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Tuesday, October 27, 2009

dialysis in the very old

As people age, their kidney function gradually goes down, usually keeping pace with overall needs. In people with longstanding diabetes or high blood pressure, though, sometimes the kidneys fail before the rest of the body does. In this situation, various toxins build up in the blood and such a person gradually becomes weaker and eventually dies.

Enter kidney dialysis.

With a machine that runs the blood through a filter, much as the kidney is a filter, the toxins can be removed from the blood. Unfortunately all of the blood needs to be run through that filter, which is somewhat tricky, and it takes about 4 hours, and needs to be done about 3 times a week.

This is barely tolerable, but better than dying, usually, if you are pretty young, or only have to do it for awhile, as you wait to receive a kidney transplant.

If you are very old, though, dialysis is physically stressful. The heart has to tolerate the movement of blood out of and back into the body, and all of the organs have to tolerate the rapid shifts in electrolytes and blood volume that are part of the process.

Not surprisingly, older folks, those over 80 for instance, don’t have much more in them than the 3 time a week dialysis sessions, and so don’t benefit in terms of energy from being dialysed, other than not actually dying of kidney failure. A study done at Stanford showed that, in fact, most nursing home residents lose their abilities to take care of themselves after starting dialysis, and within the year, almost half of them die anyway. But the over 80 crowd are in fact the fastest growing population of patients getting dialysis in the US.

Dialysis is a big business. It is a procedure and therefore is reimbursed generously by insurance companies. Dialysis centers are popping up like mushrooms, and must have patients to continue to make money. A single dialysis session will be billed at about $1200, sometimes more, and be reimbursed by medicare for maybe half that. Private insurance pays considerably better. No matter how I calculate it, that is considerably over $100,000 a year.

In our small town there were no dialysis facilities available, so everyone who needed to have dialysis needed to travel at least 45 minutes to a dialysis center if they wished to have it done. With much wrangling and organizing, the hospital eventually put in a dialysis center, which seemed like it would probably not be very busy, since there just aren’t that many people living with kidney failure around here. They opened their doors a month ago, and then, as if by some kind of evil magic, there were two dialysis centers, in a town of 20,000 people. The second one is in a mini-mall at the edge of town. Competition is good, when it can bring down cost and increase quality, but costs for these things is based on what insurance will pay, which is static, and quality is pretty well controlled by standardization. Perhaps they will compete on the quality of the cookies they serve in the waiting room? The second dialysis center was started by a specialist who was not the proprietor of the first dialysis center, and figured he could hold on to his share of the patients by building his own.

Now perhaps I shouldn’t be fussing. What harm could it do if two companies want to open up and offer services that don’t really hurt anyone in town, and in fact potentially save lives? What I’m worried about is the large population of over 80 year olds in town who will now most likely experience rather powerful marketing as both of these centers struggle to make ends meet.

These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit, since dialysis is common and easily accessible. If this made them healthier and happier it would be one thing, but I predict it will not go that way.

6 comments:

Anonymous said...

"These folks and their families will now be faced with the expectation that they should not let nature take its course when their kidneys quit..."

Whoa! It's none of your business if grandma wants to live for another year or two - unless YOU are paying for it out of your pocket. Do you know how painful a death uremia is?

To your other points:

First, there is no "competition" among centers like you are describing - if there were, it would be a good thing. Right now, to change centers, you'd have to get a new nephrologist, get permission from the new place to become their patient, make sure that the new center takes your insurance and has a spot for you three times a week at the time that works for you, ask to transfer all your medical records, etc.

It's not like you finish dialysis at one place on Saturday and just stroll into the next place on Tuesday and get hooked up. No, it's slightly more complicated.

Second, changing from one center to another, particularly to another provider, is not guided by "marketing" or any such thing. I have been on dialysis for three years. I have yet to see a dialysis "commercial" on TV, receive a dialysis flyer in the mail or get a telemarketing call. I wish that would happen! Sitting still on a chair in a brightly lit dialysis clinic with your arm immobile for three hours with two big needles impaled in it, hoping you don't cramp up or get sick to your stomach or pass out because of low blood pressure, listening to other machines suddenly set off alarms and breathing in the strange smells of the various chemicals they use is not glamorous or fun - a change in the typical environment of a dialysis clinic would actually be welcome.

After 30 months on dialysis, regardless of age, Medicare Part B becomes the primary payer whether you like it or not. And yes dialysis does cost anywhere from $600 per session (Medicare's cost) to $2500 per session (for a single session when you are traveling and have private insurance).

The fact that Uncle Sam is standing there willing to pay for dialysis forever means that the dialysis industry will just go chugging along with no incentive to seek less expensive alternatives or modalities. I need dialysis only because nothing better is even being looked for. Because there's a big pot of money for keeping things the way they are.

Dialysis is horribly expensive. A cure for kidney failure must be found, as well as an alternative to dialysis or kidney transplants, for those of us trying to work and support a family. Dialysis is set up for retirees, not for working people, and is difficult to cope with. There has to be a better way.

In the 1970s before Medicare got involved, 40% of dialysis patients did their sessions at home - much more pleasant, quieter, less stressful and less expensive. After Medicare took over, the number fell to 0.57% within a year or two. Forty years later the number is still less than 1%.

Get the government out of the medical industry and maybe actual cures would be found!!

Janice said...

Yes, I have seen uremic death, and a whole lot of other flavors of death as well, and they are all hard. Except, perhaps, the rare sudden deaths which most of us hope for.

All third party payers have the same difficulty as medicare: they aren't us, the consumer, and therefore don't really have the same values or needs as we do, in your case for some kind of kidney replacement therapy that gives you more time to be a regular person.

I don't know what happened to home hemodialysis or peritoneal dialysis...some people are still doing both of those things, but less often. There needs to be some incentive to make this kind of treatment less expensive and less complex. Right now, with fee for service, there is not that incentive. I think capitation (paying providers per patient to provide a service), if we consumers were involved in it to maximize quality, would provide that incentive.

As far as cures for kidney failure, the best hope is in prevention, which would apply to the most common cause of kidney failure -- type 2 diabetes. That disease can be mostly prevented by reducing the rate of obesity, which might be aided by reducing subsidies on corn and increasing physical education in schools, and a public health push to get people more active.

Regarding competition: I agree with you, it is not really happening in dialysis centers.

Bonita said...

My husband is 60 years old and relatively healthy and active, considering he has polycystic kidney disease. He has been on home hemodialysis for almost two years. My concern is not with the quality of care, but with the incredible costs. We started out with a cost of approximately $4,000 per week. Out of the clear blue sky, that amount increased to $20,000.00 per week a couple of months ago. We asked why, my husband's employer asked why, but no answers have been given. The staff and doctors at the clinic we go to monthly were slack-jawed when informed the company they work for is charging us this much. We dialysis at home, do the work ourselves, draw lab samples, everything, and our costs were increased times five. Why? And how can the company get away with it. Our insurance will cap out in no time. Medicare can't cover it all. How does anyone pay for this?

Janice said...

Wow--that is impressive. I'm not even sure where you should go to get answers to this kind of a question. The bottom line is that there is no competition to provide this service so you and your insurance company are at the mercy of a provider that charges an exorbitant amount. I saw this happen with an orphan drug which one of my patients needed: the cost went up 10 fold, from 300 dollars a dose to around 3000 dollars when a new company started producing the drug. No explanation. They just charged that amount because they could.

Your health insurance company might be a valuable ally if you get the right person, since they are undoubtedly not happy about this either.

Anonymous said...

I could gave written that first post - it's totally spot-on!

We just started home dialysis three weeks ago. It is far less stressful (for me, that is... my husband, not so much, poor fellow). Since Medicare is paying for it, I don't know the cost. And that's the point. Medicare shells out $28 billion a year for dialysis, kidney transplants and after-care. It's enshrined in Social Security law.

The issue as I see it, is that DaVita, Fresnius and other providers will fight tooth and nail against any cheaper, more efficient modality that they cannot profit from. So there is a perverse incentive to protect that $28 billion pot of money from outsiders who might have a new technical innovation to take the place of dialysis.

Do you think current dialysis providers would let the FDA supervise and approve trials of an invention or new modality that would threaten the dialysis payments gravy train? If you think they'll stand by and be put out of business when they have tons of money to throw around at Congress, which controls Medicare payments for ESRD, I have a bridge I'd like to sell you.

Sorry for the cynicism, but when a modality for a fatal disease hasn't changed much in 40 years in the most innovative country in the world, some factor must be at play that distorts the laws of economics which constantly seeks cheaper, more efficient solutions. That factor is government interference in the marketplace in the form of third party payer. Government doesn't care about costs if it has enough taxes or borrowing capability to cover the expenses it voluntarily takes on. So nothing changes.

Janice said...

Yes, the government is one of our third party payers, and doesn't have adequate incentive to raise quality and decrease costs, so things stay the same.