End State Renal Disease (ESRD) is the only disease condition that is covered by Medicare regardless of patients’ age. This benefit was passed in 1972. One result of Section 299I of Public Law 92-603 is that Medicare pays for two-third of dialysis patients, down from 87% in 2004. When your kidney function falls by 85% to 90% your kidneys can no longer keep you alive. According to the National Kidney Foundation, the average life expectancy on dialysis is 5 to 10 years, but many people live much longer when their dialysis is tailored to their needs. This often does not happen due to the United States’ mostly one-size-fits-all approach to dialysis, which is not ideal.
Most leading nephrologists worldwide agree that dialysis should ideally be delivered in long, frequent sessions at low ultrafiltration rates, and be carefully tailored to each patient’s physiology. Large dialysis companies, by contrast, frequently employ what John Agar, the Australian nephrologist, calls “bazooka dialysis”: treatment in brief, high-speed bursts following a one-size-fits-all protocol. Nephrologists who order longer treatments or make other customizations of their patients’ dialysis prescriptions may encounter obstruction by clinic management.
Americans with ESRD tend to go for dialysis two or three times a week to a dialysis center and spend hours at a time in a dialysis chair. For some patients, three times a week is not enough. Without dialysis their blood would become filled with toxins and they would die. Dialysis centers are often not close to patients’ homes forcing them to travel long distances for treatment. At the dialysis center they recline in chairs and remain tethered to a machine for several hours. It is the epitome of inconvenience.
There are machines that can filter blood at home while patients sleep. These machines cost about $26,000 to $47,000 apiece, according to GoodRx. It is tempting to think of dialysis as a complex lab machine but it’s really rather simple. Blood never touches the machine. The machine squeezes a tub of blood pushing it through a in-line filter similar to a fuel filter that absorbs toxins, called a dialyzer. Home dialysis is not only more convenient but is also healthier. As one can imagine, having dialysis eight hours a night, seven days a week is healthier than three times a week for three hours at a time. Not all Americans have access to home dialysis machines due to the way dialysis is reimbursed.
Dialysis in Australia is different is several ways. Australian dialysis is more patient centered.
The treatment philosophy that Agar followed for decades, until his retirement in 2020, emphasizes life quality as the main goal of good dialysis and home treatment as the best option for most patients. It’s practiced today at centers throughout Australia and New Zealand. Columbia-Presbyterian nephrology specialist Leonard Stern’s dream of high-quality home dialysis for the masses is already a reality, Down Under.
The decision to cover Kidney failure through Medicare 50 years ago made dialysis more bureaucratic and less flexible. It doesn’t have to be that way.
Many of Agar’s patients dialyze at home, not because they live in the bush — a higher percentage of Australians than Americans live in cities — but because they’ve developed the independence and confidence required to treat themselves. Agar, his nephrologist colleagues, and his team of nurses train patients to cannulate themselves and run their own machines, according to the treatment plan that best fits their individual physiology and lifestyle. (Nurses and technicians are always on call, if patients get into trouble.) For most of Agar’s patients and their families, dialysis is less an alien ordeal than a challenge of everyday life. “Our patients take charge of their own health,” he says. “We don’t even allow their partners to cannulate. In fact, for most of our patients who dialyze at home, if somebody comes near their fistula, they’ll beat him with a cricket bat. ‘Get away from my fistula! I’m the only one who looks after that.’ Patients gain a huge sense of responsibility and accomplishment. They’re not helpless victims in this process. They’re in charge.”
Medicare pays about $270 for a dialysis treatment. Depending on how many treatments a year patients need that can add up quickly. Depending on the type of insurance patients have, their costs can add up too. On traditional Medicare cost sharing is 20%. It makes me wonder if the Australian approach would not be cheaper in the long run. It would also be more convenient and better for the heath of Americans with kidney failure.
The entire article is worth reading: Australia’s approach to dialysis celebrates life – STAT (statnews.com). Excerpted from “How to Make a Killing: Blood, Death and Dollars in American Medicine” by Tom Mueller.