By Bill Peckham
Both RenalWEB and NephrOnline link to an article available online from Clinical Therapeutics: The Financial Implications for Medicare of Greater Use of Peritoneal Dialysis (pdf link). The headline is that Medicare could save 1 billion dollars a year if PD use increased to 15% of those with CKD5 who require dialysis. There is a problem with the authors' numbers.
The authors use the top line numbers from the 2007 (meaning 2005 numbers) USRDS Annual Dialysis Report of total average Medicare cost for someone using hemodialysis ($69,758) vs. the total average cost to medicare of someone using peritoneal dialysis ($50,847). They then assume that that on average someone who transitions from CKD 4 into the PD group instead of the HD group would save nearly $19,000 ($18,911) each year, as compared to the status quo or a trending decrease in PD use. That's not the right number for the sake of their scenario and they actually present the data that should have raised a red flag on their analysis.
That $69,758 average cost figure includes the cost of caring for people in nursing homes - skilled nursing facilities. Excluding those in SNF the difference in cost to Medicare of someone on HD vs. PD is about $11,400 which the authors breakdown in the paper - about $4,600 in saved hospitalization costs, $5,800 in separately billable medication costs and $1,000 in access management savings. However, it should be noted that some of the separately billable medication savings comes from having people who dialyze at home take oral Vitamin D rather than the more effective injectable Vitamin D.
Providing PD to people in SNF is highly problematic so you have to assume that growing the percent of people who use PD would create savings from switching people who are not in a SNF and who would have otherwise used HD. This would suggest $11,400 in savings rather than the $18,900 the authors use to get their savings of one billion dollars over five years. I agree that in general it would be a good thing if more people transitioning from stage 4 CKD to stage 5 CKD started with PD instead of conventional incenter HD but the savings touted in this paper are being overstated by about 60%. Still saving $600 million dollars over 5 years is a worthy goal. Which brings up another issue.
When I read the paper (which I very much appreciate having available online, in full) what I understand is how once again conventional incenter HD is expensive when compared to any other form of dialysis that provides a higher dose of renal replacement. Once again we have a paper showing better care under Medicare Part B results in Part A savings. Once again more dialysis saves money. Once again what we have here is a Part A/Part B issue and yet another paper highlighting Medicare's cruel accounting structure that inflicts needless costs and human misery because of President Johnson's and Wilber Mills' political scheme to expand access to healthcare.
It isn't that the use of peritoneal dialysis should grow so much as the routine use of conventional incenter hemodialysis has to stop. Three day a week conventional incenter hemodialysis isn't enough renal replacement - even PD is better.
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