Dialysis from the sharp end of the needle

My Comment to CMS on the Proposed Physician Fee Schedule for MCP Physicians

By Bill Peckham

The deadline to submit comments on CMS's proposed payment policies for the ESRD Monthly Capitation Payment to physicians who are following home dialyzors is NOW. Comments are due by 5PM EDT tomorrow, Tuesday August 24th. What follows are my comments on the proposed rule:

Dr. Donald Berwick
Administrator
Centers for Medicare and Medicaid Services

RE: Codes 90963-90966 under CMS-1503-P: Proposed Rule for Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2011

Dear Administrator Berwick:

Dr. Berwick when you were nominated to head CMS you were quoted saying something that is very wise:

The best health care is the very least health care we need to gain the long, full and joyous lives that we really want. The best hospital bed is empty, not full. The best CT scan is the one we don’t need to take. The best doctor visit is the one we don’t need to have.

Indeed.

Dr. Berwick you gave voice to my experience and something I believe is often true among people who use home dialysis. Missing an appointment can be a sign of health. Of success. The physician fee schedule should allow less than perfect adherence to the best practice of monthly visits. CMS should accommodate, rather than punish, success at home. I urge you to maintain current policy.

I live with stage 5 chronic kidney disease (CKD5), and have been a Medicare beneficiary under the ESRD Entitlement since 1988 when I had a preemptive transplant (I was 24 at the time; 46 today). My underlying condition - FSGS - recurred after just 26 months. Since September 1990 I have treated my kidney disease with hemodialysis (HD). Initially I used conventionally incenter HD but for the last nine years, since September 2001, I have enjoyed using a healthier, more frequent dose of HD in the comfort of my home.

I would like to offer a comment concerning the language, in Section C.1. (p 219-224) of the proposed rule, with its firm requirement for a monthly face-to-face visit as part of codes 90963-90966. I am a HD advocate and as a member, have joined a comment submitted by the Home Hemodialysis Workgroup, these additional comments are less big picture; based on my extensive personal experience.

I believe this no exceptions policy will be unfair to the dwindling number of MCP nephrologists willing to follow home patients.

I agree that it should be routine and is a medical best practice to see my MCP physician every month but a perfect attendance record is hard to achieve and unreasonable to expect. My doctor and I are in this for the long term – it would not have been fair if a 90% attendance record over the last nine years had resulted in my doctor not being paid a dozen times. Under the proposed rule my inability - due to travel, work, or family obligations - to keep an appointment would cause my doctor to pay a price. This is unfair.

Life happens. Particularly for those of us getting a higher dose of dialysis at home, it's good news. We feel well enough that other elements of our lives have higher priorities than seeing our doctor. It is a sign of health and optimal dialysis when our medical needs are no longer our highest priority and we feel well enough to live the lives we were meant to live.

When I feel unwell or have medical issues to resolve I will give seeing my doctor a high priority. Month to month, seeing my doctor is given the priority of the routine: one of life's tasks that needs to be done every month, like paying bills. That's healthy. This rule would require that I give my doctor appointments the highest priority which is inappropriate.

I routinely organize my work schedule to accommodate an appointment (note as a union worker I'm off the clock when I am at the doctor's office) but it is possible, and over a period of years likely, that my obligations as an employee, that my obligations to my employer, will trump the need to keep a routine doctor's appointment. To make my doctor pay a price for this healthy situation would be unfair.

It would be doubly unfair because my doctor is following my care even when I miss the appointment. Every month, day in and day out he is available to me and my provider, he is still reading my labs and coordinating changes in my treatment with my unit. Given this baseline of work that occurs day in and day out it is not unreasonable to continue to support the MCP physicians of healthy, thriving patients when the patients miss their appointments.

CMS should accommodate, rather than punish, success at home. I urge you to maintain current policy

Thank you for your consideration.

Hopefully the final rule will not do anything to limit access to home dialysis. You can submit your comment online.

CMS Proposes Strict Physician Visit Requirement for Home Dialyzors

By Bill Peckham

Right now there is a comment period for a proposed rule having to do with Medicare payments called: Medicare Program: Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B (for CY 2011) (Document ID CMS-2010-0205). This is another giant 671 page proposed rule (PDF link), this one covers Medicare payments to physicians under Part B. 

There doesn't seem to be any submitted comments, even though the 30 day comment period closes August 24th so maybe it's not very controversial. There's a lot in there and I can't say I've reviewed the whole thing but I have looked at one section that was brought to my attention. 

On Pages 62 to 64 there is a section that refers to nephrologists providing care to people on home dialysis:

C. End-Stage Renal Disease Related Services for Home Dialysis 
(CPT Codes 90963, 90964, 90965, and 90966)

1. End-Stage Renal Disease Home Dialysis Monthly Capitation Payment Services
(CPT Codes 90963, 90964, 90965, and 90966) 

In the CY 2004 PFS final rule with comment period (68 FR 63216), we established new Level II HCPCS G-codes for end-stage renal disease (ESRD) monthly capitation payment (MCP) services. For center-based patients, payment for the G-codes varied based on the age of the beneficiary and the number of face-to-face visits furnished each month (for example, 1 visit, 2–3 visits and 4 or more visits). Under the MCP methodology, the lowest payment applied when a physician provided one visit per month; a higher payment was provided for two to three visits per month. To receive the highest payment, a physician would have to provide at least four ESRD-related visits per month. However, payment for home dialysis MCP services only varied by the age of beneficiary. Although we did not initially specify a frequency of required visits for home dialysis MCP services, we stated that we ‘‘expect physicians to provide clinically appropriate care to manage the home dialysis patient’’ (68 FR 63219). 

Effective January 1, 2009, the CPT Editorial Panel created new CPT codes to replace the G-codes for monthly ESRD-related services, and we accepted the new codes for use under the PFS in CY 2009. The CPT codes for monthly ESRD-related services for home dialysis patients include the following, as displayed in Table 32: 90963, 90964, 90965, and 90966. In addition, the clinical vignettes used for the valuation of CPT codes 90963, 90964, 90965, and 90966 include scheduled (and unscheduled) examinations of the ESRD patient. 

Given that we pay for a physician (or practitioner) to evaluate the ESRD patient over the course of an entire month under the MCP, we believe that it is clinically appropriate for the physician (or practitioner) to have at least one in-person, face-to-face encounter with the patient per month. Therefore, we are proposing to require the MCP physician (or practitioner) to furnish at least one in-person patient visit per month for home dialysis MCP services (as described by CPT codes 90963 through 90966). This requirement would be effective for home dialysis MCP services beginning January 1, 2011. We believe this requirement reflects appropriate, high quality medical care for ESRD patients being dialyzed at home and generally would be consistent with the current standards of medical practice. 

2. Daily and Monthly ESRD–Related Services
(CPT Codes 90951 through 90970) 

In CY 2008, the AMA RUC submitted recommendations for valuing the new CY 2009 CPT codes displayed in Table 32 that replaced the MCP HCPCS Gcodes for monthly ESRD-related services. We accepted these codes for use under the PFS.

 

There are four additional CPT codes for ESRD-related services that are reported on a per-day basis. These daily CPT codes are: 90967 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age); 90968 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 2–11 years of age); 90969 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 12–19 years of age); and 90970 (End-stage renal disease (ESRD) related services for dialysis less than a full month of service, per day; for patients 20 years of age and older). 

For the MCP codes displayed in Table 32, the AMA RUC initially recommended 36 minutes of clinical labor time for the pre-service period. They also recommended an additional 6 minutes in the post-period for CPT codes 90960, 90961, 90962, and 90966. For the four codes describing daily services (CPT codes 90967 through 90970), the AMA RUC recommended including 1.2 minutes of clinical labor per day, which is the prorated amount of pre-service clinical labor included in the monthly codes. The AMA RUC also recommended that CPT codes 90952 and 90953 be contractor-priced. 

In the CY 2009 PFS final rule with comment period (73 FR 69898), we asked the AMA RUC to reconsider their recommended PE inputs in the interest of making certain that they accurately reflected the typical direct PE resources required for these services. In addition, we asked the AMA RUC to review the physician times for CPT codes 90960 and 90961 that are used in the calculation of the PE RVUs. We accepted the work values for the new CPT codes for ESRD-related services that were recommended by the AMA RUC. 

Since CY 2009, we have continued to calculate the PE RVUs for the entire series of MCP codes displayed in Table 32 by using the direct PE inputs from the predecessor HCPCS G-codes, except for CPT codes 90952 and 90953 which are contractor-priced. We have also continued to use the physician time associated with the predecessor HCPCS G-codes for CPT codes 90960 and 90961 for purposes of calculating the PE RVUs. 

In CY 2009, the AMA RUC submitted new recommendations for CPT codes 90951 and 90954 through 90970. For each of the MCP codes (CPT code 90951 and CPT codes 90954 through 90966), the AMA RUC recommended an increased pre-service clinical staff time of 60 minutes. For each of the daily dialysis service codes (CPT codes 90967 through 90970), the AMA RUC recommended an increased clinical labor time of two minutes, which is the prorated amount of clinical labor included in the monthly codes. The AMA RUC also recommended an additional 38 minutes of physician time for CPT codes 90960 and 90961. This resulted in a total physician time of 128 minutes and 113 minutes, respectively, for these codes. The AMA RUC continued to recommend that CPT codes 90952 and 90953 be contractorpriced. 

For CY 2011, we are proposing to accept these AMA RUC recommendations as more accurate reflections of the typical direct PE resources required for these services. Therefore, we are proposing to develop the PE RVUs for CPT code 90951 and CPT codes 90954 through 90970 using the direct PE inputs as recommended by the AMA RUC and reflected in the proposed CY 2011 PE database, which is available on the CMS Web site under the supporting data files for the CY 2011 PFS proposed rule at: http:// www.cms.gov/PhysicianFeeSched/. We are also proposing to use the AMA RUCrecommended physician times for CPT codes 90960 and 90961. Consistent with the AMA RUC’s recommendations, we are proposing to continue to contractorprice CPT codes 90952 and 90953.

That's the whole home dialysis related section from the 632 page document but the part I have concerns about, and I think will submit a comment about, is the last paragraph of the first section (my emphasis):

Given that we pay for a physician (or practitioner) to evaluate the ESRD patient over the course of an entire month under the MCP, we believe that it is clinically appropriate for the physician (or practitioner) to have at least one in-person, face-to-face encounter with the patient per month. Therefore, we are proposing to require the MCP physician (or practitioner) to furnish at least one in-person patient visit per month for home dialysis MCP services (as described by CPT codes 90963 through 90966). This requirement would be effective for home dialysis MCP services beginning January 1, 2011. We believe this requirement reflects appropriate, high quality medical care for ESRD patients being dialyzed at home and generally would be consistent with the current standards of medical practice.

I agree with the statement that it is clinically appropriate for the physician to have at least one in-person, face-to-face encounter with the patient per month, however, I think there should be some flexibility built into the system. This rule is proposing that if I don't get into see my doc during the month he doesn't get paid, even while he attends to my care by reviewing labs, is available to the unit and to me whether or not I have gotten in to see him that month. 

My initial reaction is that there should be some patient autonomy, and that the physician must make themselves available for monthly, face to face office visits BUT the patient needs to have some flexibility. I'm worried that this will create a barrier to home dialysis, particularly among patients who can most benefit from dialysis at home, those that can thrive while combining home dialysis with a busy life. I'm worried about adding to the dialyzor burden that comes with home dialysis. A no exceptions policy does not sound optimal.

Thoughts? Comments are due by August 24th.

Nocturnal Hemodialysis: Promising or Proven?

By Peter Laird, MD

I continue to marvel at the dialysis medical literature that in many instances completely ignores the history of dialysis. This is especially true when it comes to the subject of "alternative" dialysis strategies, such as daily dialysis or nocturnal dialysis. It is sad indeed when the pioneers of such life saving modalities are not even remembered. 

Dr. Stanley Shaldon has been overlooked for years as the original investigator of home nocturnal hemodialysis. He not only initiated the first overnight or nocturnal home dialysis treatments, but also published his results extensively in the early 1960's. We've all had access to his results for nearly fifty years!

Dr. Shaldon has reminded readers of his early work through letters to the editor in Kidney International and Blood Purification, Origin of Nocturnal Home Haemodialysis:

Dear Sir,

Precedent claims are rarely correct, thus the statement by Drs Schlapper and Diaz-Buxo in the January issue of Blood and Purification ^[1], that Uldall et al. ^[2] established the first nightly home haemodialysis program in 1993, cannot go unchallenged.  I believe that my group was the first to develop this technique 30 years earlier and that we published extensively in the period of 1963-1968 on this subject ^[3-7]. In addition, visual proof of my claim can be seen in a video of self unattended overnight home haemodialysis in 1968 by any of your readers at http://www.youtube.com/user/stanleyshaldon ^[8].

(Ed: I have updated Dr Shaldon's video link with his YouTube page URL.)

I recently read with interest another article that speaks of the promise of nocturnal dialysis, yet why is it referred to as a promising therapy nearly fifty years after its first use?

Cost Consciousness and Patient Care: Can they be compatible?

By David L. Rosenbloom

Cost effectiveness has been a byword in the business and manufacturing worlds for many decades. And we know it can be a double-edged sword, providing economic benefits while simultaneously causing unintended societal harm.  The same may be true today in our current efforts to reform medical practice in America by lowering costs while doing no harm to patients. The manner in which we educate the next generation of doctors and patients may determine the outcome.

A case in point was recently made by a commentary in the NEJM by Dr. Molly Cooke, professor of medicine at the University of California, San Francisco, and director of the school’s Academy of Medical Educators:

It is old news that the cost of medical care in the United States is unsupportable, yet we seem unable to grapple with the issue effectively. As current ideas for health care reform have percolated through Congress, cost-control mechanisms have generally been recognized as the weak component. Our country is remarkably generative in the development of new diagnostic tests, drugs, and procedures — and remarkably undisciplined in their deployment. New diagnostic and therapeutic procedures and the broadened application of established ones account for two thirds of the growth in health care expenditures. Since the importance of this problem has been recognized for nearly 40 years, one might imagine that medical educators have attempted to incorporate cost consciousness into their teaching, but such efforts have been remarkably few, and curricula remain largely silent on the role of cost in the planning of diagnostic and treatment strategies.

Dr. Cooke points to the length of a hospital stay as another important driver of the costs.

It unfortunately becomes a high priority to prepare patients for early discharge, which often serves as a rationale for preemptively ordering tests and consultations to avoid delaying discharge. Consequently, students and residents have scarce opportunity to practice cost-effective diagnostic strategies and explain their rationale to patients and families.

Dr. Michael Whitcomb, former senior vice president for medical education at the American Association of Medical Colleges, and former editor of the journal Academic Medicine, is quoted in the New York Times as saying:

“Medical schools have done a really terrible job over the years in educating students about the system that they’re going to encounter.”  According to a recent A.A.M.C. survey, about 60 percent of 102 American and Canadian medical schools include some material on health care costs, although the time they devote to it varies widely…  A separate survey of 155 large teaching hospitals, that together sponsor more than two-thirds of accredited residency programs in the U.S., found that only 41% had made sure that all their residencies included material on health care costs.

It’s not that medical students don’t have any idea of the cost of procedures.

The NY Times continues:

“You definitely try to think about it,” said Dr. Ian Warrington, a first-year resident at Beth Israel Deaconess Medical Center in Boston… All of us are aware that a CT scan is significantly more expensive than a chest X-ray, and an M.R.I. is significantly more than a CT scan”.  But resident doctors’ heavy workloads and the need to care efficiently for very sick people make it hard for them to consider the cost of tests and treatments.

I had a recent conversation with Dr. Donald W. Larsen, chief medical officer at the USC University Hospital and the USC Norris Cancer Hospital in Los Angeles. Dr. Larsen is clearly aware of this time/benefit constraint in medical education:

“Certainly teaching medical students, residents, and attending physicians these skills are a real challenge these days given the volume of skills they must acquire in a limited period of time in a rapidly changing environment. This is compounded by regulatory restrictions on work hours and tight control by the Accreditation Council for Graduate Medical Education (ACGME) on residency training programs that don’t leave much room for creativity.

Other important topics include professionalism, ethics, quality, patient safety, and risk management. Somehow they also have to learn how to manage their medical practice, as well as prepare and pass their medical boards.

I think electronic medical records will be very helpful decision making tools in the future, not only with regard to benchmarking and best practices around clinical decisions, but also may help us make cost effective decisions. Though we have to be cautious that we don’t go too far and compromise care for the sake of saving money.

The crux of the dilemma goes to the very nature of how we as a society view our physicians and how they view their role in that society.  Dr. Cooke points out that physicians see themselves, and teach students accordingly, that doctors are advocates for each patient, “obligated to eschew all considerations other than benefit to that patient and his or her preferences.”

However, she warns that:

... we must abandon the myth of the physician as single-minded advocate for any amount of benefit for every patient. We make all kinds of choices in caring for patients; some involve denying care that patients perceive as — and that might actually be — beneficial. Given that we make value-based decisions about the deployment of other finite resources, such as our time and the use of beds in the intensive care unit, why not about costly treatments?

So where do we go from here? 

For awhile now, many in the medical field, like Dr. Donald Berwick of IHI, have been advocating that patient centered care must involve the patient in the process of diagnosing and strategizing treatment. The expanded access to detailed medical information, much of it on the internet, has transformed many patients from dependent and acquiescent to activated, informed, and sometimes insistent consumers of health care services.  And in the best instances, doctors recognize patients and caregivers who are educable, and make them an integral part of the healthcare team.

I know in my own long history with kidney disease, I have become less dependent on my doctors to make those decisions.  I am the ultimate consumer of those healthcare services and I seek to know the cost-benefit ratio, particularly if a procedure or test seems unwarranted or will do more harm than good. It is often the small things we do that alter our lives for the better. Grand plans for reform rarely work as we hope. Often the simplest changes make the biggest difference. And so it is with healthcare. Medical school education is only one part of the equation. Patient education is another. Until we do something about bring the two into the equation, costs will continue to escalate.

Drug And Device Companies Will Now Have To Report Payments

By Bill Peckham

Merrill Goozner has a post that highlights a small piece of the health insurance reform legislation that will mean:

Drug and device companies will soon have to report payments to physicians in a national database, thanks to a little noted section of the health care reform bill called the Physician Payments Sunshine Act.

Too bad it won't be able to publish retrospective data.

Reading the text of S. 301*, the Physician Payments Sunshine Act of 2009 it applies to:

‘(1) APPLICABLE GROUP PURCHASING ORGANIZATION- The term ‘applicable group purchasing organization’ means a group purchasing organization (as defined by the Secretary) that purchases, arranges for, or negotiates the purchase of a covered drug, device, biological, or medical supply.

I'm not sure if that would include dialysis providers. It seems like it would, they negotiate the purchase of covered drugs, but it is the Secretary of DHHS's call. There will probably be a letter writing campaign any day now.

* it looks to me this went into the health insurance reform bill in it's entirety as Section 6002, the language as signed by the President is here but be warned it is a large file, viewing options at link.

In the Dialysis Unit, Who is in Charge?

By Peter Laird, MD

Renal Fellow Network (RFN) is a great source of up to date information on renal issues at the level of a renal fellow.  In such, I have learned much since the late Nathan Hellman, MD started his blog.  However, there have been a couple of occasions where I believe that RFN needed to go deeper, especially on home dialysis issues. 

The Renal Fellow Network is now a joint venture with the fellows and attending physicians at Mass General Hospital which is considered one of the leaders of quality medical care in America.  In a recent post on the RFN, The Nephrologist as Team Leader, Dr. David Steele spoke about the new leadership role that a nephrologist is required to perform by the new CMS conditions of coverage:

In order to prepare for the eventuality of one of these surveys, I received a memo this week with a reminder of my responsibilities as the Hemodialysis Unit Medical Director:

"By virtue of the Medical Director's leadership of the facility's Governing Body, his/her responsibilities extend beyond the primary focus on improving quality of care delivered in the facility and extends to the general management and operations of the facility. As such, all condition level citations are linked to /and are the responsibility of the Medical Director according to CMS".

Dr Steele goes on to explain some of the newly mandated regulatory requirements, but in doing so, he freely points to the fact that the mentality of nephrology practice is that the dialysis unit runs itself with its nurses, techs and administrators. 

What does this all mean? At first glance these citations/conditions may seem to be out of the realm of the practicing clinician whose focus is elsewhere, but in actuality they are integral to the proper care of our patients and the infection control lapses certainly should raise a high level of concern. We all have a natural disinclination to being surveyed but maybe these surveys are useful if they encourage us to put into place processes which ensure these lapses do not occur and if we develop systems of self assessment and quality improvement within our domain of responsibility.

Which brings me to the point of this blog. It's all about the team, and as Physicians we assume a natural leadership role when we deliver care to our patients and some of us are eventually appointed to leadership positions as our career advances. The usual dialysis unit personnel resources include Nurses, Patient Care Technologists, Dieticians, Social Workers and Administrative Staff. CMS is telling us we are responsible for the performance of this team on multiple levels. Traditionally our training has not focused much attention on preparing us for such leadership. (Emphasis Added)

When I was a practicing physician in the Army, we had many extra duties serving as medical director of different services in our hospital.  In such, it was an excellent arena to develop leadership skills which were not only a requirement of being a physician in the hospital but it was also a requirement of an officer in the Army as well.  The titles that I held clearly indicated who had the final authority and responsibility for that department: "Medical Director." 

Yet somehow, the role of final authority as medical director of dialysis units has escaped this profession in many ways. This engenders several questions that need answers: Do American nephrologists traditionally focus on running a dialysis unit as a part of their nephrology training?  Do American nephrologists get directed training as a team leader? According to this post on Renal Fellow Network, it appears that the answer is that this is a new role brought upon nephrology by CMS regulations. If CMS must tell the nephrologist to take charge, then who has been running the show up until now?

Hats off to Scribner

The Northwest Kidney Centers, with this full page ad in the Seattle Times (on page A5 today) is celebrating Scrib's achievement and honoring the physician who's insights and understanding of dialysis echoed through all the Annual Dialysis Conference sessions that I attended. His most noteworthy achievement happened 50 years ago, tomorrow.

March 9th, 1960 was a Wednesday, the second Wednesday of the month. On that day Scribner began what today we realize was the first chronic hemodialysis treatment. That treatment lasted over 70 hours. Clyde Shields dialyzed the entire day on what would have been World Kidney Day in 1960, the second Thursday of March. The whole day. That was the first World Kidney Day.

The first World Kidney Day was March 10, 1960. The day Clyde Shields dialyzed all day. The day, I imagine, Scribner first understood that ongoing dialysis might really work.

Professor John Agar receives the Medal of the Order of Australia

 By Bill Peckham

Congratulations to friend of DSEN Professor John Agar MD who has been presented with Australia's Medal of the Order of Australia "for his service to renal medicine and the Geelong community". The article goes on to note the path breaking nature of Dr. Agar's work and the inspiration that he provides.

Unstated is the inspiration via internet interaction that Dr. Agar provides directly to dialyzors all over the world. Inspiration and motivating facts, to dialyzors and our loved ones to seek out healthier forms of renal replacement. Dr. Agar's website Nocturnal Home Haemodialysis has motivated many people in the US and all over the world to dialyze more - both more frequently and for more time. 

The two articles (part 1; part 2) by Dr. Agar on Home Dialysis Central concerning fluid balance and dialysis are must reading for those of us with CKD5. Dr. Agar's presentation on needle placement convinced me to change the orientation of my arterial needle.

Dr. Agar is one of the few luminaries of hemodialysis that is willing to directly and publicly interact with dialyzors (on HDC and in comments to DSEN). He deserves a medal for that alone by my reckoning, but he does so much more. Thank you Australia for recognizing a great doctor; a great man.

Happy Birthday Dr. Eschbach

By Bill Peckham

In the early '60s the advent of chronic hemodialysis brought a host of other problems. In the Nephrology Oral History project, during the Sherrard interview, Dr. Sherrard talks about the early problems with metastatic calcification and Scribner's observation that his patients were "turning to stone". The impact of long term hemodialysis on phosphate levels was soon addressed through the use of binders but other problems remained. One of these problems was the severe anemia experienced by people using maintenance dialysis. As Sherrard says, Scribner assigned Dr. Joseph Eschbach the job of solving this anemia problem.

Reading his New York Times obituary or his Wikipedia entry provides the outlines of the Eschbach story, and this 1987 NYT article announcing the results of the first human trials of Epo (Erythropoietin) is a high water mark of his research career but the Sherrard interview provides a nice, new account of how Eschbach approached solving the anemia problem:

he started out early in the game dialyzing sheep. He put sheep into renal failure and then he made other sheep anemic, collected their urine, isolated some factor from the urine, he didn't know what it was, and gave it to his sheep that were on dialysis, and it corrected their anemia. That was sort of the, I think, the key experiment in EPO.

This key experiment eventually led to human trials at the Northwest Kidney Centers and to the approval of Epo for the treatment of anemia. What makes Eschbach's research more remarkable is that he did it while in private practice. During the day he took care of a full slate of patients and then at night he figured out how to vastly improve the lives of these same people. Dr. Eschbach was a nephrologist like no other, he was beloved by his patients because he did research that forever changed their lives.

I thought of Dr. Eschbach when My Where do nephrologists come from post generated a few emails. One nephrologist's email talked about the non financial rewards that come from being a nephrologist. He wrote that it was later during in his training when he came:

to appreciate how unique it is to have a cohort of patients whom I saw more frequently than any of my colleagues in other specialties. It is difficult for me to think of a patient-physician relationship that is more like a community than the nephrologist-dialysis patient relationship, since we see the patients so often. I treasure my patients on dialysis and have come to know many of them well.

This is true from the sharp end of the needle as well. I've come to understand that the relationships we form with our nephrologists are unique and very personal. This close partnership gives context to why Dr. Eschbach was beloved and revered by his patients, Dr. Eschbach worked nights for people he knew, he did it for his patients. I don't think researchers usually have particular people in mind when they're doing experiements.

When Dr. Eschbach retired from private practice in 1998 he didn't have a conventional retirement party. He threw a party for his patients. He wanted to honor his patients for what they had given to him – Dr. Eschbach always kept the focus on the patients.

Happy Birthday Dr. Eschbach I don't think there will ever be another one like you.

Happy Birthday Dr. Scribner

By Bill Peckham

Today would have been Dr. Scribner's 88th birthday if we hadn't lost him that gray Thursday in 2003. The New York Times' two page obituary contains a couple Scribner stories. I've heard a number of Scribner stories over the years. As the Times piece notes he famously got into some legal trouble over wine (Washington State still restricts the sale of liquor in unique and unexpected ways; in the 60's the laws were stricter). The Scribner wine incident hullabaloo is rightly credited with giving us access to a better selection of wines in the state. It's a minor achievement in the scheme of things but it should be remembered. Of more consequence is Scribner dreaming up a way to sustain the lives of people with CKD. In the Nephrology Oral History Project's Sherrard interview, Sherrard gives one version of the Scribner shunt story, that it was in response to a dream, the NYT gives another version, I've heard elements of both; it would have been interesting to hear Blagg tell it. The Nephrology Oral History Project interviews are full of Scribner references, the industry is still debating the Scribner approach to dialysis and patient care.

I have my own Scribner story. (It is times like this that I wish I kept a journal, I don't remember the date specifically but I think it would have been early 2001, before I started dialyzing at home, before Scribner published his last paper (on the HemoDialysis Product (pdf link)) and before he got the Lasker.)

Scribner invited me to his houseboat home to discuss patient travel, this was in the period of my regular trips abroad (1995-2006) and he was writing a book that was going to include a bit about travel while on dialysis. I was excited to visit with Scribner. At the time I knew less about the history of dialysis than I do today but I had met Scribner several times through the NKC board and anyone Googling dialysis to find the available papers on optimal dialysis would know and admire his work. I was excited to talk dialysis with him but I remember also being excited to visit a houseboat, which are iconic Seattle homes (in over 20 years of Seattle living, the only one I've been in is Scribner's).

Here's how I remember it. I found the address and walked down the dock where I found Mrs. Scribner watering plants. I introduced myself and was invited on board to find Dr. Scribner sitting happily in the front room, surrounded by papers. It was a large room with stuff everywhere to look at, on the walls and shelves, oars and photos, many photos - and hanging from the ceiling a radio controlled single engine plane. I had flown a Cessna 150s, I remember thinking it looked like a Cessna 172. We shook hands but before I had time to ask about the plane he asked me what my blood pressure was ... ahh, umm ... and if he could take it, which he proceeded to do.

I felt like I was back in school taking a pop quiz and I hadn't studied. I knew that Scribner considered blood pressure control central to successfully treating CKD with dialysis and I knew my BP could bounce around seemingly at random, from moment to moment. And I knew I wasn't on BP meds which Scribner ascertained while donning his stethoscope. Thankfully, I passed the quiz. On that day I had a perfectly acceptable 120/80 something. He asked how I controlled my BP sans medication. I, being a brown noser, pointed to salt control.

I'm not sure what would have happened if my blood pressure had been high that day, I have a feeling my nephrologist, a former fellow of Dr. Scribner's, would have gotten a phone call. Seattle is Scribner country. Here we believe in the importance of controlling blood pressure through fluid control. Something that Scribner believed to be inherent to optimal dialysis.

Happy Birthday Doctor Scribner, you were right.

Where do nephrologists come from?

By Bill Peckham

I received an email last weekend which I took to ask "Why are nephrologists less well paid than other medical specialties?" Not being a nephrologist I'm not really qualified to answer but this being a blog I can say what I know. My correspondent stated that there is a significant pay difference between nephrologists and other specialties. As he said money isn't everything but if you can help people and be well paid or help people and be really well paid, why not be really well paid? I'm not too sure there is much of a general disparity between nephrology and other specialties such as hospitalist and nephrologists are better paid than some specialties. If the bureau of Labor and Statistics tracked nephrologist separately they'd be a top paying healthcare occupation.

He wrote after reading my posts regarding dialysis reimbursement and/or about the low margin business of providing dialysis. I don't think dialysis reimbursement impacts a nephrologist's personal reimbursement. There is a separate fee schedule that Medicare pays to a nephrologist that is based on how often the doc sees the patient in a month. That said if you're taking care of a lot of people on dialysis their predominate insurance will be Medicare, about 75% of the census, with about 10% Medicaid. Generally Medicare and Medicaid pay less than employer group health plans so caring for a lot of people on dialysis creates a unadvantageous payer mix.

The other thing is that being a nephrologist is not just taking care of people on dialysis. A nephrologist's practice would be comprised of a variety of patients, nephrology is a large field. Attending Renal Week (the American Society of Nephrology meeting) last year drove home to me that dialysis is a small part of the broad medical specialty of nephrology. I've started tracking Renal Fellows Network and Precious Bodily Fluids for my periodic blog reports and they both cover a lot of ground without spending much time on dialysis. 

Precious Bodily Fluids recently posted Nephrology Fellowship: by the numbers which provided a number of metrics around Nephrology Fellows and the number of people taking the Nephrology Certification exam each year through the American Board of Internal Medicine. Something I haven't seen either Renal Fellows Network or Precious Bodily Fluids cover is how much does a nephrologist earn? What's the perception from the inside of the economics and life style that goes with being a nephrologist? What guidance do practicing docs have for someone considering nephrology? 

Looking at the number of people who have CKD it is clear that we need all the nephrologists we can get.