I published my thoughts on home dialysis and why the practice is not prevalent yesterday. And, while I wrote that post more than a month ago, it was percolating in the queue all along. So, I can’t really say that the government attempted to refute my findings- since their reach (approved 16 October, but published on 16 November) never had the opportunity to review my thoughts. But, I will discuss theirs, today.

The General Accounting Office (GA) paper, Medicare Payment Refinements Could Promote Increased Use of Home Dialysis, chose some interesting guidepoints.  First, the GAO stated that 16% of patients (of the then 104,200)  were on home dialysis in 1988.  And, that percentage decreased to 9% by 2008, but is now around 11% of the 450,600 dialysis census.  [For those of you who are arithmetically challenged, it means that there were 17000 home patients in 1988 and some 48600 currently.]  But, most of those patients undergo peritoneal dialysis (the split was 14% and 2% in 1988, now it’s 9 and 2% between peritoneal and hemo-dialysis).  Moreover, peritoneal dialysis has been hampered due to a shortage of supplies.  That shortage was the result of bulk contamination problems among the larger suppliers’  facilities.

The problem behind this lack of home treatment?  The GAO feels that it is profit incentives.  In-center dialysis is a better paid modality than home dialysis.  (I agree; I said that yesterday, a decade ago, two decades ago.and three decades back.)  And, because of that, in-center capabilities have expanded (the number of potential dialysis stations) by an average of 7.3%, while the number of patients increased at 6.8%.  (It is important to recognize that the census of dialysis patients is expanding at less than 5%.)

Those facts  may be true, but it shows the two big holes (like the size of Jupiter) in the GAO logic.

First, the number of dialysis stations is the number of machines capable of effecting dialysis.  But, almost every single dialysis station treats FOUR persons a day.  With a four hour treatment period, dialysis providers try to maximize their capital investment (the cost of the dialysate delivery device, the chair/bed, the space) and have achieved that.  Which means that the potential for in-center dialysis must have increased by some 30%.  Increases of that magnitude mean that providers are hell-bent to increase the number of in-center patients; when coupled with the fact that physicians are paid for four visits a month for in-center treatment compared to a maximum of one per month for home patients- you don’t have to be a financial wizard to see why there are so few home patients.

The other big hole… In 1988, Home Intensive Care was still in full swing.  (See my discussion of yesterday.)  That meant there was a big push to move as many patients to home treatment as possible.  And, as discussed over the past two days, we know that most patients would prefer to be treated at home, if they had a trained caregiver ensuring the treatment were safe and effective.

So, yes, home treatment makes sense. And, yes, the systems put in place by the government provide financial incentives for in-center treatment.  Which is probably why it’s taken years for the wearable and implantable kidney treatments to reach the market.  (I will be discussing these over the next few days.)  And, why, there’s finally a new home peritoneal device coming [from Israel!] – to ensure that this therapy is as safe and effective as hemodialysis- and can be effected at home.

Share this: