3 points on dialysis John Oliver forgot to make

Dear John Oliver,

First of all, thank you for your recent segment on dialysis. Kidney disease deserves much more attention and discussion than it currently receives. Thank you also for your full-throated support of transplantation and the need for more kidney donors. As a practicing nephrologist, there is nothing better than hearing that one of my patients has been given a transplant. Finally, thank you for pointing out that end-stage renal disease is the lone pocket of universal health care in this country. We’ve been the government’s testing ground for years, and we have a lot of experience to share.

Most of the nephrologists I spoke with felt your show brought to light some uncomfortable truths, but also lacked nuance around several controversial topics. Hey, I get it. You only have twenty-three minutes, and you’ve also got to include jokes about horse porn, cantaloupes, ferrets and Taco Bell. You blame “bad incentives, high costs and profiteering” for the poor outcomes compared to the high expenditures. I don’t disagree with that, but I think there are some larger lessons to learn.

1. Cutting costs in one area leads to higher costs in others. We spend more and our outcomes are worse than the rest of the developed world, true. But the rest of the world also covers patients before their kidneys fail. That means kidney disease is diagnosed earlier, and patients are followed closely by a nephrologist before they ever see a dialysis unit. Pre-dialysis care is critical, and has been shown to significantly reduce complications and even mortality after starting dialysis. Forty percent of American patients “crash” into dialysis with no advance preparation. We’re behind before we even start.

We should also be clear that, while Medicare covers dialysis for the vast majority of end-stage renal disease (ESRD) patients, it only covers 80% of the costs. Out-of-pocket expenses remain very high for my patients — medication copays, special diets, transportation to and from dialysis and dental care. None of these are covered by Medicare, and all of them are vital when treating a chronic disease. Patients wind up in the hospital and undergo expensive procedures all the time because they can’t afford the prevention. Medicare covers the hospital stay, but not the treatments that keeps the patient out of the hospital. It’s crazy making.

Speaking of foolish cost cuts: Kidney transplants save the government money. The upfront costs are higher, but avoiding the estimated $55,000 annual expenditure on one dialysis patient makes those back pretty quickly. We’d make a big dent in the ESRD budget if everyone who was medically eligible got a transplant. So it’s particularly infuriating that patients lose their prescription coverage for the anti-rejection drugs three years after their transplant. That’s right; Medicare stops paying for the drugs that keep their transplant functioning after three years. After the transplanted kidney is rejected, Medicare starts paying for dialysis again. It’s lose-lose for the patient and the government. And for years, Congress has been unable to fix it.

2. Bad oversight leads to waste of resources without improving outcomes. You mentioned two separate forms of oversight in your report. One was a state survey, and one was the CMS five-star rating. Both of these have their issues, and I suspect most nephrologists shuddered at the thought of more of the same oversight.

State surveys take place every few years, though they can also occur at random. It’s important to know that state surveys rarely look at outcomes. In other words, how the patients are doing – are they surviving, are they healthy — is not the object of the survey. Instead, the surveyors have a long checklist of things the dialysis unit must do. This usually boils down to filling out forms — lots and lots and lots of forms. I have to sign probably a hundred or more forms a month. Any missing signature or unchecked box is a “deficiency.” My unit recently implemented a whole new computer system just to deal with one set of forms. We weren’t having problems with performing the dialysis, but the documentation was just too complex to get perfectly right each time. We spend a great deal of time and effort making all the forms “survey ready” with little evidence that patient care is improved one bit.

The five-star CMS rating system is another form of oversight, and this one does focus on patient outcomes. There’s also the quality improvement program (QIP) that looks at similar but not identical metrics. These affect payment, so they get a lot of attention. Unfortunately, their “all-or-nothing” nature doesn’t lend itself well to the intricacies of individual patient care. Not every target is right for every patient. In a small unit, just one or two patients missing a target could cost you a star. That’s a powerful disincentive for doctors to use their clinical judgment.

3. The current dialysis payment scheme has significant disadvantages built in. We have a much higher nurse-to- dialysis-patient ratio than other parts of the world. Even using fewer nurses, most dialysis units are constantly looking for staff. Why? Well, we can’t charge more for the treatments, and the Medicare reimbursement has a razor-thin margin. Yet we’re competing for labor with the rest of the health care system and their more generous budgets. Reimbursement for doctors isn’t much better. More and more nephrology training positions go unfilled every year because nobody wants to go into nephrology. Residents can make more after graduation as a hospitalist than they can as a nephrologist with two extra years of training.

Medication costs are a big portion of the dialysis expense. This drives consolidation because larger dialysis companies can negotiate better drug prices. But Medicare, the biggest purchaser of medications, is legally prohibited from negotiating lower drug prices. We squeeze the providers while allowing the drug companies to keep their lavish profits.

Most importantly, the low reimbursement from Medicare limits innovation. Dialysis technology has not changed much in the past twenty years in this country, except new drugs. We don’t generate ultrapure water as they do in Europe, and we don’t use techniques that dramatically improve the cleaning that dialysis provides. There’s no financial ability to do so. The FDA approval process for new equipment is extremely expensive. In all other areas of the American health care system, these costs can be recouped by charging insurance companies more for newer treatments. But Medicare will pay the same base rate for a dialysis treatment no matter what. So, our patients don’t have access to technological advances that the rest of the developed world enjoys.

If America is going to adopt a single-payer system, the dialysis community has some hard-won insights to share. Dialysis care in this country has some problems, as you and other journalists such as ProPublica have highlighted. But it’s only by examining the entire system around dialysis, not just the largest providers, that we can understand the barriers to improvement.

Sincerely,