In Defense of Self-centered Care

By Bill Peckham

Self-centered care is a good idea. I look forward to discussing the macro and the micro with doubters, fence sitters and the confused. I’ll put Gary in the skeptic camp

You are obviously proposing a radical change.

It is a radical change, a different radical change from the one previously proposed. Instead of a business relationship at the center of the chronic dialysis care model, self-centered care puts the individual at the center. To be a 'patient' is to be in a business relationship. Patient-centered care focuses on the interaction between a patient and the unit - not an individual and the unit, rather an ‘average’ patient and the unit. Unsurprisingly creating a system to serve the average patient does not produce the results we want no matter the intentions of everyone involved.

The latest attempt to achieve our desired results would be a radical change. It is on the table, already working its way through Congress. It has 98 cosponsors. It is not a good idea.

DPDA (the PATIENT Act) S.2065/H.R.4143 would in effect make one of the large dialysis organizations the Part A and Part B fiscal intermediary for Medicare dialyzors throughout a region. Dialyzors at every provider in a region would have one of the two large dialysis organizations as their healthcare command point. That is a radical change, It will take an Act of Congress to demonstrate this approach.

In order for a DPDA to be tried all sorts of state regulations and requirements have to be cast aside, superseded with the signature of the president. That’s pretty radical. If DPDA works one of two giant for profit companies that have made billions of dollars providing dialysis to Americans will be paid additional billions for hitting their numbers. That also sounds radical.

I believe you are proposing to pay dialysis patients for “hitting their numbers.” Politically, I think this would be an incredibly hard sell. U.S. taxpayers are already paying for a carve-out in the Medicare program that exists just for dialysis patients and costs approximately $80,000 per patient per year. Aren’t wellness and avoiding complications enough of an incentive?

You asked about financial incentives, in a copernican self-centered dialysis system the incentives would be directed at the individual. Why would the taxpayer be willing to pay DaVita $2,000 if they are able to get that $80,000 down to $76,000 but would balk at paying patients to do the same thing. Here’s a thought experiment: every Medicare dialyzor in Network 14 is assigned to the Copernicus14 Dialyzor Self-centered Care Demonstration. If the census in the demonstration achieve census-wide savings CMS agrees to share savings in excess of 2% to all beneficiaries. 

Suddenly, the infection control seminar I voluntarily give down at the library might actually see attendance. And because it would be in my interest I might be more willing to drive an hour to give my seminar to a few other dialyzors (I don't actually give an infection seminar but I would if people attended). The units would still have their patient-centered metrics to achieve; now they would find an audience and messenger for their patient-centered education.

In the unit dialyzors engaged with the plan would have incentive to get others onboard but more than that they would have standing to monitor the unit. Handwashing policies would find advocates in the engaged. Engaged dialyzors would have an interest in improving everyone's care one individual at a time, starting with themselves.

An upside scenario comes to pass, Copernicus14 sees spending decline across the entire census by 5%. Each participant has $1,200 in SS tax paid into their account about the amount $10,000/year in wages would generate. The beneficiary would get the actuarial value of the tax, the taxpayer would get a very good deal indeed. 

I believe expecting dialysis patients to manage their overall care would be overwhelming for the vast majority, especially new patients. It takes years to develop understanding and expertise in the complexities of the various therapies and in the self-interests of the industry players. If your system was implemented, I believe nearly all new patients would have to rely on an advocate to help them. Who would fill that role… and at what price/cost?

If the self-centered QIP rewarded all the unit’s dialyzors for unit level achievement in addition to process rewards directed at the individual the incentive would be for dialyzors to work together. People wouldn’t be managing their own care, there are still techs, nurses and doctors, care plans ... but each individual would have a room full of peers who have a more direct interest in seeing them succeed. If it doesn't work, if nothing comes of the effort, we are left where we are today.

… paying dialysis patients to be engaged and involved in their care would likely result in similar demands from millions of people with diabetes, heart disease/failure and other chronic conditions.

I should hope so. Patient-centered care is widely practiced The current idea is for DPDA to be the model for the future, for dialysis then for the rest of the chronic disease spectrum, working alongside/through patient-centered care. But as long as we are talking about changing the way dialysis is provided via an Act of Congress let’s look at some options. I can make the case for what I am calling self-centered care. One could say it's paying people. I'd say motivating people to be engaged, to be a coach, and to be coached. 

The large dialysis organizations gained access to the per beneficiary Part A and Part B cost data through the various ESRD Affordable Care Organization demonstrations that are ongoing through ordinary Medicare regulatory processes. This is the first time anyone has been able to see the complete cost data beneficiary-by-beneficiary. What have the LDO’s data teams found that makes them so anxious to take responsibility for all beneficiary spending? One wonders. Give dialyzors the data and dangle a carrot, many people will be amazed at what we can do.

Comments

[Gary Peterson]

Perhaps the good people in Seattle would be willing to sponsor a demonstration project.

[Erich Ditschman]

I've been practicing self care for 12 years. I also talk to in-center patients and others about the benefits of self care every chance I get. Self care empowers dialyzors to no longer be a patient, and instead be the captain of their care team. For example, just sticking oneself, even in-center, gives the dialyzor the power. I feel a sense of pride returns. And, this pride/sense of accomplishment spills over to other aspects of one life. For a dialyzor who feels they lost control, self care, can suddenly remind her/him that they have much to offer. They can now go back to work, or step up in the home management activities–shop, cook, clean, fix things, take care of children, be a better lover, volunteer in church or the community, or simply play Bridge with one's friends with a smile instead of a frown. Thanks, Bill, for putting numbers to what I believe to be the best approach to gaining one's life back after ESRD, especially it s/he is waiting for transplant. Transplantation also requires self care. Cheers! Erich

[Bill Peckham]

@Gary If only it were only a matter of signing up sponsors, I can imagine so many different demonstrations projects. I'm sure Amazon or Microsoft are just waiting to associate their brands with the revolution in healthcare promised by self-centered care.

@Erich we both know that more people should be experiencing outcomes similar to ours, that is: living lives meant to be lived but for bum kidneys. The DPDA wouldn't have helped us and I don't think it will help people who want to achieve our outcomes.