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November 11, 2010


UPDATE: Dr. Kevin Fleming emails:

Of course, the “obvious” answer to the Medicare-funded dialysis problem will be “we need more regulation, more funding, and more government administrators”. Count on it.

When markets fail, the solution is ‘more government’, and when government fails, the solution is ‘more government’.

Such cynicism.

UPDATE: Another reader emails:

Being somewhat peripheral to the dialysis industry I feel compelled to comment on the article on Dialysis. They are mostly correct about the problems. When you sign on with one of those big companies you get the minimum care they can squeak by irregular inspections. While care quality varies considerably from place to place, overall when you are not the client you have no ability to take your business elsewhere. The problem of the population mostly being indigent is a huge one. Dialysis is like diabetes in the daily requirements of medication and watching what you eat and just showing up for treatments 3 times a week for 4 or more hours. It is not at all uncommon that people don’t bother to show up and then end up getting their dialysis in the ER after being brought in a day late in an ambulance with a life threatening potassium level. That treatment is many times the cost to the government and the hospital than if they had shown up for their appointment.

But it’s really is not all doom and gloom. Thanks to much better management of hypertension nephrologists are keeping a lot of people off dialysis by keeping their kidneys working. The population tethered to the machines here is aging and not being replaced and not growing. In this town 25 years ago a doctor would have had hundreds of patients on dialysis. A doc starting just 10 years ago would be lucky to have added 30 or 40 to their rosters now. Interestingly this also means that nephrologists as a speciality are making a lot less money than they did back then too. A lot more people are on high blood pressure medications, and if they stay on them they don’t end up on dialysis. If you are responsible and have the capacity to manage it you have other options than sitting in a scary dialysis center too. You can do peritoneal dialysis at home and even hemodialysis at home. Both of these are being done more and more at home with people who are capable of learning and adhering to the procedures necessary to keep them from infecting themselves. Sadly this leaves the homeless and many others without the ability to learn these skills and take care of themselves obsessively to be served at the problematic centers. I don’t know what the solution to improving them is, but you guarantee this situation when you have no competition and the client cannot just walk away to a better place. A generation ago the centers were owned and operated by doctors who were directly responsible for patient care. Now they are all owned by 2 different companies with a doctor on contract to check in on each patient so they can get paid. Not the same at all. No list of regulations can ever be the same as an interested local owner operator that wants to keep their clients happy and knows they could walk across the street and get better care at any time.

If you print any of this, please leave off my name. I have too many relatives who are nephrologists fighting to get good care from those dialysis corporations and don’t want to get them any closer scrutiny from their managers.

It’s all about alignment of incentives.

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