U.S. seeks to cut dialysis costs with more home care versus clinics

[rcjordan]

^Reuters
https://www.reuters.com/article/us-usa-healthcare-dialysis/u-s-seeks-to-cut-dialysis-costs-with-more-home-care-versus-clinics-idUSKCN1QL0G6

[MooseMom]

Well, finally.  How many times have we had this discussion here on IHD, that there will soon come a time where the dialysis population grows to a point that it is no longer sustainable economically, and that THAT would at long last signal a change in how dialysis is delivered and how CKD can be discovered and treated earlier?  We all KNEW that it was never really about patient safety and convenience, rather, it is and has always been about money.  But if that is what is behind a push to get more people out of the clinic and into better dialysis at home, then I'm all for it.  The devil is in the details, however, so I'm most eager to see how this all pans out.

There is an awful lot to unravel in this article.  I don't know how the government plans to expand access to transplants.  I'd love to know.

[rcjordan]

US kidney care getting revamp, HHS officials say
https://www.healthcaredive.com/news/us-kidney-care-getting-revamp-hhs-officials-say/549670/

[Shaks24]

There are a number of demonstration projects going with the aim of improving outcomes and lowering costs. Some of them are tied into the 20th Century Cures Act and alternative methods for administering care and insuring dialysis patients. It ties into making medicare advantage available to the dialysis patient community in 2021 and of course Davita and Fresenius are taking primarly rolls in the test programs. If I understand it correctly the dialysis center becomes the primary care giver to the patients while coordinating with other service providers for the many streams of care dialysis patients usually require. They will likely also be involved in offering medicare advantage plans to dialysis patients. I still marvel when I see my monthly billing for PD through medicare. Last month they billed $101,000 but medicare then pays only $3000. Its bonkers. I hate to see what private insurance gets billed and then pays.

[LorinnPKD]

Our social worker was just making the rounds at in-clinic HD to assess interest in this... It'll be a push for sure.

[iolaire]

Our social worker was just making the rounds at in-clinic HD to assess interest in this... It'll be a push for sure.

I think it will be a push as well - if people have a choice.  That being said I'd think Medicare/the government could push more people to at home treatments through policy/training/cost savings.

Pre dialysis I received dialysis training and thought PD would be best ,but then when dialysis hit HD just seemed fairly manageable for what I hoped would be a very short wait for transplant (that turned out to be 3.5 years more to make 6.5 years wait time).  There was no pressure of any type to choose anything other than HD, and honestly if I'd not done the pre dialysis training (by DaVita) I probably would not have known much about PD and would have relied on the center for all my information.  I do think if there were incentives to do something else I could have been easily swayed.  I was an ideal candidate for at home treatment as I have a care partner (but I don't think she would do needles!) and dialysis went fairly easy for me.

PS I saw a DaVita advertisement on a bus going through my neighborhood yesterday.












Sp mod Cas

[iolaire]

Second reply to focus only on "more transplants."  From what I've read I do think one quick hit would be to provide some sort of income supplement for donors well under treatment for donation.  I've read various articles and posts about this and think it is a major barrier to donation for other people.

In my case if my brother or father had volunteered to donate (brother didn't, father may have but he felt he was too old) they would have not been able survive comfortably if they were out of work for say a month of recovery.

I was only on Medicare paid dailsyis for about a year because of private insurance but even with that it would have been fair lower cost to cover a family member's lost income for a short perioud of recovery time rather than paying for a year of dialsyis. (Or even just letting me cover lost income legally.)

[MooseMom]

Agreed, iolaire, to your points about supporting live donors.  This has been a topic of discussion for such a long time.

The UK has just recently voted for an "opt out" system.  Perhaps we could consider doing the same despite the almost certain cries of "That's not FREEDOM!"

[Paul]

Second reply to focus only on "more transplants."  From what I've read I do think one quick hit would be to provide some sort of income supplement for donors well under treatment for donation

When I was first diagnosed they made no bones about the fact that it was cheaper to do a transplant than keep me on dialysis. I was sent to a two hour presentation half of which was basically an attempt to sell us on the idea of having a transplant. Pretty much told us to go find a live donor. Failing that to put ourselves on the dead donor waiting list.

Of course in Britain all our medical needs are paid for, so the donor automatically gets support with the meds, medical treatment, etc. So it is easier to convince them to do so.

[Paul]

The UK has just recently voted for an "opt out" system.  Perhaps we could consider doing the same despite the almost certain cries of "That's not FREEDOM!"

Over here the press helped with that one. During the consultation period, all the news reports (even "The Daily Mail") made it clear that this was a good thing. Many even hinted that anyone speaking out against it was a bad person. I think the "anti" lobby were too afraid to make too loud a protest.

[iolaire]

I was sent to a two hour presentation half of which was basically an attempt to sell us on the idea of having a transplant. Pretty much told us to go find a live donor. Failing that to put ourselves on the dead donor waiting list.

The transplant centers are the one's here in the US trying to get you to find a living donor. But that type of pressure sort of makes you feel like they just want to you to get a donor so they can do the transplant faster.

I for one don't feel that comfortable asking/begging people to donate to me especially since I handed dialysis well and never felt that it would kill me.  That being said if I'm older and loose this transplant I'll probably be less healthy and at that time I could see myself making more of an effort to ask my small extended family to donate.  Park of not asking people to donate relates to my small social network.  My wife and I are not religious and not part of organized larger groups like churches or social clubs, my workplace is a fairly anonymous large office setting (I have to work to identify people to go to lunch with) that that means its a fairly limited number of non family members that I would ask, and the part of my family that I know can be counted on two hands.

I think living donors work fairly well for very social people or those with large family or church networks.

[UkrainianTracksuit]

My transplant center portrayed living donation as the better option because the donated kidney lasts longer. That's the mainline I was often told.

People knew I would need a kidney when I told them I was going for transplant testing. So when I started asking, officially, it wasn't a shock. However, when I put out a group announcement, there was literal radio silence. I heard from no one. Even from the ones that said, "I'll give you a kidney because I don't want my best friend to die." Hahaha, yeah, for real. I came to accept that the people in my fairly large social group were, excuse my language, assholes.

The official party line of my religious affiliation is that organ donation is okay. Yet, not one of my church people offered at all because they don't believe in living organ donation let alone deceased. When I pursued a deceased donation, that brought up a whole other can of worms, and I haven't been back to church since. That is another story for another time.

In all honesty, my work colleagues do not score high for altruistic actions. They are the sort of folks with achieving goals, getting that house, having that family and will not tolerate any sort of impediment, such as a surgery, to donate a kidney. So, nothing from there.

My sporty people were a simple "No" because they did not want to interfere with training or any future endeavors. Like some sports, you can't compete with one kidney.

I have cousins my age and nope, no offer. It was a case of "oh that's too bad." The two relatives that offered were older. One said he would do it but he had cancer, so no go, and the other who offered, was diagnosed with cancer a few months later. Both doing okay, but that was that.

So, I told them, if you can't help me, at least use word of mouth, o.k.? Not even sure if they did. But I talked to numerous people that were not sold on the idea since they did not know me well enough. Often I was told, "I would donate to a child but I don't know how you ****ed up your kidneys." And then that led into the second part of advocating for a donor: social media. I didn't move into that area. I knew right off the bat that I didn't have a good story that could be sold or pull on heart strings. Perhaps if I was a young mother or someone could frame me as pathetic and needy, it might work, but I knew it wouldn't.

My husband offered to donate but we were incompatible . So, he said, that's fine, we'd do paired exchange, which happened twice a year at the transplant center. That was going to be our next choice I guess.

But thankfully, all this drama fell by the side of the road when I got offered to do the double transplant (SPK) and would automatically go on the deceased list. Worked like a charm.

But I often think about what is going to happen when I need another kidney? I'll obviously be in a less "cute" state to lobby family/friends/the public for a kidney. I'll have high antibodies. And with the current trajectory of the increase of kidney failure/people needing transplants, it looks pretty bleak.

Obviously, government agencies can pursue/push/force policies of home treatment or dialysis, but more often than not, the reality, numbers and supplies don't match these lofty bottom lines. Then comes all the questions on how to increase organ donation and an even bigger cesspool. Got forcefully told off that "presumed consent" is not "the American way" and "against American values" so unless people become more altruistic, we have to rely on science for further advances, which take loads of time and innovation. A long chore.

Most of the time it feels like the world just wants to put all sick people in a wheelbarrow and roll it off a cliff! 

[iolaire]

And then that led into the second part of advocating for a donor: social media. I didn't move into that area. I knew right off the bat that I didn't have a good story that could be sold or pull on heart strings. Perhaps if I was a young mother or someone could frame me as pathetic and needy, it might work, but I knew it wouldn't.

I completely understand this, also I didn’t think I could pull off the story that "I will die without a transplant" story that helps people find kidneys via signs on cars and news stories.  But on the flip side I’ve been very happy that at the time I didn’t think I would die from a lack of a transplant and had the freedom to wait for the deceased donation.

[Cowdog]

"People knew I would need a kidney when I told them I was going for transplant testing. So when I started asking, officially, it wasn't a shock. However, when I put out a group announcement, there was literal radio silence. I heard from no one. Even from the ones that said, "I'll give you a kidney because I don't want my best friend to die." Hahaha, yeah, for real. I came to accept that the people in my fairly large social group were, excuse my language, assholes."

Sorry but not being willing to under go major surgery and put their life and their families well being at risk doesn't make them an Ahole.
So glad I don't live with the stress/desperation of chasing/begging for a kidney.
I have kidney failure, I have adapted to live as full a life as possible with dialysis being a part of that full life.
At some point we all die of something. So far I've had 10.5 extra years and I'm thankful!!

[UkrainianTracksuit]

Sorry but not being willing to under go major surgery and put their life and their families well being at risk doesn't make them an Ahole.

I agree in general that someone is not an asshole if they do not want to donate when it comes to considerations of life and family. However, when individuals say for an extended period of time that they would donate and then ghost after a group announcement? Yeah, an asshole, especially when they willingly offered on their own, in the first place. Shady, shady, shady! At least have the testicular fortitude to say, "I wasn't serious about those offers I made in the past." Fine, no one is under any duress to donate, and they shouldn't be, but it is a really weak thing to do. Don't offer at all in the first place then or carry on an extended facade.

I completely understand this, also I didn’t think I could pull off the story that "I will die without a transplant" story that helps people find kidneys via signs on cars and news stories.  But on the flip side I’ve been very happy that at the time I didn’t think I would die from a lack of a transplant and had the freedom to wait for the deceased donation.

Yes, that’s on point, iolaire. I did well on HD so I couldn’t sell the whole “I am going to die story.” Further, I have a pretty good life. Whatever my husband and I built together, we did it while I was on dialysis. So, wait in line like everyone else, but I was lucky in that I had a short wait for the call. It never was a case of desperation but just waiting along.

Kidneys, or many in need organs, don't fall from the sky. People are not all that altruistic as we like to believe. So, if there is a shift towards more transplants, obviously, that must be considered in HOW. A shift to home care sounds nice but I often wonder about those elderly (not senile, still active) that may not have the support needed. They'll stay in a center, I guess. Perhaps that's why these medical ethicists are strongly pushing the "life ends at 75" argument as health care costs increase. I know at my renal clinic they are pushing conservative care more yet when I requested that, they made a big stink, due to my age.

[Cowdog]

"Perhaps that's why these medical ethicists are strongly pushing the "life ends at 75" argument as health care costs increase"

I lost my 82yo father two weeks ago after a long fight with prostate cancer. During the last year a couple of possible treatment options and the testing required prior to that treatment was brought up by his oncologist. Each time there was the caveat "If they will approve it". Testing was never done so options were never tried. I still can't get a definition of who "They" are and where "They" are.
Dad was too sick to even think about further treatment so I'm not bitter about it not happening but somebody somewhere is calculating cost and approving/denying treatment decisions.

[rcjordan]

Cowdog and I see alike on the living donor issue.  A couple of members of my family have asked about being screened. I've told them 'No.'  I'm 69. I'll take my lumps without having them risk their health or lives.

[Simon Dog]

The only offer worth accepting is "I am ready, let's do it now".  If an offer is couched with conditionals like "ask if you want me to think about it", it's time to back off as the person is not there and not fully committed.    It is unreasonable for a donee to hold grudges against someone who declines to donate for any reason whatsoever.   None of us have the right to another person's body part, no matter what the relationship.

At least have the testicular fortitude to say, "I wasn't serious about those offers I made in the past."

That person probably thought (s)he was serious.  There are certain things one cannot know until faced with the situation "for real".   

There was a recent news report about two new police officers who ran away when their Sgt took on hostile fire (they were terminated).   I would be willing to bet each one would have told you they would have remained and bravely fought fiercely if there were asked a priori "what would you do if".    Ditto for criminals who are convinced they would not turn stool on their cohorts in a crime, but are faced with either betraying their friends or spending years trying not to drop the soap when faced with the actual choice.

[UkrainianTracksuit]

I am in agreement that no one owes us any body parts and no, I do not hold a grudge. I still talk to them, as they remain close friends, but they are the sheepish ones around me. It all worked out in the end but I learned a lot about people, that's all. See, I was told, when I give my word, I give my word, even if that means I'd have to smuggle a brick of coke!

* Just wanted to say the point of the previous diatribe was not to spew anger about people but to illustrate it can be just as difficult to have a large social circle and still not receive a live donor. Small versus large: it's still a hurdle.

Ditto for criminals who are convinced they would not turn stool on their cohorts in a crime, but are faced with either betraying their friends or spending years trying not to drop the soap when faced with the actual choice.

But then there are criminals who never talk, no matter what. Look at Freddy Geas (the guy who took out Whitey Bulger). Never ratted and took out a rat because he had his views on integrity. It just shows people are different and that's life.

[Alexysis]

As to the idea of greater home care: I'd love the idea of dialyzing at home, but I can't do my own needles, and I don't have anybody at home who can, either. If a nurse or cannulation tech came by each time to insert the needles, I think we could manage the rest, including needle removal. Does anybody offer this sort of service?

As to the transplant discussion: Yeah, I'm not going to make a public spectacle of myself in the hopes of finding somebody willing to make the HUGE decision to donate a kidney to me. I can only think of one person on the entire planet that I would do the same for; why would I think that there are any more which would do the same for me? And why would I think that stupid hand-written messages posted on my car or appeals to groups of strangers would accomplish anything? Why would I wish to resort to crass hyperbole by claiming that a transplant will "save my life"? People who do this sort of stuff make me sick...