Medicare’s high cost end stage renal disease patients

Anyone who thinks America has the best health care system in the world ought to take a look at its miserable record on caring for end stage renal disease patients on dialysis.

About one of every five people who go on dialysis dies in the first year here, compared to less than one in seven in Europe and one in sixteen in Japan. Even after adjusting for age, gender, race and 25 co-morbid conditions (the primary causes of kidney failure are poorly treated diabetes and hypertension), the U.S. mortality rate is one-third higher than Europe and nearly four times the Japanese rate, according to a recent analysis. The average life expectancy of Americans on dialysis is about three years.

Taxpayers pay exorbitant sums for these poor outcomes. The Centers for Medicare and Medicaid Services, which cover treatment for end-stage renal disease, even for the non-elderly, spent $24 billion on dialysis in 2007. Just one percent of Medicare beneficiaries who are on dialysis generated a whopping 5.6 percent of the agency’s bills. Moreover, the obesity epidemic guarantees that those numbers will only shoot up in the years ahead since more than 100,000 people are now entering dialysis ever year – more than the number that die from the one of the conditions that leads to kidney failure.

You would think that the nephrology community would be up in arms over these alarming statistics, or at least looking for a less expensive and hopefully more effective way of caring for these predominantly poor patients. Yet two new studies in the Archives of Internal Medicine reveal just the opposite. A small and declining number of patients receive peritoneal dialysis, an at-home alternative that generates comparable outcomes with greater patient satisfaction at 19 percent lower cost – $53,446 per year for patients on peritoneal dialysis versus $73,008 on in-clinic hemodialysis in 2007, according to one study.

And the other study showed nephrologists do a poor job of informing patients about this three-decade-old alternative. Peritoneal dialysis (PD) has declined from 14.4 percent of the dialysis population in 1995 to 7.1 percent in 2007. In an accompanying editorial, Dr. Kirsten Johansen, a nephrologist at the University of California at San Francisco, wrote:

The data available so far have led experts to conclude that low PD utilization is, at least in part, the fault of nephrologists, who are not discussing PD options with patients, possibly owing to concern about higher mortality (which the latest study shows is incorrect), inadequate training of nephrologists, nephrologists’ bias against PD, pressures to fill HD (hemodialysis) chairs, late referral to nephrologists, and other reasons.

I was intrigued by the “pressures to fill HD chairs” statement in the editorial, so I sent Dr. Johansen an email late last night. Were there any financial incentives that encouraged nephrologists associated with the for-profit dialysis clinics that discouraged use of this less costly alternative?

“Typically the dialysis clinic owners will hire a nephrologist to be medical director,” she wrote back. “This reimbursement isn’t tied to bringing in patients but the nephrologist then has an interest in the success of the clinic, and since they have to see their patients in that unit once a week to receive maximum Medicare reimbursement, it’s better to have several patients there on each shift to increase efficiency. I don’t think there is any solid data to say that this has an impact on how well nephrologists inform patients, but many have speculated about this.”

Last year, CMS added a new benefit for end-stage renal disease patients. The agency will reimburse physicians for up to six counseling sessions just before their patients are about to go on dialysis. The agency wants more people to consider the PD alternative, which involves removal and re-infusion of an abdominal cavity fluid about four times a day and can be self-administered at home. That doesn’t sound like fun, but patients consistently rank it as a  better experience than having to go to a distant clinic three times a week for four- to six-hour sessions where they are hooked up to a machine.

If half the new dialysis patients in the U.S. chose PD over HD, Medicare could save more than $5 billion a year. The additional counseling needed to get to those rates might even jump-start the long overdue conversation about why so many people do so poorly once they’re on dialysis; why so many have failing kidneys in the first place; and what preventive measures can be taken to deal with this burgeoning public health fiasco.

Merrill Goozner is a freelance writer, independent researcher and consultant who blogs at Gooznews on Health.

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  • Winslow Murdoch

    Statistics in mortality may be unreliable.
    Most rational healthcare deliverynsystems have inclusion criteria in which patients are candidates for dialysis. My limited experience as a primary care doctor is that the vast majority of end stage renal patients regardless of premorbid functional status are told that they need dialysis almost as a forgone conclusion.
    This often starts when a patient with chronic kidney disease has an acute illness. These conversations often occur during times of extreme emotional stress for the patient, and are had by the on call nephrologist or Hospitalist with whom the
    patient has no relationship.
    The option of starting dialysis is often broached by the nephrologist with the statement that they were consulted because “you need dialysis.”
    The patient is then gets a lengthy discussion on the risk benefit and side effects of therapy, and the alternative is that you will die. Not much time is spent discussing the logistics, quality of life prior to or after starting dialysis etc.
    Often, since the patient has an acute illness and metabolic crisis, a central catheter is placed and hemodialysis is the initial inpatient therapy started and discussed.
    Most of my elderly patients with later stage renal disease have been carefully monitored and preventive care provided for years.
    As a family doc, I have discussed the if and or when they need treatment. Most frail elderly and those with multiple advanced chronic diseases prefer no treatment. If they are suddenly ill and hospitalized and offered bridge dialysis for acute decompensation and metabolic crisis, to later defer long term therapy, and die with dignity, does that count as a mortality statistic?
    In many countries, this would never be offered in the first
    place.
    So,
    We are getting much better at treating the most common diseases that lead to kidney disease.

    We need to start conversations with our kidney diseased patients early and spend time discussing no treatment as well as dialysis options. Currently insurers and Medicare/aid pay little for these often recurring and often lengthy conversations.

    We also need to compare apples to apples with statistical analysis.
    Winslow

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