First my disclaimer and request. These are my opinions/feelings only, and have nothing to do with the company I'm employed by. Second, to our moderator(s), before you move or remove this please at least take the time to read and consider this ground floor opinion.
Let me start by saying I realize this thread will get moved, or removed, but I'm posting it here to get some feedback from folks like Chuck W, Pato and other people I know and respect. Not sure how many of you pay any attention to the business side of what we do, but I try to, since I've pondered over finishing school to be an Administrator. I absolutely love many of the articles that get posted on the Renalweb home page, as many open your eyes to things outside of our world. Renalweb is a resource I've used for 10+ years, and will continue to until I leave this field. One thing I just can't agree with is so many of these articles citing how dialysis providers are "pushing" patients to in-center dialysis, based it on it being so much more profitable. For example see today's "Dialysis Choice or Dollars" article. In-center dialysis being more profitable...on what planet is that taking place? The bundle has essentially castrated many providers, especially those of us who don't have multiple revenue streams, or who's business practices don't play very close to the edge. You can read between the lines on who I might be mentioning.
Now I'm smart enough to realize that private pay insurance still provides a nice chunk of change to providers, but by percentage, how many patients spend a lifetime on private pay? We can get into the need for more incentive to keep patients employed, which I totally agree with, but that will be a massive undertaking by the entire industry, not just one provider. The bias of some of these articles is laughable, and quite frankly, insulting to those people who are more worried about patients (in our current industry structure) than shareholders or profits in general. We all want to make money in any company, but lets stop with making it sound like we hog tie patients, and drop them into our clinics just so money can rain from the heavens.
I would love to see more patients and providers take an active role in their care and explore options like home hemo, PD (which actually are profitable) and modalities we don't even provide such as hemodiafiltration. Some of us in these op-eds need to face the facts that many patients just know they need dialysis or they'll die...period. Faced with that alternative they side with what their MD's recommend, and what's most readily available, which is in-center dialysis. Faced with a life-threatening condition I'd hope that I would take an active role in my care, but fortunately for many of us we're not in that position as of yet.
This is just the opinion of one guy who is known to few, and who's thoughts matter to even fewer. It's easy to point fingers when you're high upon the throne, but when you get down on the floor you'll often find it dirty, and difficult to clean quickly.
cane, I do not see a push for in-center in my region. there is more a push for pt to go to home hemo and PD. when I asked about which is more profitable I was told home hemo and PD make more then in center for a per pt cost. I'm just a tiny drop in the bubble I realize.
I'm not referring to any one region, or any one provider for that matter. More to many of the articles, and opinions posted about them, on this forum.
What are the stats for average patient outcomes at home vs. incenter. Do patients live longer when treated at home? The home assistant should be given a small payment per treatment, like 25 bucks to help out.
There’s the conundrum. Alternatives to standard centre based HD (home hemo, hemodiafiltration etc.) have been shown to have better outcomes for patients. Look at the models in places such as Europe, Canada and Australia.
Ok, it would not suit everyone but people should be given the option. How many with a family (or a job) would benefit from nocturnal home based hemo if given the chance? Probably quite a few.
The main perceived drawback is cost. Although cheaper than unit based hemo, and medium to longer term outcomes are better, the initial set up cost is quite high. I also think that the major providers take the ‘one size fits all’ and ‘stack ’em high’ approach as this seems to offer best efficiencies and lowest cost (highest profits).
My thoughts on this is all over the place so this is going to sound very fragmented....
When I first started in dialysis, we had a single 16 station clinic with 2 of the stations dedicated to home hemo training. The patients ran for 7 hours 2X/week and were expected to gain no more than 2 kg between treatments. Remarkably, probably 90% accomplished this. Now we're delighted if weight gains are less than 4 kg every other day!
We had 25 home patients and employed one of the patients husband 3 days a week to deliver supplies.
In 1981, we opened a 15 station, self care/staff assisted facility that took over the home hemo and maintained a waiting list for both clinic and home hemo slots. One of the home patients retro-fitted his RV so he could travel the country with his water system and machine.
Fast forward 10 years or so....As dialysis clinics opened on every street corner and dialysis became more "convenient", patient attitudes seemed to change to that they desired to be taken care of rather than taking responsibility for themselves. Our home hemo program dwindled to 0 and the self care clinic converted to full care.
We maintain roughly 30 +/- PD patients. The longer term PD patients tend to be the more motivated ones who want to take control of and be responsible for their own lives. These same patients would probably do exceptionally well on hemo also. More than a few of the patients that have returned to hemo have stated that they got tired of taking care of themselves.
Profit used to result in innovation and new technologies. What advancements has Fresenius made over the last 30 years? Sure they have changed the user interface on their machines but, the workings are not substantially different from their old "E" machines.
Fresenius used to be the champions of reuse. Once they were able to produce dialyzers cheap enough, reuse was to be avoided like the plague. They even took full page ads out in the trade magazines that showed a picture of a crumbled up tissue with a caption that said "Some things shouldn't be reused"
IMHO, dialysis is this country's failed attempt at socialized medicine. It wouldn't have failed if large, publicly traded companies were not allowed to participate in the care of our patients.
DISCLAIMER : My opinions and views are mine and may not be the same as my employer.
I don't think that this change to not being responsible for ones self is is limited to dialysis rather its our whole culture and political correctness gone wild..
Why do it yourself when someone else can do it?
Give everyone the same trophy, there are no winners or losers.
Don't keep score or someones feelings will get hurt.
DISCLAIMER : My opinions and views are mine and may not be the same as my employer.
I think Cane is just baiting the moderator.
To understand what’s wrong with dialysis, try to see a bigger picture and ask bigger (and better) questions.
First of all, are you aware that dialysis patients with private insurance automatically convert to Medicare reimbursement after 33 months?
Are you aware that these first 33 months are the main source of profits?
Are the major profit motives aligned with the patients’ best interests?
Why hasn't dialysis U.S. patient survival dramatically improved like other fields of medicine?
Why has U.S. dialysis care been stagnant and why has it fallen behind other developed countries in dialysis technology and outcomes?
Why would almost no dialysis professionals accept in-center dialysis treatments for themselves, but approximately 90% of their patients end up there?
Why did U.S. nephrologists ignore dialysis patient employment and rehabilitation for decades?
What treatment modality requires the least investment per patient?
Why did U.S. nephrologists embrace a ‘race to the bottom’ in terms of treatment standards, treatment duration, and psychosocial support services for several decades?
Why has the largest non-profit provider had far better mortality and hospitalization rates than the largest for-profit providers for more than a decade?
Why are nephrologists allowed to refer Medicare patients to dialysis facilities in which they have ownership stakes?
What has a greater influence in this field of U.S. medicine: pursuit of medical excellence or pursuit of profit motive?
Are there any effective patient advocates in this field of medicine? Isn’t that the physicians’ role?
Who is making the profits from U.S. dialysis care? Who are the leaders in U.S. dialysis care? Who drives policy/reimbursement change?
Whom should the patients blame for the state of U.S. dialysis care? Or should they be blamed?
Would you want to be a sick, vulnerable patient unexpectedly entering this system of care?
I believe that understanding the status of dialysis care in the United States is only possible if you follow Deep Throat's (Mark Felt's) admonition: FOLLOW THE MONEY.
There is a Pulitzer Prize waiting for the first established journalist willing to pursue this. The last major inquiry by the established press into dialysis care was done by Robin Fields from ProPublica in 2010. She failed to "follow the money" and instead largely accepted the rationalizations of leading nephrologists and the for-profit dialysis providers.
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