Editor- To continue to look at dialysis from multiple perspectives, I invited Mr Bill Peckham to comment on Robin Fields article and provide us his thoughts on what's needed to improve dialysis care in the US. Bill Peckham has been on dialysis since 1990, and on home hemodialysis since 2001. Mr Peckham currently lone dialyzes in Seattle while asleep - five nights a week for 7 to 8 hours using the NxStage System One. Prior to switching to home overnight extended hemodialysis, he used short daily dialysis at home. Mr Peckham is a leading advocate for improving the quality of dialysis in the United States. He is past Board of Trustees chair at Northwest Kidney Centers, and has been a member of the Council at the Kidney Research Institute in Seattle. Mr Peckham has been involved in national initiatives as an expert stakeholder on an advisory group of a federally sponsored comparative effectiveness research project, on the steering committee of DOPPS,and on the 2010 CMS C-TEP developing fluid management CPMs. He has championed dialysis quality and been a vocal advocate for dialysis patients on his blog, Dialysis from the Sharp End of the Needle as well as participation in the vibrant CKD online community. He says "I've made many connections with people involved with the provision of dialysis, on both ends of the needle, and have had many discussions, over many years, concerning industry news and trends, in advocacy, reimbursement, politics regarding the provision of dialysis. Dialysis is my hobby; one I take seriously." You can read more about Mr Peckham on the following link.
COMMENTARY - Bill Peckham
If the Atlantic magazine article has a weakness it is that it takes two fundamental problems with the provision of dialysis in the United States and combines them into a single narrative. Improving the American experience of dialysis requires that we unwind these problems and understand the legacy constraints on the provision of dialysis separately from the unevenness of care.
As reported by Fields, the unevenness of care is a problem. In December, 2010 Dr. Barry Straub, then CMS's CMO commented on Fields reporting, agreeing that in some instances Medicare oversight was coming up short "We have been not able to perform the oversight functions as frequently or as thoroughly as we might like to”; that lack of oversight continues today in some areas of the country. Ten months later the industry consolidation Fields described has strengthened. This past year has seen further dialysis industry consolidation. DaVita has purchased DSI Renal, while Fresenius has purchased the newly combined Liberty/Renal Advantage. By the end of 2011, to a greater degree than just one year ago, the provision of dialysis in the United States will be dominated by two for-profit companies.
While it wasn't directly stated by Fields in her reporting the underlying reality is that in the United States the dialysis you receive depends, to a large degree, on your zip code. In some areas of the country the provision of dialysis is above Medicare's standards. There are many units with low staff turnovers. In some states, but not all, the survey agencies are well-run and provide appropriate oversight. There are areas of the country served by more than one or two providers, providing the opportunity for a real choice for patient’s of where to receive dialysis. There are zip codes where someone can dialyze in the evening and stay employed. There are many areas where dialyzors have access to all hemodialysis options. But there are also areas of the country where none of this is true; zip codes where the provision of dialysis continues to comes up short.
There are zip codes where a dialyzor does not, short of moving, have a choice of providers. Zip codes where evening hours are unavailable, and dialyzors are not expected to work. Zip codes served by units where yearly staff turnover approaches 100%. Zip codes with units that have not been surveyed this century. Zip codes where alternatives to conventional incenter dialysis are nonexistent. In these zip codes the situation is still as Fields described, the units are “run like factories” and surveyors continue to find “blood encrusted in the folds of patients’ treatment chairs”. This unevenness in care is an unevenness in dialysis opportunity.
Even if you manage to avoid this first problem and live in a zip code with good dialysis care, as a dialyzor you still face the treatment constraints that are a legacy of our dialysis history. The three-day-a-week schedule is a chance legacy that has been engrained into a defining characteristic of incenter dialysis. The three day a week schedule necessitates a dangerous dialysis weekend. Going back 40 years there has been a great deal of research pointing out the danger inherent in routinely taking an extra day off from dialysis, most recently a paper in the New England Journal of Medicine underscored the risky nature of two days off.
The way forward has to include dialysis schedules without the dialysis weekend. Clinically we've gone as far as we can go with conventional three-day-a-week dialysis. A three-day-a-week schedule may remain the standard of care for those using dialysis as a palliative treatment, but for everyone else who can accommodate an every other day schedule, dialysis should deliver better outcomes by delivering a higher dose. This way forward is not the easy way, but things that are worthwhile are rarely easy.
As I wrote in a February AJKD article an every-other-day treatment schedule should be evaluated given the incentives inherent in the expanded bundle. Yet there seems to be no movement in this direction. Each treatment delivered on a Sunday would include, on average, a $70 reimbursement premium, decrease the use of medications, and keep patients out of the hospital. With this financial incentive in place, and the evidence of harm (ensuring MAC/FI payment), it is time for providers to move forward with every other day schedules.
Providers are quick to say that their patients don't want to dialyze more, that "my patients already skip". However, it is unfair to suggest the three-day-a-week schedule is accommodating patient preference given that incenter every-other-day schedules are not available. Patients can not act ahead of administrators, administrators must act first.
It is a novel situation. There is uneven quality. Legacy standards of care that are inadequate. And to top it all, there are just two companies responsible for the provision of a life sustaining medical procedure, largely paid for with public funds.
Novel situations require novel solutions. Mark Schlesinger was right when he said in the Atlantic magazine article, that "the program has squandered an opportunity to be a model of patient empowerment" but we don't have to continue squandering this opportunity. We can go beyond the standards of today, to superior outcomes tomorrow by empowering patients and providing them with a safer dose of dialysis. The two large dialysis organizations (LDOs) can act to make this happen without further regulatory action. The LDOs can empower their patients to expect care that is attentive, not only to their health, but also to their dignity. And, the two LDOs can do away with the mandatory dialysis weekend without further changes to payment. Once the LDOs act, these problems will be solved for 70% of the nation's dialysis patient census. They should act now.
In summary, we have the tools we need. We lack only the will.