Home Dialysis hits USA Today!

Hi y’all,

It’s a BIG DEAL when USA Today does a story about dialysis–and it talks about how much better LONGER AND MORE FREQUENT HD are. Here’s the link http://www.usatoday.com/news/health/2009-08-23-dialysis_N.htm?loc=interstitialskip, and here’s the story. The emphasis in bold, below, is mine:

Dialysis treatment in USA: High costs, high death rates
By Rita Rubin, USA TODAY

Deb Lustman was late getting to work a few days every week, and often felt she wasn’t thinking as clearly as she once did.

The reason: Lustman, 50, was spending four hours a day, three days a week, undergoing kidney dialysis at a dialysis center, where a machine filtered toxins and fluids from her blood. Normally, that’s the job of the kidneys, but for reasons doctors have never figured out, hers had failed.

Nine months into her treatment, as soon as her doctor raised the possibility of home dialysis, Lustman decided to switch. So, in July 2008, after she and her husband learned the ins-and-outs from a nurse, she began dialyzing five evenings a week at her Magnolia, N.J., home, with her two Maltese, Sophie and Jake, often lounging next to her. Now Lustman, an optician, dialyzes on her own schedule, not the center’s, and she’s not late for work anymore. And, she says, “I’m healthier.”

Thanks to more frequent dialysis, totaling 15 or 16 hours a week, “I feel not only physically better but … mentally better” and no longer “loopy,” she says.

Lustman is a rarity, however: Only 8% of U.S. dialysis patients treat themselves at home. The vast majority of the more than 350,000 Americans on dialysis are treated in centers, where three treatments a week, three or four hours each, is the norm — not because it’s optimal but because that’s the way it has been done for nearly four decades.

A growing body of evidence suggests that longer and/or more frequent dialysis treatments, either at home or in a dialysis center, are far superior to the status quo. Although the USA spends more per dialysis patient than other countries, that does not result in higher survival rates or even, many argue, a better quality of life.

“The standard of care is really inappropriate,” says Brenda Kurnik, Lustman’s doctor, who practices in Marlton, N.J. “Basically, it prevents people from dying, and that’s about all it does.”

So why doesn’t the USA do better? Many blame Medicare’s End Stage Renal Disease Program. Launched in 1973, it’s the only federal program that entitles people of all ages to health-care coverage on the basis of a single diagnosis: chronic kidney failure. By paying for lifesaving care for hundreds of thousands of Americans, the program is a testament to what health insurance reform might achieve if Congress were to adopt it.

But it also may be a cautionary tale: Its cost has far exceeded initial projections, and some doctors and other analysts question whether Medicare get its money’s worth and whether patients get the best treatment. Less than one-quarter of dialysis patients ages 18 to 54 are well enough to work or go to school.

In 2007, Medicare spent $8.6 billion on the treatment and medications of dialysis patients, from babies to the elderly, according to the Medicare Payment Advisory Commission’s March report to Congress.

In addition, Medicare pays billions each year for the hospitalization of dialysis patients. Although they are younger on average than most Medicare beneficiaries, who must be 65 to qualify for coverage, “this is an incredibly sick population,” says epidemiologist Paul Eggers of the National Institute of Diabetes and Digestive and Kidney Diseases. Such patients, Eggers says, enter the hospital six times more often than Medicare beneficiaries who don’t have chronic kidney failure.

Despite the costs, a substantial proportion of dialysis patients die every year. In 2006, 20.1% of U.S. dialysis patients died, most often of heart disease or infections. In Japan, the death rate was about half that; Australia’s rate was halfway between the USA’s and Japan’s.

Explanations for why the USA has the highest dialysis death rate in the world vary. Some U.S. kidney doctors say that countries with national health programs, such as Britain, withhold dialysis from the oldest, sickest patients, while the Medicare program takes all comers. But foreign doctors deny that their countries ration dialysis. They — and many of their U.S. colleagues — attribute the higher U.S. death rate in part to Medicare’s own payment system and the resulting “one-size-fits-all” treatment.

The standard of care has become the three treatments a week for which Medicare pays, usually in a dialysis center, and no longer than four hours each. Home dialysis, which allows for longer, more frequent treatments, is more common in most countries with better survival rates.

‘Capable of doing better’
The status quo has many critics. In June, a group of nephrologists, or kidney doctors, who had met at a Harvard teaching hospital to discuss the issue sent a letter to White House and Medicare officials urging “substantial changes in the delivery and financing of care … to improve patient outcomes” for those with chronic kidney failure.

“We are capable of doing better,” they wrote to White House health policy czar Nancy-Ann DeParle and Barry Straube, chief medical officer at the federal Centers for Medicare & Medicaid Services, or CMS. “Small, incremental improvements in the outcomes for patients with kidney failure are no longer acceptable.”

When Medicare’s kidney-failure program started in the early 1970s, “the science was such that somewhere between three and six hours of dialysis three days a week was sufficient. Things sort of settled into that pattern,” says Dallas nephrologist Thomas Parker III, co-organizer of the conference at Harvard’s Beth Israel Deaconess Medical Center.

But normal kidneys work 24/7, not a few shifts a week, so the standard treatment replaces only 10% to 13% of their function, Parker says. How much dialysis is enough isn’t clear, he says, because few studies have randomly assigned patients to different amounts to test which approach is more effective.

In his July 22 prime-time press conference, President Obama endorsed the use of such studies, called comparative effectiveness research, to ensure that the U.S. health-care system gets the most value for its money. The economic stimulus package has earmarked $400 million for such research. “If doctors and patients have the best information about what works and what doesn’t, then they’re going to want to pay for what works,” Obama said.

In a report issued June 30, the Institute of Medicine listed its top 100 priorities for comparative effectiveness research. Dialysis and kidney transplantation were high on the list.

Parker said Friday that the nephrologists had received a “very promising” response from Straube, indicating that federal officials “are open to further communications” about the future of dialysis.

Only the wealthy had dialysis
When President Nixon signed the 1972 bill establishing the End Stage Renal Disease Program, only 10,000 Americans were on dialysis, and more than one-third were doing it at home. Only the wealthy could afford long-term treatment.

The world’s first outpatient dialysis center, the three-bed Seattle Artificial Kidney Center, predated Medicare by 11 years. There wasn’t enough money or machines to go around. So an anonymous committee of Seattle community leaders decided which candidates would get dialysis and live and which would not and die.

The Medicare program opened up treatment to thousands who would have died without it. “We were naive in estimating how much this was going to cost,” says Brandeis University professor Stuart Altman, an economist who advised Nixon on health policy and now advises Obama. “People didn’t realize how many more people were going to go on it, how much longer we were going to keep these people alive.”

It soon became clear: If you pay for it, they will come. “All of a sudden, large numbers of people who were not traditionally on Medicare qualified,” Altman says. “We created this giant money machine that made a lot of nephrologists and entrepreneurs rich.”

Dialysis became big business, with free-standing centers established in hundreds of cities by corporations, not hospitals. The number of U.S. centers has increased 4% every year, according to a June report by the Medicare Payment Advisory Commission. In 1998, there were 3,394; in 2008, 4,957. About 60% are owned by Denver-based DaVita, a Fortune 500 company, and Fresenius Medical Care North America, a Waltham, Mass.-based subsidiary of a German company that operates centers in 28 countries and also sells dialysis machines and other supplies.

And about 70% of Medicare dollars spent on dialysis and injectable drugs goes to DaVita, which runs more than 1,500 U.S. dialysis centers, and Fresenius, which runs more than 1,700. In the first quarter of this year, DaVita’s revenues were $1.45 billion, up more than 8% from the first quarter of 2008. Fresenius’ revenues from dialysis in North America were $1.57 billion, up 5% over the first quarter of 2008.

Since 1983, Medicare has paid dialysis providers, whether for-profit centers, non-profit centers or hospitals, a “composite rate” per treatment, which averaged about $155 in 2007. And because Medicare pays the same amount no matter how long the treatment, there’s no financial incentive to dialyze patients longer than a few hours at a time.

On top of the composite rate, Medicare pays extra for newer, expensive injectable drugs — namely erythropoietin, or EPO, a hormone that stimulates red blood cell production, and vitamin D, which plays a role in bone health — and lab tests. These extras added an average of $75, or 50%, to the cost of each treatment in 2007. Countries with national health systems don’t use the injectables nearly as much. They use less EPO and prescribe oral vitamin D pills that cost about one-quarter of the injectable versions but, their doctors say, are equally effective.

Longer, more frequent dialysis
Longer and/or more frequent dialysis can improve quality of life and survival and reduce hospitalizations, some doctors and patients believe, although the government isn’t yet convinced.

[b]“If you ever see patients who are dialyzing six or seven times a week, they are totally different” from those who receive the standard three treatments, says nephrologist Christopher Blagg, a University of Washington professor emeritus who for many years served as director of the Northwest Kidney Centers in Seattle.

Besides improved blood pressure control and lower use of EPO, they generally feel better, with more energy. And chances are they live longer, Blagg says. As he told the House Committee on Ways and Means in March, “dialysis patient deaths and cardiac incidents are significantly more frequent on the day after the two-day gap between treatments that occurs with three dialyses in the seven-day week.”[/b]

From Medicare’s point of view, though, the End Stage Renal Disease Program “is a pretty expensive program, and it needs the best justification imaginable that more dialysis would be better,” says Eggers, the kidney disease institute epidemiologist.

Most of the evidence that longer and/or more frequent dialysis is superior has come from observational studies, in which patients decided on their own to try it. Perhaps some characteristic of the patients who choose to dialyze at home or overnight in a center — and not the dialysis itself — explains why they feel better and require less hospitalization than patients at centers.

A randomized trial, in which patients are randomly assigned to a particular therapy, is generally considered the gold standard for comparing treatments. Eggers is the project manager for two such dialysis trials, funded by the National Institutes of Health. One is comparing traditional thrice-weekly, four-hour dialysis treatments with six short daily treatments, adding up to about 16 or 17 hours a week. The other is comparing the traditional in-center approach to six nocturnal, or overnight, treatments a week.

Yet, neither of the trials enrolled as many patients as had been hoped, Eggers says, and he figures he knows why. "You have to go to a patient and say, ‘here is something that you do three times a week that you hate,’ " he says, and then tell them that they might have to do it twice as often. “It’s a pretty significant thing you’re asking a patient to do without a huge guarantee.”

Because of the studies’ limited size, they won’t be able to determine conclusively whether more dialysis saves lives, Eggers says. “We might show that patients feel a lot better and have better heart function.”

Blagg says he is so convinced of the benefits of more dialysis that he felt it was unethical to enroll patients in Eggers’ trials, in which they had a 50-50 chance of getting the standard treatment.

30% could be treated at home
Home is a convenient setting for longer or more frequent treatments. About 30% of U.S. dialysis patients are candidates for home treatment, though only 8% now do it, Blagg says. By comparison, about 55% of dialysis patients in New Zealand dialyze at home, as do 30% in Australia and 20% in Canada.

Some U.S. patients don’t even know home dialysis is an option. To fix that, Congress passed a law last year requiring dialysis providers to tell patients about all dialysis methods, beginning Jan. 1.

Home dialysis may also be more cost-effective, according to a May report by the U.S. Government Accountability Office which collected information from the large for-profit chains and non-profit and hospital-based dialysis providers. All of them said their per-treatment costs are lower when patients dialyze at home.

Centers recoup the “serious upfront costs,” mainly for the machine they provide, after the patient has been dialyzing at home for a year or 18 months, Blagg says.

J. Michael Lazarus, Fresenius Medical Care North America’s chief medical officer, says he wishes more patients would dialyze at home, because it would cut his company’s overhead and help it deal with a nursing shortage. But, he says, home dialysis is a hard sell to U.S. patients. “When you build enough dialysis units so there’s one on every corner,” Lazarus says, patients think " ‘why should I go home when I can go to your dialysis unit that’s 10 minutes away?’ "

Some patients find home dialysis too disruptive for their families. After doctors in 2007 had to remove the kidney her oldest son had donated to her, Michelle Adams-Walton, 46, tried hemodialysis at her Seaside, Calif., home for a couple of months. Her youngest son, now 20, served as her dialysis partner, a requirement for home dialysis.

“That machine did not work out for me,” Adams-Walton recalls. “We were both starting to feel the dialysis was taking over our entire lives.” However, she says, she had seen enough evidence to convince her that the more dialysis, the better. For her, nocturnal dialysis has been the answer.

On Mondays, Wednesdays and Fridays, Adams-Walton, who works full time as a librarian, drives 90 minutes to one of the few centers set up to provide overnight treatment. She goes on the machine at about 8 p.m. and is taken off at 4 a.m. Then she drives home and tries to catch some more sleep.

Since starting nocturnal dialysis, she says, “I certainly feel so much better.” Before, “I was able to function, but just function.”

What happens next

Congress has ordered Medicare to revamp the current pricing system. Payments for injectable drugs and lab tests not currently covered by the composite payment are to be “bundled” into it, effective Jan. 1, 2011. Details aren’t expected to be released for a few weeks, so the potential impact on dialysis care is difficult to predict.

The open questions:

• Will Medicare keep home dialysis training costs outside the composite payment? Home dialysis advocates fear that rolling such costs into the bundle will discourage centers from offering the home option.

• Will the expanded composite payment be based on what Medicare already pays for dialysis and injectable drugs? That wouldn’t result in any savings but could lead to an excessive reduction in the drugs’ use, says Bill Peckham, 45, a Seattle dialysis patient and blogger.

• Will Medicare start paying on a weekly or monthly basis, instead of per treatment? Peckham fears that would lead to fewer, not more, treatments.

Straube of CMS emphasizes that a “quality incentive program” will accompany the new payment structure. Instead of paying only on the basis of quantity, he says, Medicare will also begin rewarding dialysis providers on the basis of quality standards, such as how well they manage patients’ side effects.

Lazarus, of Fresenius, predicts “a number of (dialysis) units will close because of the bundle. Where are they and who’s going to be deprived?” If they’re rural, for example, that could greatly impact some patients.

Still, expanding the composite payment is “the right move,” Lazarus says. “We have to do something about cost. We have to do something with a system that’s out of control. It’s a broken system, and we need to fix it.”

I think you’re right Dori. The article makes the argument that with all the money we’re spending, how come more people aren’t getting optimal dialysis? That in itself is a step forward.

this is cross posted from DSEN:

USA Today reframes what ESRD program success would look like

                                            By Bill Peckham

RenalWEB linked to a USA Today article by Rita Rubin Dialysis treatment in USA: High costs, high death rates. I think Rubin did as good a job explaining the unexplainable as anyone I’ve read - certainly in the mainstream media. I have to admit I thought the paper skimmed issues, boiling them down to a graph but this was an in depth article. I’m looking at USA Today in a new light and not just because they quoted me, I think the article broke new ground.

Kaiser’s coverage of the USA Today’s article makes clear that the failure of the ESRD Program is evinced by the low use of optimal dialysis. The USA Today article even used the word optimal in reference to dialysis:

The vast majority of the more than 350,000 Americans on dialysis are treated in centers, where three treatments a week, three or four hours each, is the norm — not because it’s optimal but because that’s the way it has been done for nearly four decades.

That’s as close as we’ve been to having the main stream media identify optimal dialysis as our goal. Rubin did give the context against which CMS is demanding a Randomized Controlled Trial (RCT):[I]

When Medicare’s kidney-failure program started in the early 1970s, “the science was such that somewhere between three and six hours of dialysis three days a week was sufficient. Things sort of settled into that pattern,” says Dallas nephrologist Thomas Parker III, co-organizer of the conference at Harvard’s Beth Israel Deaconess Medical Center. [/I]

So in order to improve on a regime settled upon because it was sufficient we need a RCT? Under the circumstances observational data coupled with properly credited savings, due to fewer hospitalizations, should be all we need to go forward with accommodating more frequent dialysis in the new expanded bundle payment framework.

Great Timing with tomorrows Webinar…I think this is a good example of Treatment Options and Informed Consent… Many paitents just are not given the choice or informed about the different options and what may be best for them.
For the most part, many of the dialysis centers only offer one type of machine for treatment and do not push home hemo dialysis. They may give you the choice of PD or In-center Hemo and thats about it…
Sad to say, I have run into many RN’s that cant believe people do Hemo Dialysis at home. Yes, Even In-center Dialysis nurses. There have been a few that when i say I do Home Hemo they say “you mean Peritoneal” and I say no, “Home Hemo” and then say they had no clue it could be done at home… If the nurses and some doctors dont know, how are they patients going to find out other than through their own research…


Thanks for the cross-post, Bill. It was very cool to see you and Chris Blagg quoted in a national news article. :smiley:

MM, I agree that the timing is perfect for our Webinar tonight (there are still a few seats left, folks!). And it is APPALLING that any nurse could not know that there is such a thing as home HD! I can write a column for the Nephrology Nursing Journal about home dialysis, but haven’t done it in quite a while. Perhaps it’s time to resurrect it. Still, chances are that the folks who actually read nursing journals and who go to meetings and listen to presentations are not the ones who are so sadly ignorant. The question has always been how do you communicate with professionals who DON’T do those things?

All ideas welcome. Maybe we need a groundswell of education from dialyzors up…

Where will the new Conditions for Coverage rules come into play? Maybe our efforts should be towards educating state surveyors on the meaning and importance of patients knowing all of their treatment options.

If uninformed staff are describing the available options I would expect people to still believe that conventional incenter dialysis is the best option.

Harvey Wells wrote a great comment about this article that you can read here: http://blogs.usatoday.com/oped/2009/08/letters-gentler-dialysis-also-can-help-kidney-failure-patients-.html?csp=FacebookC1. There are some other good responses, too, and you can write your own!

I saw that. True too that the article skipped right over PD.

Here is a cross post from my blog

The USA Today article was good but there are nits to pick

Coming home from the meeting Saturday, I took Sunday off. I went back to bed after I got off dialysis. Two days of discussing dialysis reimbursement and the politics of healthcare left me spinning and spent. In that state reading the USA Today article by Rita Rubin Dialysis treatment in USA: High costs, high death rates was refreshing. The article was a great overview of a program I just spent two days discussing but one comment in the article seemed out place. It’s in the side bar on prevention where I too am quoted:

J. Michael Lazarus, Fresenius’ chief medical officer, says: “Every nephrologist would love to see patients earlier. But nobody sends them. … I’ve seen them in the emergency room at the end.” That’s because many rarely have seen any kind of doctor, let alone a kidney specialist, he says. End-stage renal disease “is a disease of the indigent,” he says. “They show up because nobody treated their hypertension, nobody treated their diabetes.”

"renal disease “is a disease of the indigent,”? Really?

I don’t think the way that reads reflects what Dr. Lazarus believes. He knows severe CKD is an equal opportunity disease - I know this because I’ve spent time with him so I know he knows me. Seriously though, I think it’s likely he was saying that poverty is a risk factor for severe CKD. That those who are indigent are disproportionately likely to need dialysis. I don’t think my quote in that box reads quite right either:

“It’s kind of immoral the way it works now,” says Bill Peckham, 45, a dialysis patient and blogger in Seattle. Though about one in five dialysis patients die every year, Peckham says, “you keep the chairs filled with new people, because Medicare doesn’t show up until you’re in the dialysis unit.”

I’m don’t think I said those statements in proximity to each other.

I believe the immorality was in reference to the way people are funneled into conventional dialysis - the lack of informed consent. And the second part doesn’t sound like how I normally state the problem. Those are three points I make but I don’t think they are related in the way the sentence makes it out.

If I had to guess Rita Rubin didn’t write the side bars.

The docs from that Harvard conference have really gotten a lot of mileage out of that letter they wrote to CMS (http://www.homedialysis.org/files/pdf/pros/BostonLetter.pdf, in case you missed it)–including this USA Today article. Another piece that has really gone viral, and was picked up in USA Today as well, was the Pauly et al article, which found that survival on nocturnal HD was equivalent to deceased donor transplant. And it hasn’t even hit PAPER yet! Here’s that abstract:

Nephrol Dial Transplant. 2009 Sep;24(9):2915-9. Epub 2009 Jul 7. Links
Survival among nocturnal home haemodialysis patients compared to kidney transplant recipients.

Pauly RP, Gill JS, Rose CL, Asad RA, Chery A, Pierratos A, Chan CT.
Department of Medicine, University of Alberta Hospital, University of Alberta, Edmonton, AB, Canada. robert.pauly@ualberta.ca

BACKGROUND: Kidney transplantation is the gold standard renal replacement therapy. Nocturnal haemodialysis (NHD) is an intensive dialysis modality (6-8 h/session, 3-7 sessions/week) associated with a significant improvement of clinical and biochemical parameters compared to conventional dialysis. To date, no studies have compared survival in patients treated with NHD and kidney transplantation. METHODS: Using data from two regional NHD programmes and the USRDS from 1994 to 2006, we performed a matched cohort study comparing survival between NHD and deceased and living donor kidney transplantation (DTX and LTX) by randomly matching NHD patients to transplant recipients in a 1:3:3 ratio. The independent association of treatment modality with survival was determined using Cox multivariate regression. RESULTS: The total study population consisted of 177 NHD patients matched to 1062 DTX and LTX recipients (total 1239 patients) followed for a maximum of 12.4 years. During the follow-up period, the proportion of deaths among NHD, DTX and LTX patients was 14.7%, 14.3% and 8.5%, respectively (P = 0.006). We found no difference in the adjusted survival between NHD and DTX (HR 0.87, 95% CI 0.50-1.51; NHD reference group), while LTX survival was better (HR 0.51, 95% CI 0.28-0.91). CONCLUSIONS: These results indicate that NHD and DTX survival is comparable, and suggest that this intensive dialysis modality may be a bridge to transplantation or even a suitable alternative in the absence of LTX in the current era of growing transplant waiting lists and organ shortage.

That makes four studies that have found survival comparable to transplant with daily or nocturnal HD, and national press about it. Will this make CMS stand up and take notice when bundling comes around, or will they continue to wait for the impossible dream of a huge, prospective, randomized controlled trial that will cost tens of millions?

RenalWEB has a tease up:
Response from CMS Chief Medical Officer, Dr. Barry Straube, to the Boston ESRD Steering Committee Letter To Be Published Here Friday at 9 AM EDT

I wonder what Straub has to say.

IMHO? The usual weaseling and refusal to admit that there is an evidence basis for longer and/or more frequent HD. I’m very disappointed in this response:

Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S3-02-01
Baltimore, Maryland 21244-1850

Office of Clinical Standards and Quality

Thomas F. Parker, M.D.
100 Highland Park Village
Suite 200
Dallas, TX 75205

Dear Dr. Parker:

I want to thank you for your thoughtful and considerate letter of June 5, 2009, addressed to Nancy-Ann DeParle at the White House and me at the Centers for Medicare & Medicaid Services (CMS). As you know, this letter outlined some of the imperatives to reform the delivery of care to U.S. ESRD patients, focused on simultaneously improving patient outcomes as well as increasing efficiency and value. CMS appreciates the summary and recommendations that you have submitted from the April 2009, international conference in Boston titled ESRD: State of the Art and Charting the Challenges for the Future. Many of the findings of this conference have been known for years and, for a number of reasons, have yet to be successfully addressed. CMS would agree that now is a good time for us all to attempt to address the conference findings, as well as many others not articulated in your letter.

Some additional issues include:

  1. The U.S. healthcare system spends more per capita on healthcare than any other nation in the world, often with quality outcomes far inferior to other developed nations. This is true of ESRD care. While some aspects of our payment and reimbursement system contribute to this, other factors are involved, including failure to follow evidence-based guidelines, lag in adoption of health information technology, inability and reluctance to measure and hold accountable quality and efficiency at the individual provider level, etc. Focusing on payment system reform alone won’t correct these other factors.

  2. There is disagreement, often due to a lack of sufficient evidence, for many of the proposed clinical interventions and initiatives that patients, providers and suppliers sometimes raise as solutions to ESRD treatment shortcomings. Any major changes we consider in the ESRD treatment and payment arena should, as a general rule, be based on sound, documented evidence, not opinion.

  3. The epidemic of Chronic Kidney Disease (CKD), still largely unrecognized by most Americans, must be included in any discussion of ESRD challenges. If we do nothing more to prevent the estimated 25 million Americans with CKD from progressing to ESRD, the financial and delivery system burden will be overwhelmed, reducing any hope of achieving the goals your letter raise. In addition, for those patients who inevitably progress to ESRD, the management of their transition from stage 2-4 CKD to stage 5 will be critical.

Page 2 – Thomas F. Parker, M.D.

  1. Addressing the many issues facing CKD and ESRD care in the U.S. will involve not just consideration of potential regulatory and administrative remedies that CMS might be able to implement, but also identification of issues that are beyond CMS/HHS authority and that would require statutory changes through standard legislative channels. Furthermore, there are many improvements that ESRD providers, patients and suppliers, as well as pharmaceutical and device manufacturers, might be able to achieve independent of statutory, regulatory, or administrative changes at the federal level, and are simply part of expected, “good” healthcare by providers and “responsibility” that patients should take. Finally, other payers have a role in addressing these issues.

As a next step, I would suggest that we arrange a preliminary discussion of the issues you’ve raised, either by teleconference, or in person. I plan to call you about this, and my Administrative Assistant, Shanterri Brown-Jones, will be in touch with your office(s) to set this up and coordinate the logistics, including who should participate in ongoing discussions. It will be important to assure that all stakeholders have an opportunity to participate in any such discussions over time, including beneficiaries and their advocates. As you know, there are a number of proposed payment rules currently in the active public comment phase and we are about to go into the rulemaking process for Section 153(b): ESRD Bundled Payment Reform, in the near future. Any discussions about specific payment changes need to be limited during rulemaking, but there are numerous issues outlined in your letter that we can preliminarily address.

One last issue, the address that you used to send me your letter is not a CMS address, but a private residence in Baltimore. Would you please correct the address in any database or listings that might contain it to 7500 Security Boulevard, S3-02-01, Baltimore, MD 21244-1850.

I want to thank you again for raising these important issues pertaining to CKD and ESRD and look forward to working with you and others on these matters. If you have any questions, or if I can be of assistance at any time, please do not hesitate to contact me. I am also sending this response to the co-signer of your letter.


Barry M. Straube, M.D.
CMS Chief Medical Officer
Director, Office of Clinical Standards and Quality
Centers for Medicare & Medicaid Services

CC: Nancy-Ann DeParle

“Despite the costs, a substantial proportion of dialysis patients die every year. In 2006, 20.1% of U.S. dialysis patients died, most often of heart disease or infections. In Japan, the death rate was about half that; Australia’s rate was halfway between the USA’s and Japan’s.”

I have to wonder how Japan is compensating the people who run their clinics?

The DOPPS data points to high fistula use and all nurse staff carefully cannulating for the Japanese outcomes.

I’ve always wanted to know how long each country runs people in terms of minutes per kilogram. I think the average 65 year old American is quite a bit heavier than the average 65 year old in Japan. Even if they each dialyzed for four hours per treatment the minutes per kilo would be very different.

At one time Japan paid per hour for dialysis but I don’t think that is true any longer. I think it is per treatment.


Thanks! You do have quite an impressive grip on all this! I do hope we find out the minutes/kilogram per dialyzor for each country someday.

By the way, we almost have the new dialysisethics website ready. The test site is looking good. Work slowed down when my old job wanted me back (hard to be so loveable sometimes). At least it is 40 hours per week rather than the grueling hours I was putting in before. I am seeing a niche for DE in all this.

The Harvard docs made USA Today again!:

Kidney doctors concerned by Medicare financing

By Rita Rubin, USA TODAY

Doctors concerned about the care of chronic kidney failure patients in the USA hope to meet this month with the chief medical officer of the Centers for Medicare & Medicaid Services, which pays for most of it, to explore how it can be improved.

In June, a group of leading nephrologists, or kidney doctors, voiced concerns in a letter to Barry Straube, the top CMS doctor, and White House health policy czar Nancy-Ann DeParle. The letter urged “substantial changes in the delivery and financing of care … to improve patient outcomes.” Although the United States spends more than any other country on treatment of chronic kidney failure patients, most of whom are on dialysis, it has the highest dialysis death rates.

“While some aspects of our payment and reimbursement system contribute to this, other factors are involved,” Straube wrote in response to the nephrologists’ letter. Other factors he noted included a failure to follow scientific evidence-based guidelines and a reluctance to measure dialysis centers’ quality and efficiency.

Some of the many questions facing the care of kidney disease patients would require action by Congress, but other improvements could be achieved without any statutory, regulatory or administrative changes, Straube wrote.

Medicare is due to change how it pays for dialysis on Jan. 1, 2011, but CMS hasn’t yet revealed details of the new payment structure, which had been expected in July.

“The proposed regulation is still under review,” CMS spokesman Peter Ashkenaz said Wednesday. “We do expect to meet our obligations under the law and the administration’s goal of ensuring people have access to care while continuing to pay providers appropriately for that care.”

Dallas nephrologist Thomas Parker III, co-chair of a Harvard conference that gave rise to the letter to Straube and DeParle, says Straube’s response showed “a willingness to address the entire program and to gain an understanding of what we can solve.”

Parker says he and members of his steering committee are drawing up an agenda for a meeting with Straube. In addition, Parker says, he would like CMS to meet with more stakeholders in the end-stage kidney disease program later this year or early next year.