Efficiency of dialysis health care systems across the world?

[kristina]

Hello ...
... In continuation of comparisons of dialysis-care in different countries, I have a couple of questions:
In the USA medical insurance gives a level of private health care many abroad can only dream about, and this makes me wonder about two things. Firstly, are the dialysis centers and the dialysis machines kept spotlessly clean, as I would imagine them to be with private health care insurance? Hospitals in the USA always appear in the media as modern and surgically clean. Are the floors clean of dirt, waste and spillage, and are there signs of blood splatter? And, are the toilets spotlessly clean to avoid contamination? And are toilets segregated Male & Female, or can anyone use them? Secondly, because the nurses receive much better pay in the private sector in the USA,  are there more nurses working at dialysis centers so as to provide a much more personal attentive service for the dialysis patients?
 The medical treatment offered in the USA through private medical insurance is often envied by those of us abroad. It would be interesting to know if our perception of USA medical care is right or not. State funded health care systems starved of cash suffer all manner of difficulties, so it is interesting to learn how effective and efficient other health care systems are. Your comments would be appreciated. 
Many thanks from Kristina.

[Simon Dog]

Medicare (low payment) and private insurance (high payment) patients receive treatment in the same US facilities, and with the same services.  The staff performing dialysis is not even aware of a patient's payment status, so there is no difference in treatment. The Medicare care standards actually drive what everyone gets.   The staff does keep the place spotlessly clean like a hospital, as their success and infection rates are tracked and reported.   Dialysis is carved out for Medicare payment after 30 months on D, which makes it the one disease which is largely govt funded (about 80% of D patients are on Medicare).

The new facility in my area as separate M and F toilets - in fact,, they had to shrink the waiting room size at the last minute because the building code required this.  An older facility a couple of towns over only has one in the waiting room.   I think the toilet inside the treatment area is unisex in the new facility, but I am not certain.

But, we are limited to 3 days/week in-center since the goal is "adequate" treatment not "best possible".  Also, the US is not necessarily the best - for example, I believe Italy has a nephrologist on duty in D facilities at all times; no so in the US.

I believe the typical ratio is one RN for 12 patients and one tech for 4 patients.   I'm not sure how that compares to the rest of the world.

[lulu836]

@Simon Dog  Did you possibly mean 3 months instead of 30?

[Simon Dog]

@Simon Dog  Did you possibly mean 3 months instead of 30?

Nope.

Here in the US, private insurance covers the first 30 months of dialysis, after which it becomes Medicare primary, private insurance secondary.   Once one hits 30 months, Medicare becomes primary insurance for everything (not just dialysis).

I don't know the exact rule for someone not covered by private insurance.

[lulu836]

OK small disconnect.........I am in the US lifetime.  I misread your parameters.  I've been retired since 2005 so I had Medicare a looooong time before kidney failure.  I'll start reading things twice, I think.  LOL

[Simon Dog]

the 30 months is "regardless of age" (or is it irregardless?).  If someone is of Medicare age they don't wait for Medicare coverage.

[Paul]

In the USA medical insurance gives a level of private health care many abroad can only dream about

You have that the wrong way round. People I know who have traveled from Europe to the USA say the clinics in the US are nowhere as good as the clinics in most European countries (NB "most European countries" not "all European countries"). As far as England is concerned, I know that the English NHS contracts some of its clinics to Fresenius, and the rules Fresenius have to abide by when working for the NHS have are stricter than the rules in the US resulting in, for example, a better patient to nurse ratio than in America. I cannot remember any incidents offhand, but several time I have been reading a thread written by an American and thought "Blimey, the nurses would not get away with that over here."

Also, most European countries have full free healthcare, which  is why the average length of life is a lot less in America than in most European countries (well, that and the burgers).

[Simon Dog]

What people dream about is the incredible access the fully insured in the US have to prompt specialty care.    I actually had to wait a full two days once while an MRI was approved by my insurance company!!!   Compare that to the weeks or months long wait people have in some countries with "free" care.  The catch is "free" care puts everyone at the same level of access, whereas the US system has different levels of access depending on your insurance/economic status.

It's largely a zero sum game with winner and losers in either system.

[kristina]

Many thanks for your kind replies, Simon, Lulu and Paul. I find this most illuminating as it seems to highlight the differences in the health care systems in different countries. It seems that nothing is perfect and all systems have good points and bad points. What one can say about this, I am not quite sure, but it is fascinating to read the different viewpoints.
Many thanks again from Kristina.

[iolaire]

In the USA medical insurance gives a level of private health care many abroad can only dream about

You have that the wrong way round. People I know who have traveled from Europe to the USA say the clinics in the US are nowhere as good as the clinics in most European countries (NB "most European countries" not "all European countries"). As far as England is concerned, I know that the English NHS contracts some of its clinics to Fresenius, and the rules Fresenius have to abide by when working for the NHS have are stricter than the rules in the US resulting in, for example, a better patient to nurse ratio than in America. I cannot remember any incidents offhand, but several time I have been reading a thread written by an American and thought "Blimey, the nurses would not get away with that over here."

Also, most European countries have full free healthcare, which  is why the average length of life is a lot less in America than in most European countries (well, that and the burgers).

I've not seen much of a difference in non US centers versus US. Other than most non US centers provide a snack and many non US centers have beds rather than chairs. 

[kristina]

Many thanks iolaire for sharing your experiences, it is very much appreciated.
Thanks again from Kristina.

[Simon Dog]

There are really two separate issues:

1.  Quality of dialysis service

2   Availability for those who cannot cough up the cash

In third world countries, #2 suffers, and in many, no cash, no treatment.    (pretty much the same terms visitors to other countries face).

[Paul]

2   Availability for those who cannot cough up the cash
In third world countries, #2 suffers, and in many, no cash, no treatment.

I would keep quiet about that if I were you, because there are lots of Europeans who consider the US is a third world country because of its lack of general free healthcare.

[Simon Dog]

I would keep quiet about that if I were you, because there are lots of Europeans who consider the US is a third world country because of its lack of general free healthcare.

Yup.   One of the things that helps with affordability is the price discrimination on drugs.  The pharma companies charge vastly more to US customers, and set up barriers to make reimportation difficult.   A great example is Harvoni for Hep-C.  A treatment cycle goes for $95K in the us; $2K in India; same drug; same manufacturer.   It's like college or car pricing - work to charge each customer the maximum that person can afford, rather than just set a fixed price for everyone.

And another thing is the MDs union (AMA) in the US, limiting supply of doctors to prevent price competition.    No wonder so many foreign MDs seek US residencies.

[Paul]

One of the things that helps with affordability is the price discrimination on drugs.  The pharma companies charge vastly more to US customers, and set up barriers to make reimportation difficult.

But the UK pays the same price as the US and the British government still pays most of the cost of all medication. We pay between nothing and $16 per prescription however many medications are on that prescription, and regardless of the actual cost of the medication. What you pay depends on your medical state (I pay nothing) and regardless of how many different medications are on the prescription, the most anyone pays per prescription is the equivalent of about $16 in total, for everything (I have 13 different things on my prescription). This is not just pills and medicines, it includes injections (e.g. EPO, insulin, etc.) and other stuff (e.g. blood sugar testing strips, lancets, etc.).

Because of my fragile foot bones I need special shoes. This involves my feet being measured, molds made of my feet so they can cast feet to make the shoes round, then when they are finished hand making these shoes I try them on and they make any minor adjustments needed. This takes months, and costs a fortune, but I pay nothing, the state foots the entire bill (pun unintentional).

But most importantly, when/if I get a transplant, the state pays for the anti rejection pills for life (mine or the kidney's, whichever dies first). In the US, one in ten transplants fail when the state stop paying. One in ten transplant operations are a waste of time and money because of this. More importantly, one in ten kidneys are wasted. And for that alone I consider the US a backward, third world, tin can little country.

 

[Simon Dog]

But the UK pays the same price as the US

Not always: https://www.bloomberg.com/news/articles/2017-09-04/why-drugs-cost-less-in-the-u-k-than-in-the-u-s-quicktake-q-a

Here is the US, Medicare is prohibited from negotiating Rx drug prices.  There is markup limit for the middleman, however, the drug companies can charge Medicare whatever they want.  The UK can negotiate, and deny formulary status if it does not get a good deal.

The end result is US drug buyers subsidize those in other countries.

[cassandra]

Well thanx US tax/premium/contributions/medicines payers. Maybe president Trump can change the regulation concerning Medicare?

[Paul]

Maybe president Trump can change the regulation concerning Medicare?

Careful what you wish for, Trump wants to make matters worse, not better. Only congress has stopped him so far!

[Simon Dog]

Maybe president Trump can change the regulation concerning Medicare?

Careful what you wish for, Trump wants to make matters worse, not better. Only congress has stopped him so far!

Actually, Trump has stated that he wants to do something about the pharma pricing.

[Simon Dog]

In many federal government procurement contracts, there is a "best customer" policy.  The vendor must agree to give the govt the best pricing of any customer, with a lookback period (for example, not being able to charge the govt more than the best price a customer got in the previous year).   I've worked at companies that could not offer a discount to close a deal because it would trigger the "best customer" clause and require rebates to the government.

If the govt had "best customer" on Medicare, and used a broad expanse of customers to include foreign purchasers, it would both reduce medicare costs and increase the cash flow from non- US countries to the US as pharma firms would be reluctant to offer outer b.f. (or wherever) a 90% discount relative to US Prices.

[kristina]

One of the things that helps with affordability is the price discrimination on drugs.  The pharma companies charge vastly more to US customers, and set up barriers to make reimportation difficult.

But the UK pays the same price as the US and the British government still pays most of the cost of all medication. We pay between nothing and $16 per prescription however many medications are on that prescription, and regardless of the actual cost of the medication. What you pay depends on your medical state (I pay nothing) and regardless of how many different medications are on the prescription, the most anyone pays per prescription is the equivalent of about $16 in total, for everything (I have 13 different things on my prescription). This is not just pills and medicines, it includes injections (e.g. EPO, insulin, etc.) and other stuff (e.g. blood sugar testing strips, lancets, etc.).

Because of my fragile foot bones I need special shoes. This involves my feet being measured, molds made of my feet so they can cast feet to make the shoes round, then when they are finished hand making these shoes I try them on and they make any minor adjustments needed. This takes months, and costs a fortune, but I pay nothing, the state foots the entire bill (pun unintentional).

But most importantly, when/if I get a transplant, the state pays for the anti rejection pills for life (mine or the kidney's, whichever dies first). In the US, one in ten transplants fail when the state stop paying. One in ten transplant operations are a waste of time and money because of this. More importantly, one in ten kidneys are wasted. And for that alone I consider the US a backward, third world, tin can little country.

 

Many thanks again for your kind thoughts and replies, it is very much appreciated. The thought-provoking communication between Simon Dog and Paul is most fascinating and is certainly serious food for thought and very much appreciated !
Kind regards and thanks again from Kristina.

[GA_DAWG]

This does not really relate to dialysis per se, but does kind of point out things. The US, among the 35 countries in the Organization of Developed Countries,  recently was ranked number 35 out of 35 in infant mortality because of the lack of healthcare for poor pregnant women. Our system is great, so long as one can afford it.

[Simon Dog]

Our system is great, so long as one can afford it.

That is the key to understanding the relative ratings.   If you are well insured (or even on Medicare), you will fall on a different part of the curve than the uninsured masses.

It is quite possible for a country to rank at or near the top for well insured middle class people, but near the bottom for the uninsured poor.

[Katie07]

Kristina, I am still receiving dialysis in the hospital dialysis unit, until I am being dialyzed for four hours. My time is increased half an hour each day. The dialysis has been extremely unpleasant, but thinking about how it will be at the out-patient center terrifies me. The nurses have told me, that once I am transferred there, there will be little nurse contact. They will hook me up, and pull the needles out. Beyond that.... I have had significant reactions to dialysis, so knowing, that there will be little help if something happens... I guess, in short, having health care does not automatically mean better care. Even in the hospital center, after watching me cramp up so much, I couldn't walk, or unclench my fingers, the doctors and nurses told me, that it was all in my head. No one bothered, until much later, to realize that I am extremely alcholotic, and the dialysis bath was killing me. Maybe it's because we are supposed to have such high standards, that those running dialysis centers don't have to listen to patients, because "they know it all."

[Paul]

Even in the hospital center, after watching me cramp up so much, I couldn't walk, or unclench my fingers, the doctors and nurses told me, that it was all in my head.

In such circumstances I think it should be OK to punch the nurses (seriously). Try taking their name and asking for the contact details of their lawyer.

Cramps are caused by too much being taken off or too fast a flow rate. The maximums tolerable vary from person to person, so it will take a while and a bit of pain to work out your personal limits. However THE NURSES SHOULD BE WORKING ON CALCULATING YOUR LIMIT. By telling you that it is all in your head the nurse was basically saying "Sorry, I am incompetent and do not know how to do my job properly. I should be fired immediately."

I have no idea which country you are in, but in Britain a complaint further up the line would get instant disciplinary action against the nurse who told you that.