Cuts Could Mean Loss Of Dialysis Care For Thousands Of Americans

[Zach]

... and as of next year the Part D Donut hole will be closed because of the ACA.

Actually, I think the Donut Hole will be closed in 2020.

[okarol]

I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.

This isn't the case. Obamacare was paid for when the legislation passed

That is contrary to what I have been reading. There was no funding.

[ChrisEtc]

Jeannea, Amen Sister!!  But, as long as you have a pulse you are a money maker for these Dialysis Centers.  Hamster on a wheel generating money.  Sad but true. 

Will these Dialysis Centers who make millions off sick people and Medicare really close their doors?  We would start dropping dead after about a week.  Are they really going to do this?  I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time.  You know how fast Congress works.

Those on Home Dialysis better start hoarding supplies.  The rest of us won't have a chance.   

         

Actually, the two issues are quite related and intertwined. Those that opposed Obamacare to start with warned that Obama was going to raid Medicare and that cuts to the seniors would come shortly. The fact that we see these cuts beginning is not a surprise. Obama gutted Medicare to "pay" for the ACA.

http://www.breitbart.com/Big-Government/2013/02/20/With-Election-Over-Obama-Announces-Medicare-Cuts-To-Fund-ObamaCare

Completely ignorant.  The problem with responding to reactionary folks like yourself is that you can post links from poorly written articles or politically slanted sites to claim the sky is falling very easily but it takes me a good amount of time to explain why your conclusions are wrong on a topic that is necessarily complex due to the nature of health care.  I'll be responding when I have the time.

Those of you in the US worried about losing dialysis altogether, not going to happen.  If there is any change in your level of care it will be due to the greed of the large providers to generate profits.  As long as health care is a for profit industry without regulation this is always going to happen, Obamacare or otherwise.  The money cut from Medicare was cutting the allowed rate of growth in future payments.  Medicare payments rise a certain percentage each year, due to Obamacare Medicare growth was expected to decline in the rate of growth so the rate of growth in payments was cut to adjust for that.  Incidentally, the Romney/Ryan plan for Medicare cut the same 700 billion that Obamacare cut.  It was going to be gone one way or another.

The sky is not falling.  Take the time to educate yourself on Obamacare before you fall for the fear, doom, and gloom that is being thrown about by these dialysis companies.  This is a lot like Sarah Palin and her death panel nonsense.  Lot of noise, little substance.

[ianch]

While I would stress that HomeD is not a solution for every ESKD suffer, it should be part of the overall solution.  The US and NZ in-center costs are not too dissimilar.  In NZ the government promotes HomeD where it can because its better for the patient and the health budget.  I believe you can get 4 HomeD for every one in-center.     

As of 2011 33% of Hemo was HomeD in NZ.  If the US pushed this more then there would be a significant cost savings that could ensure those that cant do HomeD would not loose hours or access to medications.
 
The US clearance target I believe is actually below NZ so it would be quite a negative to drop this further by reduced funding.

I'm not sure if NextStage is the right solution though.  I have a Fresenius and its very very stable.  Never had an issue in almost a year and have run it past its max operating time of 10 hours. 
   

[Hemodoc]

Jeannea, Amen Sister!!  But, as long as you have a pulse you are a money maker for these Dialysis Centers.  Hamster on a wheel generating money.  Sad but true. 

Will these Dialysis Centers who make millions off sick people and Medicare really close their doors?  We would start dropping dead after about a week.  Are they really going to do this?  I'm sure if they cut ALL Medicare they would close their doors and someone would step in but not in time.  You know how fast Congress works.

Those on Home Dialysis better start hoarding supplies.  The rest of us won't have a chance.   

         

Actually, the two issues are quite related and intertwined. Those that opposed Obamacare to start with warned that Obama was going to raid Medicare and that cuts to the seniors would come shortly. The fact that we see these cuts beginning is not a surprise. Obama gutted Medicare to "pay" for the ACA.

http://www.breitbart.com/Big-Government/2013/02/20/With-Election-Over-Obama-Announces-Medicare-Cuts-To-Fund-ObamaCare

Completely ignorant.  The problem with responding to reactionary folks like yourself is that you can post links from poorly written articles or politically slanted sites to claim the sky is falling very easily but it takes me a good amount of time to explain why your conclusions are wrong on a topic that is necessarily complex due to the nature of health care.  I'll be responding when I have the time.

Those of you in the US worried about losing dialysis altogether, not going to happen.  If there is any change in your level of care it will be due to the greed of the large providers to generate profits.  As long as health care is a for profit industry without regulation this is always going to happen, Obamacare or otherwise.  The money cut from Medicare was cutting the allowed rate of growth in future payments.  Medicare payments rise a certain percentage each year, due to Obamacare Medicare growth was expected to decline in the rate of growth so the rate of growth in payments was cut to adjust for that.  Incidentally, the Romney/Ryan plan for Medicare cut the same 700 billion that Obamacare cut.  It was going to be gone one way or another.

The sky is not falling.  Take the time to educate yourself on Obamacare before you fall for the fear, doom, and gloom that is being thrown about by these dialysis companies.  This is a lot like Sarah Palin and her death panel nonsense.  Lot of noise, little substance.

Dear Chris,

Let me make a few corrections to your post.

1) You state that the LDO's are not regulated. Sorry, look up the 2008 CFC's and read through the entire document. For your interest, even the regulators who do the Federal inspections complained that they were too complex and time consuming. Bill and I both participated in several conference calls and Bill attended a conference on this very issue on how to revise the inspection process. Note, this conference headed by a high level CMS official did not reduce the complexity of the 2008 CFC's for the LDO's. It simply addressed the difficulty the inspectors had in complying with the 2008 CFC's inspection requirements. So the regulators are saying they are too much to handle in a timely fashion, yet they did not reduce the requirements for the LDO's.

You may wish to read the regulations for yourself to make your own judgement on whether it is an "unregulated" industry.

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/downloads/esrdfinalrule0415.pdf

2) The oversight for the LDO's and all dialysis providers is "supposed" to be in large part through the ESRD networks. Unfortunately,  they are only an extension of the LDO's and providers who fund these networks. True patient oversight is essentially lacking. CMS has not responded to multiple complaints at various levels on this incestuous relationship between the LDO's and the patient oversight process.

3) I am not at all reactionary my friend, just a fiscal conservative sadly watching our current government lead us into bankruptcy as a nation. Simply because you disagree with me does not in any manner make me ignorant or reactionary.

4) The Romney/Ryan plan had the medicare cuts in place because it is the law of the land as SCOTUS told us last summer. I guess you didn't read that they also promised to overturn and repeal Obamacare if elected.

5) Medicare payments to LDO's allegedly do not cover the full cost of treatments. LDO's make their most profit off of private insurance during the first 30 months of dialysis. If in fact, the medicare payments are lacking as many well respected folks contend, then indeed, a nearly 10% cut in Medicare reimbursement will have significant ramifications. In my opinion, it will not be their profit margins that suffer the most.

6) I have spent a great deal of time reading on Obamacare and my conclusion is that it will be an economic and health care disaster for this nation. Personally, Obama's tax policies pose a significant risk to my retirement and my healthcare I have through Kaiser. With the cuts that will occur with Medicare due to Obamacare and his tax policy, my own retirement plans will need to be completely revised. Thankfully, I still have 10 years before the biggest bite comes. Hopefully, I will be able to make the right changes to my plans now but that is not a reactionary or ignorant issue, it is my own personal reality and my wife's as well.  In all seriousness, the taxes to my health care plan may force me to give it up altogether just to put food on the table at some point in time.

7) I have not yet written any posts on the Medicare cuts, but they will not be based on your alleged fear and gloom from the LDO's. Far from it. I am already quite well aware of the fear and doom that this nation's government controlled dialysis industry has wrought on hundreds of thousands of dialysis patients who suffered in units with the highest rate of death internationally. The untold torment of the last 40 years of the ESRD program where LDO's have made billions if not trillions of dollars from tax payers while producing the highest dialysis mortality and morbidity of any industrialized country is overlooked by those that should be ashamed and alarmed by this horrific medical performance in our dialysis units across this nation. Yes, congress and CMS has given a blind eye to these things for over 40 years while keeping a revolving door between the LDO's and the CMS regulators wide open.

Will the LDO's simply absorb these cuts without any reduction in services?? If you believe that will be the case, I have a bridge I would like to sell you.

[Hemodoc]

While I would stress that HomeD is not a solution for every ESKD suffer, it should be part of the overall solution.  The US and NZ in-center costs are not too dissimilar.  In NZ the government promotes HomeD where it can because its better for the patient and the health budget.  I believe you can get 4 HomeD for every one in-center.     

As of 2011 33% of Hemo was HomeD in NZ.  If the US pushed this more then there would be a significant cost savings that could ensure those that cant do HomeD would not loose hours or access to medications.
 
The US clearance target I believe is actually below NZ so it would be quite a negative to drop this further by reduced funding.

I'm not sure if NextStage is the right solution though.  I have a Fresenius and its very very stable.  Never had an issue in almost a year and have run it past its max operating time of 10 hours. 
 

Actually, the NxStage is an excellent platform with the advantage in my opinion over the current FMC machines. I cannot comment about the machines in development by FMC due to NDO but keeping to the Baby K for comparison, NxStage is a real contender for the leader in Home therapy. First, the NxStage has ultra-pure dialysate. Their Pureflow home system works well. The only complaint I had about the NxStage was low total dialysate. However, in April, the FDA approved an upgrade to the NxStage System One that will increase dialysate maximum flow rates by 50%, from 12 liters/hour to 18 liters/hour. The Baby K does not have ultra-pure dialysate which is a significant contributor of inflammation in dialysis patients.

The NxStage upgraded machine will produce 300 ml/min of dialysate flow which is still below the Baby K but a significant improvement over their prior settings I am looking forward to running 60 Liters in 4 hours instead of my current 40 Liters. I believe my clearances will approach those of a conventional in-center machine.

It takes me about 10 minutes to set up and about the same to clean and disinfect. The Baby K is a significant investment in time and effort. The NxStage is portable and the Baby K is not. When traveling, you can bring your own machine and NxStage will ship your supplies. When traveling with the Baby K, you must go in-center unless you are one of the rare patients to have a unit that offers NxStage for travel.  The NxStage requires no RO system and no complex plumbing. With the increased dialysate flow rates which should offer significantly improved clearances, NxStage is well set to compete against FMC and the other corporations now and in the future in my opinion.

Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.

[ianch]

My challenge with NextStage was 1) the number of complaints on this site and B) the sales rep in Australia that wasnt able to confirm the machine could match my current module for performance - I only wanted NextStage for holidays.

My machine runs for 10 hours every 2nd day.  I'm asleep for most of that.   Long hours and slow speeds increases clearance significantly over the shorter 4 hour sessions at higher speeds.  I have charts to prove this, and most research backs it up.

I guess the day to day impact is zero complications for long hours verses crippling complications for short hours pretty much sealed my opinion of NextStage.  The other issue was cost.  They wanted 40k plus 20k per year for supplies.  Thats more than the state pays for my current machine with no-where near the performance.   

Not all people want to do long hours so NextStage will appeal to others.

I personally will never again dialysis for less than 8 hours.  I have my life back, quite a bit of my energy, and whats the negative when I get cleaned while fast asleep.
 

[ianch]

Also didn't know what Baby K was.  Never heard of it.  We use 4008B's in home and 5008 in-center.  Parts of the country use Gambro but don't know which model.

[Bill Peckham]

I'm pretty sure they'll have to repeal Obamacare to get us out of this mess.
The money to pay for it is coming from ESRD patient care.

This isn't the case. Obamacare was paid for when the legislation passed

That is contrary to what I have been reading. There was no funding.

I'd like to see the links to the analysis you've been reading but here is a PDF (http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11307/reid_letter_hr3590.pdf) of the CBO analysis  the summary statement is "CBO and JCT now estimate that, on balance, the direct spending and revenue effects of enacting H.R. 3590 as passed by the Senate would yield a net reduction in federal deficits of $118 billion over the 2010–2019 period."


And since it has now been the law of the land for a while you can check what the current federal deficit is and see if it has indeed gone down http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html
"it estimated an annual deficit for 2013 of $845 billion, but some budget observers have said they expect the deficit for this year will come in lower than that."
so yes, as projected the deficit continues to go down

[Bill Peckham]

Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.

Just to agree with Peter and say since the NxStage could make it down 400KM of the Colorado River through 125 rapids proves that it is very durable

[Hemodoc]

Lastly, the NxStage is a VERY reliable system with much less maintenance issues than the Baby K. If there is a problem, they will ship a new machine overnight. NxStage is truly an excellent choice for home dialysis therapy.

Just to agree with Peter and say since the NxStage could make it down 400KM of the Colorado River through 125 rapids proves that it is very durable

Yes, we always seem to agree on dialysis issues. Not so much on politics.

[obsidianom]

I too am a BIG fan of NXSTAGE. I am a physician also . I run it for my wife 5 days per week. She feels so much better with the more frequent dialysis. Days off are hard on her. In center she felt terrible. now she walks on treadmill 25 minutes daily and SINGS.
The Nxstage system is SO easy to set up and run and clean up after. It is quick and simple. When i needed a new machine they had it out in under 24 hours ready to go.
The techs are there ALL the time as I have called them at 2;00AM once. They get on the line quickly anytime I call and during treatment even quicker. If ANYTHING goes wrong they talk me through it easily and clearly. I feel like they are in my house next to me.
The pureflow is great as it uses very little of my well water and the dialysate is great fertilizer for my fruit trees. i have the best PEE-CHES(peaches ) and apples ever this year.
The machine is quiet and I hardly have to touch it once it is running for the 3 hours of dialysis. The bags of dialyaste are great for emergencies or traveling. They are like a backup always there if I need them. I have NO complaints with Nxstage now. We have used it for over a year. Our machine feels like part of our family now. It gives us a lot and asks little in return.

[Rerun]

Fertilizer for your fruit trees?  Ikkky!

           

[ianch]

I personally don't have any complaints about NexStage, it just does not meet the minimum operating requirements required and is quite expensive for what to does.

I was quite intrigued however by the comment "they had a new machine out in 24 hours" and "the techs are there all the time".  Probably need more context here, but the whole point of HomeD is that its independent and costs less.   If a particular model needs constant replacement then it surly cannot be very robust.  This also suggests the a huge amount of support is built into the 40k price I was quoted.
   
Someone is paying every time a tech shows up, and probably a lot more for 2am so I'm struggling to get the financial benefit of HomeD here.   I think I have had 1 tech visit in 9 months for recalibration (+ their annual 3hr service), and I have not called the support team in over 7 months.  that's 1,200 hours of treatment.

I live in a very small country where the state pays therefore efficiency and productivity is a key drive in keeping taxes down.   

I guess I'm just saying that if the US is suggesting that funding may need to be reduced due to escalating costs then perhaps a focus should be on getting the best efficiency and productivity out of the process. 

[cattlekid]

I do agree that more context is needed.  I used NxStage successfully for a year and a half on a 5x per week schedule and I credit it for allowing me to continually work a full time job while I was on dialysis, keep a home and still maintain a semblance of a social life.  In the 18 months that I had the machine, I had to get one new machine and only called technical support a handful of times. 

I always had good labs while I was using NxStage and was able to be more liberal with my diet. 

Was my success with NxStage because I still urinated and never needed to remove much fluid (many times never removing anything but rinseback)?  I don't know.  All I know is I could no longer tolerate the long recovery times after harsh in center treatments and having to arrange my life around treatments was sending me down the depression spiral.  NxStage changed all that and I am forever grateful to IHD which is where I found this modality, because it sure wasn't being advertised by my center.

[Hemodoc]

DaVita is threatening to close some urban and rural clinics that are most dependent on Medicare and Medicaid payments. Folks can discuss the merit of the cuts or not, but the threats I believe are quite real.

http://www.bizjournals.com/denver/news/2013/08/06/davita-warns-of-closing-clinics-due-to.html

In the context of the rest of medicine, many docs today refuse Medicare and Medicaid patients because of a simple fact. These government payments for healthcare do not cover in many cases even the overhead for a doctors visit. Medicine today is quite complex and doctors must have folks in their office who bill, collect, keep data bases, fix their computers, compliance officers to keep up with all of the Federal, state and local regulations in addition to all of the medical staff. When you consider the overhead costs of running a modern practice, there is good reason many of my colleagues have decided to avoid these government run programs. They simple cannot afford to do so with such minimal compensation.

Understanding these trends throughout medicine today, i don't for one minute believe that the threat to close clinics is at all an idle threat. There will be real consequences of the CMS cuts for one simple reason, the current payment system does not effect the market cost involved. It is an artificial payment in many ways even though yes, the prior system was quite abused by the industry especially with the separately billable items such as EPO.

Nevertheless, simply digging in and saying the LDO's deserve what is coming to them belies the message that it is not Kent Thiry who will suffer when the cuts hit nor will DaVita.

[Bill Peckham]

DaVita is threatening to close some urban and rural clinics that are most dependent on Medicare and Medicaid payments. Folks can discuss the merit of the cuts or not, but the threats I believe are quite real.

http://www.bizjournals.com/denver/news/2013/08/06/davita-warns-of-closing-clinics-due-to.html

In the context of the rest of medicine, many docs today refuse Medicare and Medicaid patients because of a simple fact. These government payments for healthcare do not cover in many cases even the overhead for a doctors visit. Medicine today is quite complex and doctors must have folks in their office who bill, collect, keep data bases, fix their computers, compliance officers to keep up with all of the Federal, state and local regulations in addition to all of the medical staff. When you consider the overhead costs of running a modern practice, there is good reason many of my colleagues have decided to avoid these government run programs. They simple cannot afford to do so with such minimal compensation.

Understanding these trends throughout medicine today, i don't for one minute believe that the threat to close clinics is at all an idle threat. There will be real consequences of the CMS cuts for one simple reason, the current payment system does not effect the market cost involved. It is an artificial payment in many ways even though yes, the prior system was quite abused by the industry especially with the separately billable items such as EPO.

Nevertheless, simply digging in and saying the LDO's deserve what is coming to them belies the message that it is not Kent Thiry who will suffer when the cuts hit nor will DaVita.

Are they saying they can't sell the units? Because that would be a surprise that DaVita is operating a unit that is unsaleable at 2011 reimbursement rates. IIRC in 2011 units were being sold for over $70,000/patient.

This to me illustrates too big to regulate. The company that FMC grew out of - national medical? - extorted more money in the '80s when the composite rate was being established by threatening to close their units.

I haven't heard about many docs quitting Medicare, I've heard about the few who have started Concierge practices I wouldn't say that has been "many docs" by any standard. Medicaid is another issue and is very state dependent. It is true cuts to Medicare also cut reimbursement from dialyzors insured all or in part by Medicaid.

If DaVita has a unit in a state that is a poor Medicaid payer, and that unit's average reimbursement rate is below DaVita's costs then they should sell. I'll predict that these threatened units are in states that are the worst Medicaid payers ie states that pay nothing or very little of the 20% not paid by Medicare for people who are dual eligible and states who pay at or close to 80% of the Medicare allowed for those that Medicaid primary - for example South Carolina. Also units have been getting this extra money as hemoglobins have declined but for no longer than 2.5 years - are these units that dependent on this relatively new source of gravy that they have to be closed without it?

[Bill Peckham]

I personally don't have any complaints about NexStage, it just does not meet the minimum operating requirements required and is quite expensive for what to does.

I was quite intrigued however by the comment "they had a new machine out in 24 hours" and "the techs are there all the time".  Probably need more context here, but the whole point of HomeD is that its independent and costs less.   If a particular model needs constant replacement then it surly cannot be very robust.  This also suggests the a huge amount of support is built into the 40k price I was quoted.
   
Someone is paying every time a tech shows up, and probably a lot more for 2am so I'm struggling to get the financial benefit of HomeD here.   I think I have had 1 tech visit in 9 months for recalibration (+ their annual 3hr service), and I have not called the support team in over 7 months.  that's 1,200 hours of treatment.

I live in a very small country where the state pays therefore efficiency and productivity is a key drive in keeping taxes down.   

I guess I'm just saying that if the US is suggesting that funding may need to be reduced due to escalating costs then perhaps a focus should be on getting the best efficiency and productivity out of the process.

The context is that there are 5,000+ units in use. Cost-wise the swap out maintenance model is the true business innovation of the device. I'm sure the total cost of a technician taking half a day or day to visit a far flung house is much greater than simply mailing a new device. My machine was swapped out when it reached 5,000 hours of use, a courier brought over the new one and packed up my old one - from the company's point of view think of the complexity that has been removed and their highly trained technicians stay hard at work chained to their desks.

Also Oz does speak an English of sorts, I'm sure you've talked to people for customer service that were located all over the world - NxStagers downunder may well be getting their tech support form the same US group as we do now - spreading efficiencies.


EDITED TO ADD: The cost savings are from fewer hospitalizations not less money spent providing dialysis.

[Hemodoc]

Bill, Medicare reimbursement rates have been under the cost overhead for quite some time. Many docs have left in the last few years and that trend is growing.

http://www.forbes.com/sites/brucejapsen/2013/01/01/27-pay-cut-or-not-more-docs-to-leave-medicare-in-2013/

As far as selling the units, who will buy? I would hope some of the non-profits could gain, but if the patient mix does not have enough private patients, the unit will have a hard time meeting their financial thresholds and cost overhead.

As far as what the reality of their finances truly is, no way to know that for certain. I am only relating that I doubt that the cuts will be passed to the share holders of FMC and DaVita. Instead, they will look to squeeze the patients once over again. I don't believe that these cuts will go with pain and suffering on patient's part much more so than the companies or their investors whether it is justifiable or not.

That puts advocates in a difficult spot. Advocate against the  cuts, you contribute to LDO profiteering. Advocate for the cuts, it will certainly the patients that pay a large part of the cut. Once again, the LDO's are likely to gain more ground against the independents and SDO's more so than lose market share.

Yes, NMC operated in many unethical ways and that is how FMC was able to take over a much larger corporation that was facing severe fines and government penalties. It appears that the administration under Benn Lipps was much more responsive to date to patient needs than it appears it is today. I believe we both share a concern for further industry consolidation and the cuts in the end analysis will be much more damaging to the smaller dialysis providers that cannot operate on the economies of scale of DaVita and FMC.

That is the most likely outcome, but I suspect that DaVita especially will use this as an excuse to add further burdens to the patients. It leaves advocates in an uncomfortable position.

[ianch]

As far as I am aware NZ does not subscribe to NextStage.  There could be some private users but it was very expensive own and operate privately.  On the basis HomeD was promoted to me as a long-hours option, I doubt any unit that that operates for less than 6 hours would be approved by the government for general use.   My machine easily does 11 hour sessions while I'm asleep.

NZ is made up of 2 islands and I am of the understanding that in the South Island every hemo patient is HomeD.  Across the whole country its 33% and new funding is approved for training centers not dialysis centers. 
 

[obsidianom]

I had to replace 1 Nxstage machine after over a year for a minor repair. They just swapped it out using a currier to switch. No big deal.
The techs NEVER come to house. I just call on phone with questions or any concerns. I tend to call when I want info but really have had few issues.
In the US we dont do enough home dialysis . In my area of Maine there are just 3 of us doing home hemo. I think a lot of people are scared to do it themselves. 
The liquid dialysate is cleaner then manure for fertilizer. It does contain MUCH nitrogen and does make my whole place GREEN.

[Bill Peckham]

And since it has now been the law of the land for a while you can check what the current federal deficit is and see if it has indeed gone down http://money.cnn.com/2013/05/07/news/economy/deficit-falling/index.html
"it estimated an annual deficit for 2013 of $845 billion, but some budget observers have said they expect the deficit for this year will come in lower than that."
so yes, as projected the deficit continues to go down

I misstated the projected deficit for 2013 by about 200 billion dollars. Sorry about that, I should have gone to the CBO for the most current numbers.

Here is the CBO's "Updated Budget Projections: Fiscal Years 2013 to 2023" http://www.cbo.gov/sites/default/files/cbofiles/attachments/44172-Baseline2.pdf

"If the current laws that govern federal taxes and spending do not change, the budget deficit will shrink this year to $642 billion, the Congressional Budget Office (CBO)
estimates, the smallest shortfall since 2008. Relative to the size of the economy, the deficit this year—at 4.0 percent of gross domestic product (GDP)—will be less than half as large as the shortfall in 2009, which was 10.1 percent of GDP. "

$642 Billion is a lot to me but it's not a trillion.

[jeannea]

Can that really be true that in NZ south island all hemo patients are at home? How does that work? If you can't handle doing it yourself do they send a nurse out? Or do they deny you care? It sounds impossible to me although an interesting dream.

[Zach]

Can that really be true that in NZ south island all hemo patients are at home? How does that work? If you can't handle doing it yourself do they send a nurse out? Or do they deny you care? It sounds impossible to me although an interesting dream.

Perhaps that also includes PD?
 

[ianch]

Hi Zach,  Good point.  I was actually correct but there there is always devil in the detail.  In NZ the health system is designed to catch potential ESRD long before dialysis is required.  When this works and the patient falls under 15% dialysis workup is started.  The choice of mode is then determined and PD plays a role here. If hemo is the choice then ability to be independent which includes using a family career is vital for most parts of the south island.  This is because the area is vast and medical facilities only existing in the cities.

I am only aware of one private dialysis centre in my city mainly for inbound tourism, and only 3 public ones - I'm in the north island. 

NZ and Australia are world leaders in HomeD and usually promote it when the patient is younger, cant do PD, or needs more treatment to sustain their lifestyle.  Thus nocturnal is normally the solution.  In my case 10 hours per session.   Its well documented that the 3 days per week for 4 hours is very damaging and so where possible we go for the home option.

So not impossible and not a dream.  The machines are easy to use, incredibly reliable and backed by a strong training program. 

There will always be fringe cases and I imagine those individuals who cannot be independent would need to move the closest hospital.  Its fair to say we do less well in the rest of the country but in the main city (Auckland) there is renewed investment in HomeD training centers.