Dialysis from the sharp end of the needle

UK Prime Minister Brown endorses wider use of home hemodialysis; NxStage is ready to help

By Bill Peckham

RenalWEB links to some exciting dialysis news out of the UK. Gordon Brown, Prime Minister of the United Kingdom and Leader of the Labour Party will promise a "personalised" revolution in health and social care in an upcoming speech. Aside from the possibility Brown won't win the election to retain his Prime Ministership this suggests that home hemodialysis (HHD) will become more widely available in the UK.

I was recently discussing what I thought it would take to get more people on HHD in England and I went through the usual suspects: the need to explain the benefits of HHD to dialyzors and their docs, over coming dialyzor needle fears and nephrologist's inertia, but I failed to mention that it would be very helpful if the Prime Minister identified HHD as a national priority:

Addressing an audience at health think-tank The King's Fund, Mr Brown will pledge a broad reform of community healthcare, giving people the option of chemotherapy and dialysis without having to travel to a clinic or hospital.

It would also be easier to access palliative care and care for the elderly at home.

Committing to ensure that within the next five years 1.6 million cancer sufferers have access to one-to-one nursing care in their homes, Mr Brown is to say: "When faced with the fears and uncertainties of a serious illness, dedicated nursing, such as that provided by Macmillan nurses, has the potential to transform the experience of care for the patient and their family too.

"Not just improving the outcomes of care, but helping them to understand their choices and options.

The timing of this is ideal.

NxStage has recently announced a partnership to provide the System One to dialyzors in the UK. Their goal is to increase the number of NHS dialysis patients on HHD to over 10%, from currently 2%. Before this announcement I was thinking it would take a lot of leg work to reach the 10% threshold, but now it sounds like the challenge will be keeping up with demand. That's a good problem for NxStage to have.

Do it yourself hemodialysis - the Chinese model

By Bill Peckham

Today RenalWEB linked to an interesting story out of China. A hemodialysis co-op was being used by 10 people to manage their stage 5 Chronic Kidney Disease (CKD5). A couple dialyzors bought a machine, which they shared, and where no doubt able to provide themselves dialysis for less than $30US a treatment (excluding the initial expense of buying a machine and water treatment system). This compares to the cost of a dialysis treatment in neighboring Chinese Taipei where dialysis is reckoned to cost about $127US per treatment.

The article indicates that the police are unsure how to proceed:

"They were ordered to stop their treatments. Considering the fact that a direct ban could threaten their lives, the enforcement is a little different for these patients, but the place will still be shut down in a few days."

The health authorities have asked the ten patients to contact their own local governments and return home to find a solution to their problems.

At 5 pm, officials from the district Health Department and Public Security Bureau visited them again. They said they would continue to talk with the patients to find a solution.

The patients refused to return home.

I hope the Chinese authorities decide to allow the experiment to continue. Absent an entitlement for dialysis or a wide availability of healthcare people with (CKD5) should be allowed to find their own way to pay for their treatment. In this situation it is hard to see the State's interest in preventing true dialysis co-ops.

The Dialysis Manifesto. #8 from the UK's 10 point declaration of principles Defends Travel

By Bill Peckham

The Renal tsar's blog linked to the Dialysis Manifesto** (PDF download) a communication released in October of 2008. The manifesto is the result of a Dialysis Summit convened in July 2007 by the All Party Parliamentary Kidney Group in the UK. It is an interesting insight into how short comings with the provision of dialysis are addressed outside of the US. Will there be lobbying efforts to get it implemented?

Reading the minutes of the summit** (PDF download) gives you an idea of the discussion behind these ten points:

1. Increase dialysis provision to match patient numbers and plan for the expected increases in prevalence
2. Enable choice of dialysis for every patient
3. Improve early recognition of patients who will need dialysis
4. Consider pre-emptive transplantation for all patients before dialysis
5. Provide vascular access and PD catheter access surgery early
6. Ensure every patient has an individualised care plan
7. Use the Renal Registry to plan and audit dialysis services
8. Improve the provision of ‘away from unit’ dialysis
9. Implement free car parking at hospitals for all people using dialysis services
10. Maintain the commissioning status of dialysis services as specialised services.

As an outsider looking in I would say the most pressing need is for #1 capacity. In the discussion there was talk of two treatments a week strategies to increase capacity. Thankfully, a two day a week schedule was seen as clearly counter to the interests of the dialyzed. The issue of access to more frequent dialysis was framed as a problem with access to financial capital, which I take to mean an accounting issue. The capacity issue was also the focus of issue #8 regarding accommodating patient travel. If there is no spare capacity you can't visit.

I wrote of my concern that government payers in the US do not appreciate the value of travel to a person living with severe kidney disease. I wrote in defense of travel. I have received notes of support from my fellow dialyzors with a wanderlust comorbidity. In the US it is not seen as an issue among advocates. I was very pleased to see the issue of travel has been brought forward in the UK at the Dialysis Summit, they summarized the issues** (PDF download) as:

1. There should be one single price for dialysis across the country. What should be prohibited is for a unit to charge £ 250 rather than £ 150.
2. Capacity issue. When a patient returns to the unit infection control guidance states patients have to be quarantined for 3 months so you have to cater for this.
3. People going to the Indian subcontinent are happy to pay. People going to EEC never a problem because there are no capacity problems.
4. Outside EEC Countries. We have a bursary from the KPA to subsidise travel on a limited basis.

I'm not at all sure why there is a 3 month quarantine after travel. Which destinations would require quarantine? From/for what? That needs to be explained more but a quote caught my eye. It's from Bob Dunn at the NKF "I would like to see everyone getting 4 weeks leave from dialysis a year". I know what you mean Bob. That's what travel is, it is leave from dialysis.

When I travel I still dialyze but dialysis while traveling is not the same as dialysis while at home: it is less of a burden. Travel relieves the endless grind of routine. Travel is a break from the grind of dialysis, it is leave from dialysis. Travel matters. Dialysis wears you out; travel is a tonic. Good for the UK to say so and work to accommodate travel in the provision of dialysis.

** I'm not sure why but this link works for some people but not others. I can get in from work and home, but Anna and others are being denied access. The PDFs of the Manifesto and the minutes are on my site and should be accessible.

In defense of travel or why the provision of dialysis should accomodate travel

By Bill Peckham

Anu writes in comments of her desire to travel from India to Canada. Unfortunately the only way for her to do this while using hemodialysis to treat her CKD5 is to pay from her own pocket. I am not sure what a dialysis treatment would cost in Canada, the only time I have dialyzed in Canada it was on a boat in Sydney marina using the NxStage System One, but I am sure it is hundreds of dollars. Having to pay the marginal dialysis costs would be one thing but visitors have to pay the full counter rate, this is what is keeping Anu home.

This is a problem with a solution but before it can be fixed it has to be understood to be a problem. It's a problem, understand?

Travel matters. The point of dialysis is to allow people to live the life they were meant to live, dialyze to live, don't live to dialyze as is so often said. Travel is a part of that, travel is an important part of the life I am dialyzing to enjoy. Travel matters.

I travel as a part of a full life. I have a fear that in the US the new expanded dialysis payment bundle will be rolled out as a monthly payment. Even a per treatment expanded bundle payment has the potential to create a small barrier to travel within the US but a monthly payment frequency would be a large barrier to travel. The fear, that US government payment systems are indifferent to the importance of travel, is well founded. Medicare payments stop at the US border and people whose dialysis is funded by Medicaid are often confined to their home state because Medicaid will not reimburse for out of state medical care. This is not how it should be, dialysis funding schemes should be designed to accommodate travel.

Yesterday RenalWeb linked to an article from Arab News telling of free hemodialysis provided to pilgrims completing the Hajj (I believe Saudi Arabia also provides free dialysis to those on the Umrah, a pilgrimage to Mecca outside the week designated for the Hajj). However, providing dialysis to foreign visitors does not have to be based on Saudi Arabia's charity model. You could also accommodate international travel through a dialysis exchange program.

To take Anu's example, I will assume she is dialyzing incenter. The details can get confusing because in Canada the funding varies from Province to Province - there are different buckets of money - and I am sure there is a range of funding schemes in India as well but someone is paying some amount per treatment. If a person on dialysis in Canada would visit India at the same time Anu visited Canada the payment for both treatments could stay the same - Anu's funding would pay for the Canadian's treatment in India while the Canadian's funding would pay for Anu's treatment in Canada. They would literally take each others place at no cost to the funding system. Accommodating travel in this way is budget neutral.

Setting up paired travel wouldn't work but creating travel banks between countries could. While the decentralized nature of dialysis in India would make it harder to implement for Anu, it should be possible between Canada and the US, using Medicare as the US standard of reimbursement. The Dialysis Exchange Bank could be started slowly and grow with demand. It could be done in a budget neutral way with administration handled by a donation supported nonprofit. If you've always wanted to see Paris Toronto, dialysis shouldn't be the thing that stands in your way. It can be done but first payers must understand that travel matters.

EDIT - thanks to Kamal for pointing out my pronoun misuse

Malaysia: the view from the sharp end of the needle

by Bill Peckham

I've just seen an article from last June by Datuk Salleh Majid, who's been on dialysis for over 11 years. In A different kind of donation he gives an overview of dialysis in Malaysia, including some cost information:

Treatment for dialysis can be very costly, except if one is lucky enough to receive it at a government hospital where places are limited. If one does it at any of the private centers, the charges can range from RM150 per session to RM250. At three times a week, 12 times a month, 144 times a year, the amount needed for dialysis is RM36,000 (if we take the higher figure of RM250 per session). Imagine, this figure is only for one year.

The current Malaysian Ringgits exchange rate (1MR to $.275US) puts the per treatment cost at between $41US to $69US. This confirms a previous data point. I think I will have to personally investigate if this rate applies to Americans.

Saudi Arabia lacks resources for dialsyis?

by Bill Peckham

RenalWEB links to a story in the Saudi Gazette Woefully Inadequate: 9,600 kidney failure patients, 40 dialysis machines. Come on, the story doesn't support that headline:

Fawaz Al-Remaid, Medical Director of King Khaled Hospital in Hail, said there was a shortage of dialysis machines.

“There are 41 machines, one of which is no longer in service, and we need 50,” he said. Al-Remaid said the department needed 14 new machines to cope with the large number of renal failure patients in the region.

“About 150 renal failure patients visit our department every day,” he said.

That's 40 machines for 300 people, assuming 3 day a week schedules. They're running four shifts to keep up. Not very alarming. The 9,600 number is, of course, the total number of people in Saudi Arabia that have stage 5 chronic kidney disease, which is the article's lede:

Hospitals around the Kingdom are growing increasingly concerned at the plight of patients suffering from renal failure and bemoan the lack of kidney dialysis machines.

The Kingdom’s 9,600 kidney failure patients also face long waiting lists for treatment, a situation which only serves to exacerbate their health problems.

Even this is not too alarming. According to Wikipedia the Kingdom has about 21.5 million native residents (one imagines resident foreigners with CKD5 are sent home, though it should noted that this should be balanced against free dialysis for foreigners during the Umrah or the Hajj). Overall "CKD5 being treated with dialysis" incidence rate in the Kingdom is less than 1 in 2,000. Compared to the US, with over 350,000 people using hemodialysis, out of a population of over 300,000,000 (more than 1 in 900). Additionally, the Kingdom does have a long standing PD program. The Kingdom is doing just fine.

Cost of providing dialysis in Tehran

by Bill Peckham

Hemodialysis International has an abstract available that provides another data point on the cost of providing and/or buying hemodialysis around the world. Here's an except from Hemodialysis cost in Tehran, Iran:

... Health care sector costs associated with each HD session were estimated at US$78.87. Most of the total maintenance expenditure was made up of medical supplies (36.19%), with dialyzers as the major cost driver. Staff salaries represented 17% of the cost and fixed direct capital costs accounted for 21.4%.

Here in the US Medicare reckons labor makes up a bit over 50% of the cost of the current dialysis composite rate (that is the potion of the composite rate subject to the geographic wage adjustment). Medical supplies might actually be cheaper in the US, in actual dollars, for most units with supplies costing $28.50 in Iran, while the overhead numbers seem pretty close as a percentage of cost.

It isn't clear from the abstract if physician fees, medications or lab tests are in the Iranian dialysis bundle but in any case costs are lower largely due to lower labor costs.

Will the bad financial news impact the provision of dialysis?

It is hard to know what will come dialysis-wise of the financial news rippling through the world economy. In general the dialysis industry is highly leveraged, that is expansion and consolidation of dialysis has been fueled with borrowed money. In order to buy Gambro, DaVita borrowed over 3 billion dollars. The alphabet soup of medium sized dialysis providers that spun out of the DaVita/Gambro, FMC/RCG mergers were, in large part, funded through debt.

The credit markets are at the center of the current financial problems, if a dialysis provider's business plan relies on their ability to borrow money then they will have a problem pursuing their strategy.

Dialysis in Malaysia

The Star online carries an NKF-M KIDNEY CARE public service announcement, a community education program by National Kidney Foundation of Malaysia. Good for NKF Malaysia to support dialyzors, about 15,000. NKF-M provides subsidized dialysis treatments and free medications and laboratory tests - here in the US we'd call it an expanded bundle of subsidized dialysis.

Malaysia comes in with a data point under $100US:

Each dialysis costs around RM250 at private hospitals. This will amount to about RM3,250 per month.

NKF patients who qualify for subsidy need only pay RM50 per treatment, amounting to RM650 per month. The remaining cost is borne by the Ministry of Health Malaysia and NKF.

I take this to mean the unsubsidized cost is 250 Malaysian Ringgits which at today's exchange rate is about $80US. This is the lowest rate this blog has reported.

 

The Irish find that driving people to and from dialysis costs money

RenalWeb links to an Independent of Ireland article on the Irish health service's, Health Service Executive (HSE), spending on routine dialysis transportation: taking people to and from dialysis. The article highlights situations where people are being transported past idle machines to units farther away.

One frustrating example is that there are "five dialysis machines in Tullamore Hospital lying idle because of a lack of nurses." There may be a low population density in Ireland requiring small units but generally a five station unit is an inefficient size to operate requiring more staff per station than a 15 station unit. If staff are in short supply then larger units make some sense. Larger units, mean fewer units, which then mean that more people will have to go farther to get to dialysis.

There is an alternative not mentioned - home dialysis. According to the article

The HSE paid for taxis, private ambulances and mini-buses for 1,150 kidney patients in 2007 -- 175 patients provided their own transport, according to an RTE report. It said over 90 patients travelled from one HSE region to another for treatment.

There are currently around 1,300 people around the country on dialysis treatment.

There is no mention of home dialysis, PD or hemo. According to the collective wisdom of the respondents to the 2006 Dialysis Opinion Study of those 1,300 dialyzors on the order of 400 should be on home dialysis, 300 on PD and 100 on home hemodialysis with the remaining 900 incenter.

What I have trouble understanding is the seeming inability of national health services to reckon all the costs of care and then spend the money in the most effective way. According to the article the HSE is spending 10 million euro a year on transport. Do all the math and based on 156 treatments a year that comes to 55Euro per treatment for transport on average - those farthest away are sure to spend that in each direction.

That money would be put to much better use if it provided a stipend for a home helper and increased the use of home hemodialysis. Simply using the transport money to instead pay a helper, whether the helper be a family member, friend or part time worker, would make financial and logistical sense but reading the article this option isn't even on the table to be considered.

Of course, in the US we do the same and worse - people are transported by ambulance to dialysis at a cost of five or six hundred dollars, for a one hundred and fifty dollar treatment. If that money was used to instead bring the dialysis to the nursing home or long term care facility, it would save financial costs and costs in human suffering. In the US we blame the healthcare payment structure that has different payers paying for different parts of the care. What excuse do the world's national health systems have?

I'll know a healthcare system is efficient when it can redirect spending on services like transportation to services like better care. Better care that avoids the need for the transportation. I have yet to hear of such a system.

Expanding dialysis access in India

This is an interesting article from the Times of India about the provision of dialysis in India. By the article's reckoning in India about 150,000 people transition into Stage 5 CKD a year needing a kidney transplant or dialysis. With fewer than 10,000 people receiving care (note a "lakh" is 100,000):

At present, of the 1.5 lakh new patients who suffer from end-stage renal failure annually, only 3,500 get kidney transplants and 6,000 undergo dialysis. The rest perish, thanks to an acute shortage of dialysis centres in India and nephrologists to man them.

The mathematics of dialysis (program growth stops when annual mortality rate, equals the rate of new patients) means that if India provided dialysis so that the mortality rate went from 93% to 20% - if they provided universal access to dialysis - then they would need to dialyze 750,000 people a year. Basically twice the size of the US dialysis industry, 9,000 dialysis units. That's a lot of dialysis.

The article does give some cost figures.

At present, the health ministry pays Rs 850 for every dialysis session that a CGHS beneficiary undergoes in stipulated private hospitals. An official said "The rates, both for CGHS beneficiaries and common people visiting the dialysis centres, will be less than Rs 1,000 which is almost one-fourth of the cost in private hospitals."

At today's exchange rates Rs1,000 is equal to $24.74US; Rs 850 is about $21US. Those are the lowest number I've seen for dialysis reimbursement. $21 in the US would be about the cost of disposable supplies. The article concludes

Dr Johri, [Delhi Nephrology Society president] welcoming the Centre’s move, said, "India’s dialysis programme is awful at present. Hospitals don’t have standalone facilities because it isn’t profitable. There is also an acute shortage of nephrologists. The ministry needs to start short-term courses to train medical officers in dialysis." According to Dr Johri, a patient requiring dialysis, that lasts 4-6 hours, three times a weekends up spending nearly Rs 10,000.

Spending Rs 10,000 puts the costs back into the $240US range but it is not clear at all what is included in any of the payments; and it is not clear what the Rs 850 payment is meant to cover. The article does say that more units are on the way but the cost to operate them has to be over Rs 850 a treatment. What solution is there but to build thousands of dialysis units? More home dialysis like Kamal Shah?

Modality neutrality: bad for adults, worse for kids

RenalWeb links to a paper that looks at the impact of higher doses of dialysis in kids. Turns out higher doses of dialysis leads to better outcomes.

Intensified hemodialysis regimens: neglected treatment options for children and adolescents by Müller, et al (Pediatric Nephrology), concludes:

Virtually all studies consistently demonstrate that intensified hemodialysis modalities provide improvement in quality of life, biochemical and cardiovascular parameters, and likely anemia and nutrition. Provided that a solution to the reimbursement problem is found, intensified dialysis is expected to become a prevalent choice in the treatment of ESRD.
[snip]
Given the increasing shortage of donor organs, intensified regimes reducing the side effects of ESRD are mandatory. It should be realized that standard hemodialysis provides only minimal requirements of survival with renal replacement therapy. The still limited data from pediatric centers as well as our own experience imply that intensified is an effective and safe method with superior clinical outcomes compared with conventional hemodialysis or peritoneal dialysis.

It's a question of reimbursement but it is also incumbent on nephrologists to end their modality neutrality and tell people what is their best renal replacement option.

Nephrology Dialysis Transplantation abstract: The cost of renal dialysis in a UK setting

Just in time for our bundling discussion here in the US we get a few data points from the UK. There is an abstract up from Nephrology Dialysis Transplantation giving the provision of dialysis costs in the UK (note at the current exchange rates one Pound is equal to about two Dollars($1.96)):

BACKGROUND: The UK National Health Service (NHS) will fund renal services using Payment by Results (PbR), from 2009. Central to the success of PbR will be the creation of tariffs that reflect the true cost of medical services. We have therefore estimated the cost of different dialysis modalities in the Cardiff and Vale NHS Trust and six other hospitals in the UK.

METHODS: We used semi-structured interviews with nephrologists, head nurses and business managers to identify the steps involved in delivering the different dialysis modalities. We assigned costs to these using published figures or suppliers' published price lists. The study used mixed costing methods. Dialysis costs were estimated by a combination of microcosting and a top-down approach. Where we did not have access to detailed accounts, we applied values for Cardiff.

RESULTS: The most efficient modalities were automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD), the mean annual costs of which were £21 655 and p£15 570, respectively. Hospital-based haemodialysis (HD) cost £35 023 per annum and satellite-unit-based HD cost £32 669. The cost of home-based HD was £20 764 per year (based on data from only one unit). The main cost drivers for PD were the costs of solutions and management of anaemia. For HD they were costs of disposables, nursing, the overheads associated with running the unit and management of anaemia. CONCLUSIONS: Renal tariffs for PbR need to reflect the true cost of dialysis provision if choices about modalities are not to be influenced by erroneous estimates of cost. Knowledge of the true costs of modalities will also maximize the number of established renal failure patients treated by dialysis within the limited funds available from the NHS.

Assuming 156 treatments that's about  £209 a treatment ($410 US), and like the bundle CMS is proposing, the yearly NHS bundle is meant to cover all the services a dialysis unit routinely provides to one of their patients. CMS proposes allowing $234.66 per treatment for these services (remember too that CMS pays 80% of this allowed rate) while the NHS reckons that the cost of those service in the UK is about $410US - paid entirely by the NHS. The nearly 40% lower cost of home hemodialysis and peritoneal dialysis illustrates the amount of labor that goes into providing an incenter hemodialysis treatment. CMS is getting a great deal and yet they demand more.

Dialysis in India

Dialysis in India has been in the news because of the illegal transplant ring that was exposed recently. Here Bharati Prasad tells of her dialysis expenses, dialyzing two times a week "Bharati who spend[s] more than Rs 50,000 a month on dialysis". At current exchange rates Rs50,000 is a bit more than $1,220 US or about $150 US per treatment.

The Republic of China reimburses $127 for holiday dialysis treatments

The Taipei Times reports that holiday dialysis reimbursement procedures have been tightened in Chinese Taipei. "Payment for health services is capped at ... NT$4,100 for dialysis, the bureau [of the National Heath Insurance] said." 4,100 New Taiwanese dollars at todays exchange rate would be a bit over $127US.

A couple things strike me about this. One, I would not be surprised if ethnic Chinese from Chinese Taipei get a break on treatment charges when they visit the People's Republic of China even if the countries are at odds politically. So the $127 could be intended to fully reimburse ( while I'm sure visitors from the West are charged western prices). Two, $127US is about what Medicare actually pays per treatment (+/- due to case mix, geographic wage adjustment & remembering Medicare pays 80% of the allowed charges). So while an American  dialyzor with Medicare as their insurer gets zero reimbursement for dialysis costs incurred outside the US (and outside of Medicare certified clinics), dialyzors in the Republic of China receive $127 if they have the original receipts.

$127 would not go far in today's dialysis world unless it was towards a subsidized treatment but $127 would help and Medicare doesn't save money if the dialyzor just stays home and vacations in the US. How many more dialyzors would take a dreamed of trip if they had just a little help from their insurer? And how many countries could be persuaded to accept the Medicare stipend instead of their full retail rate? You never know unless you ask - has anyone ever asked?

Dialysis in Nigeria cost data

In Africa treatment for kidney disease is often financed in part by non-profit organizations. In Nigeria Kidney Consultants International "is a registered, not–for-profit organization determined to improve the renal health care of Nigerians by expanding access to dialysis and transplants at very reduced costs to patients." Interestingly this not-for-profit effort is supported by Dialysis Clinics Incorporated of Nashville, the United State's largest not-for-profit dialysis provider.

Looking at KCI's website on a page dated 2007 in Nigeria dialysis cost per year per person, three times a week, NGN3,255,368. Which converting from Nigerian Nairas (NGN) to US Dollars it's about $27,600 or $177 per treatment. One more data point: $177 per treatment is the non-profit cost of dialysis in a low wage country.

Another Nigerian dialysis data point: The Tide Online reports that a 17 station dialysis unit has been commissioned by Chief Godswill Obot Akpabio of Akwa Ibom State who will provide 85 million Nairas or about $44,000US per station.

Dialysis in Belize

There are a number of news sources reporting changes in the way dialysis is provided in Belize. This Channel 5 Belize interview gives the best overview.It seems one of the main healthcare providers in Belize Universal Health Services, has been sold. One element of the deal is causing a political debate - the Belize government has agreed to pay UHS $300,000 Belize Dollars (Belize dollar's exchange rate is currently 2 to 1 with the US dollar) a month to UHS largely to support the dialysis program. According to this story from LoveFM the political objection is not whether there should be dialysis rather it is who should provide dialysis UHS or a public institution like the Karl Huesner Memorial Hospital.

The Channel 5 story "on average, they require three sessions a week, at five hundred dollars for each sitting". At the current exchange rate that would be $250 USD. Surprisingly expensive.

In a related story, Evanston Illinois has a sister city relationship with Belize and continues to support the provision of dialysis in Belize City. This 2005 story speaks of the relationship. All this talk of Belize is creating some wanderdesire in me - another country goes on my list of places to visit.

The view from Peru

This video is from Peru presents the work of a father (the nephrologist) and son (the engineer) team who are making inexpensive dialysis machines to increase access to hemodialysis in Peru. The 6+ minute video is from 2001 but was recently posted on YouTube with the embedding feature turned off.

The impact of cutting the cost of the dialysis machine is a bit surprising because I would have thought that the marginal costs of dialysis (disposible suppies, staff time) were a greater barrier to access than the upfront fixed costs (the machine, water treatment).

Portugal adopts weekly bundled rate for hemodialysis

RenalWeb links to a press release from Fresenius Medical Care announcing a new bundled treatment rate for outpatient (satellite) hemodialysis:

The “Comprehensive Price Payment” model will include all necessary dialysis services, the deployment of dialysis-related products, laboratory services and other complementary medical tests and the administration of renal drugs for anemia management, bone management, blood pressure and cardiovascular control as well as vitamins.

The new reimbursement structure will provide for payment of a national reimbursement rate per week per patient. The main characteristic is that the amount of this reimbursement will directly depend on the fulfillment of certain treatment results and quality control parameters with the dialysis services provided. The therapeutic goals include, among others, the adequacy of dialysis, targets for hemoglobin levels, bone metabolism status, water quality as well as outcome measures such as mortality rate and hospitalization days.

The US equivalent would be the current composite treatment rate, plus routinely administered medications and lab tests. This rate will vary depending on meeting goals including hospitalization days. This would be hard to do in the US because of the artificial Part A/Part B accounting wall but it is clearly in the best interest of all concerned to include hospitalizations.

Via Google translation from http://www.fabricadeconteudos.com

Companies of dialysis who work on behalf of the State can pass the charge to the supervision 547.94 euros per patient, per week, or 78.28 euros per patient per day.

$547.94 Euros is equal to $809.664 USD at today's exchange rates. This is a weekly amount so the comparable bundle in the US would be $269.88 USD per treatment at a three day a week frequency. I think this is in the ballpark of what a US bundled Medicare allowed rate would have to be but it is not clear from the translated text or the FMC press release how clinical outliers will be accommodated. For instance there does not appear to be any case mix adjustment so how would the State reimburse for someone with a high BMI, who needs additional dialysis treatments - four treatments a week v. three?

By including routine medications the bundle turns medications into cost centers, expenses to be controlled. Corporations do a great job of controlling expenses; unanswered is how the State will make sure that those who need more medications than average will receive the appropriate care.

The other element to keep in mind when trying to compare reimbursement in Europe with reimbursement in the United States is that the Europeans may well have better prices on Epo. I believe there is a Amgen competitor in Europe - a Roche product. Lower medication costs would mean that the Portuguese bundle is relitively more generous.

The cost of renal dialysis in a UK setting

In an ongoing effort this blog will try to document dialysis prices in the US and around the world. On December 27th an article indicated $307 per dialysis treatments in Australia. Yesterday RenalWeb linked to an abstract from Nephrology Dialysis Transplantation (doi:10.1093/ndt/gfm870 ) presents numbers for dialysis in Great Britain:

Background. The UK National Health Service (NHS) will fund renal services using Payment by Results (PbR), from 2009. Central to the success of PbR will be the creation of tariffs that reflect the true cost of medical services. We have therefore estimated the cost of different dialysis modalities in the Cardiff and Vale NHS Trust and six other hospitals in the UK.

[snip]

Results. The most efficient modalities were automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD),the mean annual costs of which were £21 655 and £15 570, respectively. Hospital-based haemodialysis (HD) cost £35 023 per annum and satellite-unit-based HD cost £32 669. The cost of home-based HD was £20 764 per year (based on data from only one unit). The main cost drivers for PD were the costs of solutions and management of anaemia. For HD they were costs of disposables, nursing, the overheads associated with running the unit and management of anaemia.

Yesterday 1 British pound = 1.98 U.S. dollars. Beyond that it is a bit hard to make a direct comparison - but $63,000 a year for renal services is about 3 times the outlay by Medicare to dialysis units per person, per year for the composite rate and medications.  According to the USRDS Annual Dialysis Report (PDF link) the total per year outlay by Medicare per person on dialysis is about $64,000 on average but that includes everything paid by Medicare: hospitals and skilled nursing facility fees. My read is the British number includes the doctor but not hospitalizations or SNFs. All together it implies about a 50% premium over the US Medicare rate once the 20% not paid by Medicare and the Doctor fees are considered, using a 2 to 1 exchange rate.

About $220 per treatment by my reckoning.

 

Dialysis Financing Outside the US

In an ongoing effort this blog will seek to explain the financing of service for those with stage 5 CKD. The particular focus will be the financing of dialysis in the United States. To provide context any information about the financing of dialysis outside of the US is always appreciated.

Today an article in the Sydney Morning Herald presents the Top 10 list you don't want to be on. The article presents the most expensive medical procedures as reimbursed by Medibank Private which reports to be Australia’s largest and only national private health insurer. The article indicates that renal dialysis was among the five most common same-day procedures listing the cost as $351AU.

That $351AU at today's exchange rates is a bit over $307US. Further research will reveal what is included for $307 - for instance are medications billed separately as in the US? What about doctor's visits? Further research will also try to put the $307 payment in the context of payments from other sources. For instance what is the per treatment reimbursement rate for someone who relies solely on government financed healthcare? How are other elements of stage 5 CKD care reimbursed in Australia?