of those funds are employed for federal ‘oversight’ and ‘program management’ (roughly 1/3 the total).  She points out that the two big providers generate $ 2 billion in profits, but neglects to state this is world-wide, not just the US and that one of the providers is a fully-integrated firm (providing supplies to itself and others) and thus makes the greater portion ($1.5 billion).

I am not saying I am proud of dialysis care.  For years, I have been lamenting that the goal of our government is to squish all the small players, leaving one or two providers.  This would let Medicare cut its reimbursement rates, with little public fanfare. (Medicare rates stayed at $ 138 per Rx for years, dropping to $ 123 after a decade, where it has remained [until next year]). And, that has happened- in the last twenty years, the number of moderate to large chains has dropped from more than ten to a handful (with fingers left over); the number of independent, single or two clinic, facilities has disappeared from the marketplace.  (The total number of clinics in the US is around 5,000.)

Providers have been able to retain all funds not spent on care, with nary a penalty nor bonus for the quality of care.  Even with the new proposed rates, the bonus and penalty is probably way too low. And, until now, the use of erythropoietin (to elevate the red blood cell levels in patients) was an additional cost that Medicare reimbursed (another complaint I raised for years), so that the “core business [of the clinics] became giving patients injectable drugs” {d}ialysis was just the loss leader that got [patients] in the door  (Dr. R.A. Hirth, University of Michigan School of Public Health from Robin Field’ article).  Medicare is now setting maximum therapeutic levels for such drugs, because the data has proven that such overuse leads to heart problems and death.

Ms. Fields also points out that dialysis patients are less likely to complain, since their population derives from the poorer segments of our society.  Blacks encounter kidney failure 4X as does Caucasians; the rate for Hispanics is 1.5X non-Hispanic populations.  There are patient advocacy groups (which have existed since before the advent of federally funded dialysis), but they have had little impact on the overall care and treatment of patients.

Ms. Fields ends the treatise stating that the “biggest potential gains may rely on keeping people off dialysis in the first place.” I, among many others, am looking at that specific need.   It’s what I alluded to about the new manufacturing effort I am considering.

Note:  RenalBusiness posted comments about a day after mine.  You could have found then until 2015 or so.  That’s when I was alerted that their site had bit the dust.  Sorry I never saved a hard copy to share.     [It was listed as written by “keith” in November 2010.   As you can see, I have updated the post after I was told the link was dead.]

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