Kidney Caucus Letter Repayment Basis
Can we shake up the way dialysis is done in the U.S. by changing the way it is paid for? Mel Hodge has kindly shared this letter that he sent to Congressman Jim McDermott in the hopes that you, too, will contact your representatives and advocate for optimal dialysis! He’s made it easy for you with this template—and you can look up your elected representatives here.
21238 Sarahills Drive
Saratoga, California 95070
Voice/Fax (408) 741-5047
May 26, 2016
Jim McDermott, Kidney Caucus Co-Chairman
1035 – Longworth House Office Building
Washington, DC 20515
Dear Dr. McDermott,
I write to offer a proposal directly responsive to the last of the nine stated goals of the Kidney Caucus – Evaluate alternative payment policies to improve care for millions of Americans with kidney disease.
I propose: (1) Replace the current bundled payment per treatment for hemodialysis patients with a bundled payment per treatment hour and (2) Annually adjust (reduce) the hourly treatment payment amount to offset the increase in global dialysis cost that might otherwise result from this change in payment base.
This proposal, first suggested to me by Dori Schatell, would align the interests of ESRD patients and the dialysis industry, interests that are now in direct conflict… and the patients are the losers.
John Agar, an Australian nephrologist and articulate advocate for dialysis patients on the World stage, summarized the importance of dialysis time:
- There are no shortcuts in dialysis
- Symptomatic dialysis is ONLY encountered when treatment time is too short
- Inadequate treatment time is invariably the core threat to most dialysis patients
Dr. Agar added:
“The slower, the more gentle, the longer and the more frequent your dialysis treatment is ... the better you will feel, the less symptomatic your treatment will be, the more stable you will find your blood pressure will become, the less will be your pill burden, the more healthy you will feel, the longer you will live, and as you move towards an acceptance of your (sadly essential) treatment, the more at peace with both the dialysis process and yourself you will become.”
Contrast the dialysis patients’ interests with those of dialysis providers:
- With fixed payment per treatment, profit is maximized by maximizing patient throughput which results from minimizing treatment times
- Increasing treatments beyond three/week upsets M-W-F vs. Tu-Th-Sat balance, creating idle capacity and thus reducing throughput
- Moving patients to home treatment, while eliminating the first two barriers (and reducing direct costs), is discouraged by perceived inadequate Medicare hemodialysis training reimbursement and the need to avoid increasing already existing excess in-center dialysis capacity (as documented in the recent GAO report).
My proposal would resolve this conflict between patients and providers.
- Providers would now be incentivized to maximize patient treatment times.
- Provider excess capacity (and the associated perverse incentives) would be productively eliminated.
- Provider incentive to provide more billable patient treatment hours would hasten transition from in-center to home dialysis (and its inherently lower capital and operating costs).
- The incentive is likely to be strong enough to justify subsidizing the home dialysis training deficiency rather than incur the cost of increasing in-center capacity.
- Annual reimbursement adjustment would only magnify these provider incentives.
I believe this proposal outlines a path to transform ‘adequate dialysis’ –- dialysis that serves little purpose beyond keeping patients alive –- into optimum dialysis –- dialysis that results in feeling well, living longer and a chance to leave dependency and once again lead productive lives.
This proposal will also destroy the present dialysis industry business model and require creation of a new one. Initial reflexive opposition might be expected. Strategies that have worked for decades will have to be replaced by new strategies. But as someone who spent most of his working life founding and leading businesses here in Silicon Valley, I assure you that very smart people run the dialysis companies. You will be surprised how creatively and rapidly they will respond once instinctive opposition is replaced by the challenge to reorient their businesses and exploit the competitive opportunity that change always presents to a business.
I no longer have a stake in this fight. My wife, Jane, died at age 85 in September 2014 after more than 12 years of daily nocturnal hemodialysis, a time during which we shared the gigantic nuisance of dialysis at home, but also a time when she felt well, engaged in normal activities and was limited only by other health issues, one of which resulted in her death. At age 86, my only incentive is to relieve my anger, knowing that half a million very sick people don’t have the care Jane had. More than 20% will be dead in their first year of dialysis and half will be dead in less than four years. One out of five of these deaths will be suicides, deliberate withdrawals from dialysis… and nobody cares enough about these deaths to get NFL football players to wear colored socks and gloves on a given Sunday.
Most serious health issues require us to look to medical science. But dialysis is a health system issue. Only Congress holds the solution I have outlined in their hands. I will be grateful for your thoughtful consideration of this proposal.