Kidney Caucus Letter Repayment Basis

This blog post was made by Mel Hodge on May 26, 2016.
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.

Melville Hodge
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.

Sincerely,

Comments

  • Nieltje Gedney

    May 30, 2016 2:32 PM

    Great letter Mel, may we reprint this on the HDU page?
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    • Mary

      May 31, 2016 10:37 PM

      By all means, post it everywhere. I hope the caregivers, family, friends, and community members that are aware of the patient on dialysis take a day to go with the patient to witness their experience.
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    • Mel Hodge

      May 31, 2016 10:32 PM

      Thank you, Nieltje. I would be delighted if you would reprint it at HDU. The only chance this proposal has of being adopted is if enough patients rise up and say, "I'm mad as hell and I'm not going to take it any more..." As a longtime HDU member before my wife died, I know that there is no better group of patients who know what I am talking about in my letter and I'm sure share my wish that all patients had the benefits that there for the taking from longer, more frequent treatments at home.
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  • Mary Conner

    May 30, 2016 12:54 PM

    The most traumatic part of hemodialysis is the attitude of the providers. Questions were not answered or entertained, no attention is given to a change in weight, or adverse effects of medication. The nurse tell the patient to"tell that to the them". The attitude of the provider is such that the patient feel as if they were money makers for that center and if that patient died, there would be 10 more waiting for that chair. If the patient complained about being ill or not feeling well, they were ignored. Most patients are pulled too hard( flow too high) or too much is taken off, which cause the blood pressure to drop and causes nausea. This is treated with large doses of saline which causes the stress on the heart because saline causes the arteries to expand and send more blood to the heart than normal. The heart struggles to process the extra flow of blood. After months of this process, a heart attack usually or stroke takes place.
    A closer look at the treatment process would be a heaven sent. Mary
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    • amanda

      Jun 04, 2016 10:22 AM

      You hit the nail on the head right there Mary... I remember being at first appalled, then distraught, then very very scared, from my own experiences in the dialysis unit.
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  • David Rosenbloom

    May 27, 2016 8:04 PM

    A very interesting and most humane proposal, Mel, but it unfortunately it ignores the biggest barrier to any significant change in the way we provide dialysis in the U.S. - the profit motive. LDOs are for-profit corporations built on the business model of providing a standardized treatment - one-size-fits-all. They make money by filling more chairs with more people over a limited time each day. They are not interested in earning less per hour. Their whole economic model is based on throughput, not patient health. And even with this model, their profits are being squeezed by Medicare's bundled payment plan. Add to this, Congress's reluctance to allocate additional funds into the dialysis system, regardless of modality, change is very unlikely. And if your wonderfully idealistic plan was adopted, I think the LDOs would find a new formula that would still not provide adequate dialysis. The only real solution is to remove profit from the equation entirely, as most advance nations have done concerning healthcare. Then time on dialysis becomes a strictly medical, quality-of-life issue.

    My hope is that technological advancement in the form of implantable, artificial kidneys will sound the death knell for the for-profit dialysis industry, and hopefully with the work being done at UCSF and Vanderbilt, it will come sooner than later.
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    • Dori

      May 31, 2016 6:30 PM

      David, if the LDOs made the same amount per hour--and were able to bill for more hours, they would make MORE money, not less...
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      • David Rosenbloom

        May 31, 2016 7:39 PM

        Dori, if I read Mel correctly, he assumes lowering the reimbursement rate while increasing the hours of treatment to keep costs level. "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."
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  • Vanessa Evans

    May 27, 2016 5:29 PM

    As a dialysis patient for almost 18 years I could not agree more with Melville's letter. While the dilaysis industry continues to grow and profit, the patients suffer with less then adequate treatments. It is time to put an end this and overhaul a system that is only proven to fail.
    Vanessa
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  • John Agar

    May 27, 2016 1:40 AM

    Well stated, Mel. This is more than just sensible, it is right. It deserves not only to be read, by all legislators, but to be acted upon by them. I can only hope it strikes a chord ... John
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