Cuts Could Mean Loss Of Dialysis Care For Thousands Of Americans

[Bill Peckham]

I just want to say with this whole argument about doctors denying patients and not being paid, be careful not to confuse Medicare and Medicaid. You will find statistics for both but it's easy to see something like "25% of doctors refusing patients" and see the Medi part and just assume. Some changes are happening to Medicare and some to Medicaid.

Unfortunately, in a general way nothing will change. The system has a lot of flaws now and it will have a lot of flaws later. For some people things will get better. For some people things will get worse. For some people it will be pretty much the same. Being on dialysis sucks and will continue to suck.

True. Medicaid plays a big role in it in another way - a lot depends on whether a state pays the 20% not covered by Medicare for people who qualify for both Medicare and Medicaid. For people using dialysis about 50% of the people that have Medicare as their primary insurance have Medicaid as their secondary. Right now, according to my info, 21 states Medicaid does not pay or pays a small portion of the 20%. For docs reluctance to accept Medicare patients it is largely due to a judgement about their secondary insurance. If they're in a state with Medicaid that does not pay secondary to Medicare then they have to think if getting paid 80% of Medicare allowed rate is going to work for their business.

Our system leaves the states with the job of setting Medicaid policy. If that's the policies the people of Texas and Florida wish to live with then that is their right. Medicare shouldn't have to increase their reimbursement for the whole country to make up for the states with low Medicaid reimbursement.

[NDXUFan]

Rocker, HemoDoc has never, ever supported For-Profit Dialysis companies. 

I don't understand how this is in any way related to this thread, nor how you imagine that I thought that.

He has, however, argued against the cuts, and takes their hostage rhetoric seriously.  I am for the cuts, and think their rhetoric is bull.

If you think Kent Thiry would not protect his wallet over a dialysis patient, you are drunk and have been drinking.  Davita DOES NOT have compassion for any dialysis patient. If you believe that, you are nuts.

Since I have said more or less exactly that, I'm not sure what you're arguing...?

Yes, I have been in management, just like you. 

I didn't say I was "in management".  My husband and I own a business.  We are those "small businesspeople" that politicians like to pretend they're pandering to. But the "concerns" politicians claim we have are generally not remotely close to reality.

Look at the numbers, do you think the employer is going to pay a fine of $2,000 or health insurance costs that are thousands upon thousands of dollars?  Many employees are not highly skilled, not like the majority of people in your company, that is not reality.

Right, that's not what HD said.  Of course the McD's and WMs are going to do that - they don't care about their employees.

What in fact HD said was that companies that now provide insurance (NOT WM and McD's, but companies that care about employees) would stop doing that and pay the fine instead.

Which is ludicrous.

What happens to a business who pays an employee much more than that employee produces??? 

This is, ummmm, kind of a silly question. If an employee is not doing the work they were hired to do, they are fired.  If, however, your business model is so bad that no employee can produce enough to cover their costs - then you have a deeply flawed business model and will quickly fail regardless of law.

Firing employees is a very expensive proposal, as I have been told by a number of CEO's, mostly small business people.  Many small business people are opposed to ObamaCare, especially employers who are offering health insurance to their employees...... 


Jancoa CEO Mary Miller testified on the impact of Obamacare: 

Staff
Cincinnati Business CourierJancoa Janitorial Services CEO Mary Miller testified this week for the Committee on Oversight & Government Reform on the economic and job creation impact of Obamacare.

The health care law’s employer mandate will force the Cincinnati-based company to either increase premiums, cease employee coverage and pay a penalty, or downgrade workers from full-time to part-time, Miller said.

“The law will force my husband and me to choose between several impossible options in order to remain in business,” Miller said in her statement to the committee. “This will jeopardize our ability to offer jobs that employees value.”

The commercial cleaning company has 320 full-time employees. Miller also will be featured on the “Willis Report” on Fox Business channel this evening at 6 p.m. to further discuss the issue
http://www.bizjournals.com/cincinnati/news/2012/07/11/jancoa-ceo-mary-miller-testified-on.html

Yes, I do live in Cincinnati and I am aware of the company.  No, they do not have margins to afford Obamacare.  They will have to pay either $684,000 in fines or $1.5 million in increased health insurance costs.  The company simply does not have the margins to afford this expense.  As Obamacare pushes these companies out of business, this will mean less tax revenue for dialysis, not a really smart idea, is it? 

[NDXUFan]

[quote author=NDXUFan link=topic=29264.msg464816#msg464816 date=1376476489

  What Obama is doing is not compassion, he cares more about how he thinks of himself, that the actual reality of what he is doing to people on dialysis and the average individual.  I hate to inform you that most law school grads, like Obama, have little to no knowledge about Basic Economics.  Yes, I am in law and I was an Economics major.  Obama also knows nothing about science, most of my family is in the hard sciences, Chemistry and Physics. Obama bashes certain groups, because it wins votes, it is just that simple.

These are the kinds of sweeping statements that make people tune out.  You do your arguments no favors when you indulge in this sort of rhetoric.  No president knows everything about every subject, which is why they have advisors. 

I doubt the President "cares more about how he thinks of himself", but it is probably true that he, like every other politician in Washington, cares too much about the health insurance industry and other corporate interests.  Unfortunately, he has to put forward ideas and legislation that will actually get through Congress.  So, to get a more accurate view, I suggest that in your post, replace "Obama" with "Congress".
[/quote]



As you are probably aware, I am not a fan of Davita and "Millions" Thiry.  I do not care about the health insurance industry, nothing, zip, and zero.  Politicians protect the health insurance industry by not allowing individuals to buy health insurance across state lines, in other words, it is a health insurance monopoly, this is one of the main reasons that health insurance prices are so outrageous.  Think of how cable acted without the satellite dish industry or MaBell acted without competition, remember?  Obama likes to dictate, not work with...... 

By the way, here are some comments from an elected Democrat: 

Whatever happened to the rule of law? If he gets to write his own laws and decide which ones he will ignore, when do we get the chance to decide which laws we will follow and which we won't? Sound likes anarchy to me. 

https://www.facebook.com/dusty.rhodes.731?fref=ts&ref=br_tf   

From the Liberal Washington Post: 

Can Obama Write His Own Laws? 

"Which followed hundreds of Obama­care waivers granted by Health and Human Services Secretary Kathleen Sebelius to selected businesses, unions and other well-lobbied, very special interests." 

You want to talk about special interests???

http://www.washingtonpost.com/opinions/charles-krauthammer-can-obama-write-his-own-laws/2013/08/15/81920842-05df-11e3-9259-e2aafe5a5f84_story.html

[NDXUFan]

This may be a simple question regarding a complex subject, but it seems to me that most politicians are telling us that entitlements need to be cut.  So, why are any of you surprised and/or outraged that cuts will be made to the ESRD program?  It's an "entitlement", isn't it?  Aren't there a lot of people out there telling us that government shouldn't be involved in our health care?  And don't a lot of people vote for these politicians who run on this sort of platform?

Yes, it is correct that entitlements need to be cut.  You are right, government should not be involved in our health care, because it greatly increases the cost to the patient or health care consumer.  For example, in a health insurance policy for a family, there are around 2,000 mandates from government, this makes the health care policy unaffordable to most working and middle class families.  In addition, this drives the cost of a office visit to the physician from $20.00 to $100.00, because the physician or physician's group has to hire so many people to keep up with government and private insurance regulations.  A high deductible policy is much, much more economical for the vast majority of people.  Yes, I realize that is too expensive for some individuals and families, therefore, eliminating government mandates will drive down costs to those folks.  The government pays for 45 percent of all medical bills in the United States, meaning our health care system is not a truly free market system.  There are many problems with our health care system, mainly, a lack of competition in hospitals and physicians, this greatly increases cost to individuals and families.  One of the reasons dialysis is so expensive, is a lack of competition, mainly just two providers, DaVita and Fresenius.......  How has that worked for the dialysis patient?   Costs are generally excessive when there is no competition, think of the cable and phone companies, years ago.  Remember, paying $.10 per minute for a long distance phone call? 

Health care is a business and we need to start realizing that to protect our wallets.  It is a business, not a charity.  The way to protect our wallets is to introduce these people to competition.....  If you dislike what the XYZ grocery store charges or the quality of their products, you leave them and go to the ABC grocery store.....  If any group of people need the protection of competition, it is dialysis patients.  Trust me, Old "Millions" Thiry would protect his wallet, he is never interested in protecting your wallet or that of the working and middle class taxpayer.

[NDXUFan]

Does anyone on here really believe that "Millions" Thiry is worth his yearly compensation?  Do you think Davita is really worth billions per year?  Competition and choosing other providers is the way to register our disapproval of "Millions" and his crappy dialysis care. 

[rocker]

Firing employees is a very expensive proposal, as I have been told by a number of CEO's, mostly small business people. 

Expensive....how?  Why?  The only "cost" I'm aware of related to firing is the cost of hiring and training a new employee to replace the lost worker.  But that's the same regardless of whether they are fired, or quit.

Many small business people are opposed to ObamaCare, especially employers who are offering health insurance to their employees...... 

Yes, many small business people are opposed to all kinds of laws.  However, small businesses have little reason to oppose Obamacare - as the employer mandates do not apply to businesses with fewer than 50 employees. 


[story about a cleaning business]

Yes, I do live in Cincinnati and I am aware of the company.  No, they do not have margins to afford Obamacare.  They will have to pay either $684,000 in fines or $1.5 million in increased health insurance costs.  The company simply does not have the margins to afford this expense.  As Obamacare pushes these companies out of business, this will mean less tax revenue for dialysis, not a really smart idea, is it?

First of all, 320 employees is much larger than "small business".  A small business is generally considered to be one with fewer than 50 employees.

From the story, it appears that what they offer employees is nothing resembling "insurance" if they are worried about Obamacare "mandates".  (Like, a limit on OOP costs.)  You can easily buy "insurance" policies around here that advertise that they cover "up to $1000 if you are hospitalized!"  I think we all know that $1000 won't even get your blood pressure checked.

Roughly three-quarters of bankruptcies in the US are caused by medical expenses - of those, roughly two-thirds of the people had insurance at the time their expenses were incurred. There is a lot of worthless crap calling itself "insurance" in the US. Of what possible use is a high-deductible (say, $10,000) policy to someone making $400 a week? In my experience, unless it's an emergency, doctors will demand payment up front from people with policies like that.

The annual employer penalty is, IIRC, around $2000 per full-time employee.  If this business owner is complaining about the huge new expense the penalties will cause them - well, what kind of "insurance" do you suppose you can get for less than $2000 per year?

Also, didn't you claim to be an economist?  Are you suggesting that this company's customers will simply forego cleaning services, and thus that revenue will be lost?  Doesn't the market model suggest that if this business fails, another one will take its place to fill the need?  So how is that tax revenue "lost"?

[Zach]

Smoke and mirrors: What is really behind protests over the ESRD bundle payment cut?
http://www.nephrologynews.com/blogs/5-guest-blog/post/109706-smoke-and-mirrors-what-is-really-behind-protests-over-the-esrd-bundle-payment-cut

Nephrology News & Issues
Richard Berkowitz August 23, 2013

As a home dialysis patient, I visit my clinic every month to see my nephrologist and care team. I had such a visit last week and before I left, my social worker came to see me. After we talked, she put a letter in front of me and asked me if I would sign it.

It was entitled “Protect dialysis treatments,” and was obviously a letter intended for Congressional representatives, although it did not list them by name. Essentially, it said that I rely on dialysis to remain alive and that the proposed 12% cut by the Centers for Medicare & Medicaid Services to the ESRD bundled payment would threaten my ability to receive my treatment. After saying I wouldn’t sign it, I was asked if I was absolutely sure. I said I was.

It’s amazing what the renal provider community can do when they put their minds to it. In this case, it is about protecting money—their money. This effort to get patients involved in a letter writing campaign—hundreds of these form letters have already been sent to Congress with the help of the provider community—has to do more with the bottom line than patient care. Patients should not be used as pawns in a series of scare tactics to protest a change in a payment dispute between a payer and a provider of services. The industry relies heavily on Medicare to operate its clinics, but that’s no excuse to leverage its position by hiding behind dialysis patient chairs and using us to stop a pay cut. In my view, it is unconscionable.

“We were alarmed…”
Astute chief financial officers of dialysis companies large and small must have known this day was coming. CMS’ proposed 12% cut in the ESRD bundled payment rate––actually, a 9.4% reduction after CMS added in a 2.6% increase after its annual market basket review of operational costs––is not based on an arbitrary review. The Medicare Improvements for Patients and Providers Act of 2008 instructed CMS to use 2007 data to build the ESRD bundled payment model, so the agency did what it was told to do. That was the most complete data available at the time.

Being pre-bundle, ESAs were still separately billable and profitable for dialysis clinics. The damaging CHOIR and CREATE studies were published in late 2006, but the debate over the results stalled any real change in dosing patterns. And the FDA black box warning changes issued in March 2007 about minimizing the use of ESAs did not lead to a major drop in dose, according to a recent study.1  So, as a baseline year to determine payment for ESA use, 2007 was a positive for providers dealing with the bundle––particularly if CMS didn’t make any subsequent updates.

The proposed 12% cut came about after a Government Accountability Office report, released in December of last year, questioned whether CMS should have been doing exactly that: making adjustments to the injectable drug payment as dialysis clinics started ratcheting down ESA doses shortly after the bundle took effect. In essence, CMS was paying clinics for using high doses of ESAs at the same time as providers were cutting back use of the drug to save money.

That, said the GAO, cost Medicare between $660–$880 million in excess payments. “Although MIPPA did not explicitly authorize CMS to further recalculate this rate—referred to as rebasing the payment rate—to account for changes over time in the utilization of dialysis and related items and services, such as ESRD drugs, beginning in 2012 CMS [was] required to annually increase the bundled payment amount to account for changes in the prices of bundled items and services and for changes in productivity.”

And CMS did make adjustments for changes in productivity, giving dialysis providers an increase in the base rate over the last two years: 2.1% in 2012, and 2.3% in 2013, and, as proposed, a 2.6% increase for 2014.

So as of today, here is the scenario I see:

 ... CMS is paying dialysis providers for injectable drugs (GAO says 73% of that is ESA use) based on much higher dosing patterns from 2007, as they were instructed to do by Congress.
 ... Dialysis providers have collected those payments for the last 2 ½ years, while ratcheting down ESA use. Among patients receiving intravenous epoetin, mean prescribed dose has decreased by 33% since the bundled payment system was put in place in January 2011, according to data from the Dialysis Outcomes Practice Patterns Study’s Dialysis Practice Monitor.
 ... Dialysis providers have been issued two increases to the base composite rate, and a third is on its way for 2014.
 ... So Congress, in a twisted way, perpetuated use of ESAs as a “profit center” for dialysis clinics within the bundle, and CMS added fuel to the flames by not adjusting the payment. And now, the renal community has been able to get patients and 200 members of Congress––who approved the American Taxpayer Relief Act of 2012 authorizing CMS to make a payment cut in the first place––to criticize the agency for the size of the reduction.

That’s called good lobbying.

If CMS had taken action at the end of 2011 and 2012 to adjust the injectable drug component of the bundled payment model, which MIPPA gave them the authority to do, and still offer the market basket-based increases to the base rate, we might not be hearing providers screaming today about closing dialysis clinics and the ESA payment rate would reflect the true utilization by providers.

Where has all that money gone?
Despite those extra dollars funneled down to dialysis providers, many still complain of thin profit margins. Some of that money, they say, has helped to pay for unfunded mandates, like implementing CROWNWeb and its myriad reporting requirements, and for collecting data for the Quality Incentive Program. The recent 5% increase in the cost of Epogen has also had an impact. Those costs are real, especially for the small independent providers and medium-sized dialysis organizations.

But is that worth putting patient faces on ads and threatening to shut down clinics—before even sitting down with CMS to negotiate a compromise? Facing cuts they basically brought upon themselves, dialysis providers and advocacy groups, including patient organizations dependent on industry funding, are saying that patient care will suffer, that dialysis centers may close, and that staff will be reduced. In fact, they are saying that life-saving therapy is at risk.

Build it, buy it…and build some more
If a business has thin profit margins, it doesn’t seem to make sense to expand. As the renal community is threatening to close clinics because of the bundled payment cut, they are also making announcements of new ones opening. DaVita has also made heavy investment in buying clinics overseas over the last two years and, of course, recently bought Healthcare Partners with $3.66 billion in cash and 9.38 million DaVita common shares.

In 2012-2013, the nation’s 10 largest dialysis providers, as ranked by NN&I each year, added 298 clinics, either via new construction or acquisition/consolidation. That was a big jump from 214 clinics added by this group in 2011-2012 and remains the largest growth in clinic ownership among the 10 largest providers over the last five years.

That expansion seems out of sorts with the declining growth in the patient population. At the end of 2010, U.S. Renal Data System data showed the number of new patients starting therapy on hemodialysis declined for the first time in more than three decades.

Specifically, according to the USRDS’ 2012 Annual Data Report: “…The total treated ESRD population [at the end of 2010] thus rose to 593,086 — growth of 4% from 2009, which is the smallest increase in 30 years. The rate of prevalent ESRD cases reached 1,752 per million population, an increase of 1.1% from 2009, and also the slowest growth in the last three decades.”

So why is an industry that complains about thin profit margins spending millions of dollars on building or acquiring clinics or other providers during a period when growth in new patients on dialysis is at its lowest in three decades? Again, is money going toward the bottom line, or patient care? Has the provider community been using profits to build or buy more bricks and mortar, and finding out the patients are coming?

EPO is the first to go
I believe what has brought on the bundle payment cut is similar to a confluence of circumstances — almost like a perfect storm, with dialysis patients the only ones in the water. The cutback on using injectable drugs was predictable. I remember speaking at the CMS Town Hall Meeting in October 2009 that underutilization of pharmaceuticals would be an unintended consequence of the bundle. More specifically I was concerned patients would suffer because of the fear if any money was taken out of the system that it would be taken out of patient care. And, our track record for dialysis patient care is less than stellar.

Compared to the rest of the industrialized world, we could be doing a lot better.
 ... Our mortality rate is the highest among developed countries.

 ... Home dialysis — the therapy I have chosen — is only being used by roughly 10% of patients in the United States, one of the lowest percentage penetration among developed countries. Ironically, 90% of nephrologists in the United States say in polls that they would pick home dialysis for themselves if they had to be on dialysis. It’s not clear to me why you would choose a superior modality for yourself but not recommend it to your patients.

 ... There is no serious attempt at rehabilitation of individuals once they go on dialysis. Unemployment between the prime working ages of 18-54 is 80%.2   A new study out this week shows that ESRD patients who are unemployed are less likely to be referred for a transplant. So the industry’s lack of interest in helping patients return to the workforce also clearly impacts their chances of getting a new kidney.

 ... For-profit dialysis providers, which make up the bulk of the industry, offer inferior care. In the article, “Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities” published in June in the American Journal of Kidney Diseases, researchers noted that “ratios of RNs and LPNs to patients were 35% (P < 0.001) and 42% (P < 0.001) lower, respectively, but the PCT to patient ratio was 16% (P < 0.001) higher in for-profit than nonprofit facilities (rate ratios of 0.65 [95% CI, 0.63-0.68], 0.58 [95% CI, 0.51-0.65], and 1.16 [95% CI, 1.12-1.19], respectively).3

 ... We also learned from the Agency in Health Care Research and Quality in December 2011 that, “Compared with the nonprofit chain, mortality risk was 19% higher at one for-profit chain and 24% higher at a second for profit-chain. Overall, patients from for-profit facilities, regardless of chain status, had a 13% higher risk of mortality than non-profit facilities.”

Change in ESRD QIP also influential
Patients have been harmed by the underutilization of ESAs, and CMS can be partly blamed by helping providers push the ESA dosing envelope. The clinical measure to track hemoglobins in the ESRD QIP only penalizes clinics if patients go over 12 g/dL; there is no penalty for hemoglobins under 10 g/dL. That’s just a green light to providers to underutilize. And why an upper limit?  It makes no sense and is counterintuitive. Providers are not going to spend the money to keep hemoglobin levels that high. But clearly there is an incentive to lower hemoglobins: reduce costs. One documented impact of lower ESA use and subsequent lower hemoglobins is the increase in transfusions, now estimated at approximately 20%.4

CMS has floated a new quality measure developed by Arbor Research that would bring the hemoglobin  “floor” back, and its proposed 2014 QIP includes a clinical measure requiring clinics to report more about how they are using ESAs. That’s a step in the right direction. We need to make sure that ESA dose isn’t being dictated by bottom line calculations, but by what is best for the patient.

Is there a level playing field?
One thing needed is to level the playing field between the better performing small dialysis organizations and medium dialysis organizations and the lower performing large dialysis organizations. It is the small dialysis organizations and medium dialysis organizations that will likely be impacted most by the proposed cut. I would urge CMS to look at finding some way there can be a differential built into the PPS to ensure the smaller dialysis centers can survive and not be gobbled up by the LDOs. We cannot afford to lose them.

The bottom line (for dialysis patients and providers)
There has been a torrent of comments on social media regarding the proposed payment cut. I’ve never seen patients more engaged in an issue, as they are being told their lifeline therapy may be taken away. Patients are posting all over Facebook that they don’t want to die, including home dialyzors. I wish those home dialyzors would jump on a broader bandwagon and call on CMS to increase reimbursement for home hemodialysis training. Low home training reimbursement, particularly for home hemodialysis, is one barrier to growth in the United States.

The dialysis provider community is positioning the cuts as if they will affect future operations, including keeping centers open and maintaining staff levels. Nothing is said about increasing the utilization of medications to its appropriate levels, which was the cause of the proposed cuts in the first place. If the cuts are mitigated in any amount, the money should go back and reverse the care and service impacted in the past. Restore an appropriate level of ESAs and other biologicals. Reverse the trend of more dialysis patients requiring transfusions. Don’t play games with the fragility of dialysis patients’ lives. Let’s figure out the real impact of the cuts and sit down with CMS and negotiate a compromise. Scare tactics with patients at the center give the renal community a black eye.

References
1. Thamer M., Zhang Y, Dejian L, Kshirsagar O, Cotter D. Influence of safety warnings on ESA prescribing among  dialysis patients using an interrupted time series. 
     BMC Nephrology 2013, 14:172 doi:10.1186/1471-2369-14-172

2. Table 20 ESRD Network Program 2011 Summary Annual Report

3. Yoder LA, Xin W, Norris KC, Yan G. Patient care staffing levels and facility characteristics in U.S. hemodialysis facilities, Am J Kidney Dis. 2013 Jun 27. pii: S0272-6386(13)00830-5. doi: 10.1053/j.ajkd.2013.05.007, USRDS 2011

4. Sack K. Unintended consequences for dialysis patients as drug rule changes, NY Times, May 11, 2012

Mr. Berkowitz is a home hemodialyzor from Skokie, Ill, and president and founder of Home Dialyzors United

[Icare]

I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.

[Hemodoc]

I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.

That is the problem, health care should not be government or for profit, but instead, as it started as non-profit entities. I just transferred from Kaiser to Group Health. At Kaiser, FMC had a joint venture with Kaiser in several dialysis units. My experience in that Kaiser/FMC joint venture was all positive.

Now that I am with Group Health, the FMC unit here has no such arrangement and I am quite unhappy with this new unit. Today, they discussed reducing my dialysate for cost purposes even though they acknowledge that I am doing very well on my current treatment. When money matters more than people, that system will inevitably fail to provide for their patients. I have nothing against capitalism but it does NOT belong in the health care arena. My experience providing care in a non-profit for my patients was such that I was able to provide for their needs. The for-profit health care outfits cannot provide the level of care as a non-profit. So, agreed on the failure of socialism, but for-profit dialysis companies not the solution my friend.

[NDXUFan]

I'm sorry but in capitalism companies are formed to make money, either for individuals or stock holders. If these private companies go out of business and you have to count on the government hang on! We lived next to the Canadian boarder and people from Canada were paying out of pocket for .cancer treatments because they were on a one year waiting list in Canada! Socialism SUCKS!! Our system has problems but the free market is the only thing that dialysis patients have going for them. If these private clinic don't fight for you who will? It took me 5 years to find this site. (by accident). Our government is trying to demonizes big business but that is what made this country!! Support the effort of your clinics to save your rights to good care! They are spending their money to do it. My wife is a dialysis patient and as it is we have had to loose everything to get the help we get!! So I surely can't fight big brother but my wives clinic can.

I am a Milton Friedman trained economist and I was with Davita for five years.  If you think Davita is existing to help me and your wife, you have been drinking.  Thiry is out to help his own pocketbook, not your life.....  I am NOT an Obama supporter, not ever, ever.  Why would you build so many more dialysis clinics if you were not going to make money and why would Warren Buffet invest in your dialysis company, if he did not think you will be making money, Buffet is worth billions from stock picking.  Good care, you have to be joking!!!!!

[Rerun]

Free Market or Capitalism is one thing.

Making huge profits off sick people and Medicare (aka taxpayers) is another.

[NDXUFan]

Free Market or Capitalism is one thing.

Making huge profits off sick people and Medicare (aka taxpayers) is another.

How much profit is too much?

[Hemodoc]

Free Market or Capitalism is one thing.

Making huge profits off sick people and Medicare (aka taxpayers) is another.

How much profit is too much?

When it comes to healthcare, all of it is too much. The differences between FMC in joint partnership with Kaiser and the level of support and supplies compared to FMC for-profit alone is the difference between night and day. The FMC/Kaiser experiment shows that a  "for-profit" entity can be tamed by joining contractually with a non-profit by setting up a system to improve care and reduce secondary costs from ER visits and hospitalizations.

When I spoke to Ben Lipps a year and half ago in person, this was his vision of improved care in America. Then nephrologists are rewarded financially for keeping hospitalizations down. In such a system, the for profit entities can be tamed to provide cost effective care that is also the best for the patient.

In reality, the current system is not actually the "fault" of the for-profit entities alone. It all comes back to the wall between part A and part B of Medicare that produces a system where the outpatient facilities maximize their profits by denying care since they have NO responsibility for the in-patient costs from failing to provide the best care. So, when FMC joined with Kaiser in a capitated payment system with incentive bonuses for reducing hospitalizations, everyone benefits including the for-profit industry.

Long story short, for-profit medicine can actually provide excellent care if you simply change the incentives. CMS thus is at the heart of the horrible outcomes because of the wall between Part A and Part B. The FMC/Kaiser experiment demonstrated this in a profound manner. I miss that system greatly. Who is to blame then? FMC or CMS and congress for putting this disincentive to good care into the system controlled by the single payer Medicare ESRD program?

[Rerun]

But, what if you need to go to the hospital but they won't send you because they want the incentive?  Any good idea is corrupted by someone.

I personally think Medicare has it right.  DaVita charges what they want (65K per month) and medicare doesn't even look at what they want they GET $3,000.  Like the Mom whose kid wants the whole box of cookies but she gives them 1.

[Hemodoc]

But, what if you need to go to the hospital but they won't send you because they want the incentive?  Any good idea is corrupted by someone.

I personally think Medicare has it right.  DaVita charges what they want (65K per month) and medicare doesn't even look at what they want they GET $3,000.  Like the Mom whose kid wants the whole box of cookies but she gives them 1.

pm sent to Rerun

[jeannea]

In that article it says less people are starting dialysis. Why? I am 44 and I am part of the baby bust. We came after the baby boomers. My brother's graduating class was the lowest in number graduating for our area. Schools closed all over. After him, the classes increased every year. Are they buying and building dialysis centers for when the increasing population over 50 starts?

For places making lots of profit, the decreased bundle will only affect care if those centers allow it by cutting staff and medicines, etc. For many small rural clinics there will be a big effect. Those are the patients that can't change centers because there is no place else. Those studies that decide the centers don't need the money, are they based on a sampling or an average or what?

I'm sure docs would want to do home hemo but they have a certain confidence in their ability to handle it than many of us. I'm so shaky from Prograf that I can barely tie my own shoes. I don't think I could cannulate myself. I live alone so here they wouldn't let me do it anyway. If you live in a nursing home, you probably can't do home care because there's no room in your 600 sq ft apt.

The problem is that statistics need context. It's really hard for me to know which way my support goes. I know that when I went to dialysis, the only center in the county had 2 buildings about 5 miles apart owned by the same doctor group. There were no other options without a much longer drive. And this was only about 1 1/2 hours from Philadelphia. It's complicated.

[Hemodoc]

Dear Jeannea,

Self cannulation is a totally different endeavor than sticking a needle into someone else's arm or neck or stomach or back or chest or shoulder or knee or arm or leg. (Had to think of all the procedures I did as a doc) However, when it came to sticking my OWN arm, not easy at all despite the number of needles I had stuck in my patients over the many years. But it is the single most important determinant of survival in many years since most home patients self cannulate. Once you are able to get over the initial repulsion to sticking yourself, it becomes much easier with time. It becomes just something you have to do but the consolation is that most that stick themselves do it better than the nurses or techs and have less complications in the long run than even the "expert" cannulators.

Lastly, I did dialyze in a 500 sq. ft cottage we rented from Sept. 2009 to Sept. 2010. No, not much space, but we did manage to get things done and that was with 2000 pounds of dialysate bags each month. The PureFlow supply list is significantly less than the bags and in such, having a very small apartment is not an absolute reason to not consider home dialysis.

[Lucinda]

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.

I haven't been here for a long while. Hi Everyone.  Sorry to resurrect this post but it worries me that you guys are nervous to do dialysis on your own. I was googling something else and your quote came up jeannea.  I am in Australia and I have been on dialysis now for six years.  I do it at home on my own.  It really is not a big deal and I have been doing the same thing for six years.  I work full time, do dialysis every second day/night and that has been my smooth routine for years.  Techs come out once every few months to check the machine and I never call on the nurses.  The only problem I have had is a blocked access a couple of times which has nothing to do with home dialysis.  That gets reviewed and I am home the same day. 

I am sorry you guys over there are nervous about doing it at home yourselves - and that you are not allowed to do it at home by yourselves.  The bottom line is it is almost impossible to kill yourself.  It has just become a way of life and an extension of my day.  I don't want a transplant - I am happy with being on my machine.  It is barely a blimp for me.  I hope everyone is doing well and lots of love to everyone. http://ihatedialysis.com/forum/Smileys/classic/new_flower.gif

[obsidianom]

You have a great attitude. Keep up the good work.

[jeannea]

Personally I don't know if I could do it. I have a very bad hand tremor from Prograf that didn't even go away when I was on dialysis between transplants and not taking Prograf. But when I made that comment I was thinking more about older people who cannot handle the set up or bedridden people who can't do things like that or even someone too scared. It seemed impossible to me to have everyone on home treatment unless you send the scared person home to die. Here in the US I would not be permitted to do home hemo. I live all alone, not married or anyone else. Centers here will not train you alone.