By Peter Laird, MD
In my last post on dialysis practices in Japan and the false hope of financial incentives for renal donation, Zach asked an interesting question that I would like to follow up on with a full post:
Does Japan reimburse on a per-hour basis rather than a per-treatment basis?
Posted by: Zach | September 26, 2008 at 03:43 AM
I contacted Dr. Christopher Blagg for any information he might have to Zach's question and he was kind enough to contact a colleague in Japan to answer Zach's question:
My friend says that "A dialysis program is paid per session, and the nephrologist is paid per session in Japan." I understand that Japanese patients dialyze for 4 hours three times a week, weigh significantly less than usual US patients and are much more disciplined and usually carefully follow the instructions from the doctor and facility.
I find this to be a fascinating observation on how Japan has possibly been able to achieve a 10% annual mortality when I compare what features are similar to my own American unit that likewise has achieved a 10% annual mortality as well. From Dr. Blagg's answer from Japan, my unit dialyzes for 4 hours for all patients as do the patients in Japan. The HEMO study did not find an increased survival based on dialysis times, but within the patient population of my own unit, one of the biggest differences was increasing dialysis times from an average of 3 hours at outside contracting units up to 4 hours when my unit opened 5 years ago when they repatriated patients into this joint FMC/HMO venture. The impact on reduced complications and mortality with 4 hour treatments as the rule in my unit is likely part of the answer just as it appears to be in Japan.
A large portion of the patients in my unit have a BMI over 30 which is different from Japan. Data suggest an actual survival advantage for obese patients in America which would not correlate with the Japanese dialysis population.
My nephrologist takes a very personal interest in his patients and has a renal care coordinator, dietitian and pharmacist that works directly with all of his patients at the contracting HMO starting in pre-ESRD status for all patients. I can personally attest to the helpfulness that this team played in my own coordination of care as I transitioned into dialysis and since then as well. Fistula use has dramatically increased at my unit with this team approach which has been shown to reduce hospitalizations and mortality.
Patient noncompliance in my unit has been an issue with a minority of the patients, but I would be hard pressed to believe that the level of compliance in all patients at my unit would be higher than that of the Japanese population. I have seen too many patients at my unit eating food from McDonalds, potato chips and dark cola's that certainly are quite bothersome to the unit dietitian that has counseled them against such practices.
My unit is payed per session just as is Japan so that is not likely a difference. My nephrologist is an HMO physician so his pay is not based on per session payments and is separate from the facility per session payments.
One special project that my nephrologist has undertaken is to establish a nonprofit organization to supply protein supplements to at risk patients with poor financial resources. He has some very interesting data showing a mortality improvement as the program was implemented. Certainly elimination of protein malnutrition has been a large component of improving care at my unit.
I am not sure if we can draw many conclusions about this observational data from Japan and from my own unit other than to state there are some similarities starting with a dialysis time of 4 hours. Certainly, that may be the most important factor since I have observed that other units have a standard 3 hours for each patient treatment time to generate more income for the dialysis unit by keeping staffing overhead costs minimized. Under treatment has been shown to adversely effect mortality rates.
The take home message that I would like to bring to this discussion is that my unit has been able to achieve excellent mortality rates with a coordinated team approach. I do not see one specific factor that is the sole reason for this improvement, but instead, taken together in little incremental improvements,the net result is a significantly reduced mortality rate compared to the national dialysis mortality rate. This should be the goal of optimal renal dialysis care to seek improvement in a number of factors that add up to significant mortality reduction overall. Perhaps the underlying commitment to optimal renal care is the single most important factor in both Japan and my own unit.
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