Dialysis Unplugged: "The Dialysis Industrial Complex Revisited"

Editorial - Dr. Ajay K. Singh

Dr. Peter Laird writes in his blog HemoDoc, from a few days ago.

 “How America devolved into the world's worst dialysis program in the developed world is a subject of much debate, but one issue is clear, the origins of this noble experiment as Dr. Scribner described dialysis produced one of the most amazing medical marvels of the twentieth century.  Prior to the 1960's ESRD was uniformly fatal and often in a very short period of time. With the advent of the Scribner Shunt, patients could now expect several years of productive lives. By 1973, 80% of the dialysis patients dialyzed in the comfort of their own homes on a thrice-weekly schedule of 6-9 hours nocturnally in most centers. Patients worked and lived their lives rehabilitated from a certain death. It truly is one of the brightest stories in medical history that cost only $7000 a year at home after the first year but up to $29,000 a year in centers.

However, by the early 1980's, the majority of American dialysis patients dialyzed in large dialysis units where the owners and the nephrologists fought over splitting the huge profits, yet at the same time, mortality and morbidity increased nearly as fast as their doctor's bank accounts. Today, DaVita and Fresenius dominate the American market with the most expensive dialysis population and the world's worst outcomes. History records in the public record the 1978 congressional hearings where the testimony of Edmund G. Lowry, the vice president at that time of National Medical Care, single handedly doomed an entire generation of dialysis patients to short, violent sessions coupled with daily nausea, vomiting, severe fatigue, cramping and bouts of syncope.”

Dr. Laird implies that the pursuit of thrice weekly dialysis by companies such as DaVita or Fresenius doomed an entire generation of dialysis patients. I respectfully disagree.

The for-profit model that developed at the dawn of commercialized dialysis care had it's positive attributes -- it was an engine for tremendous innovation– smaller cheaper more biocompatible dialyzers; improvements in water quality; improved dialysis machines, including the development of volumetric control, and the list is long. Dialysis innovation dissipated when the facility fee (the fee for the dialysis procedure) couldn’t keep up with inflation. For-profit and even not-for-profits needed to generate a margin and they did so through strategies that saved money. They cut corners, including changing the clinical model from nurses to patient care technicians, overusing drugs like epo, and for some, sketchy and potentially illegal practices like wasting medications to over-charge CMS. Almost everyone knew what was going on, including CMS, which turned a blind eye to these practices.

The reason we lost our way is not because of the DaVita’s or the Fresenius’s of this world. DaVita and Fresenius are motivated by the pursuit of profit -- for shareholders and for their employees. They are doing what they are incorporated to do. And, if there were profit in home dialysis comparable to the current thrice-daily model they would be aggressively dominating this business.

The reason we lost our way -- and I agree with Dr. Laird -- is that nephrology became a part of this “Dialysis Industrial Complex” – “the owners and the nephrologists …splitting the huge profits”. We joined hands with the dialysis companies, and big and small pharma, to push for things that didn’t necessarily represent the best for our patients. We wrote guidelines that were misguided, and not supported by the science, and we pushed for incremental improvements in dialysis care but not patient-centered outcomes like quality of life or mortality that could have been transformative.

With the current deficits in the US economy only getting worse, it is likely that the pressure on economizing dialysis care will increase. Robert Brook writing in JAMA (JAMA, August 10, 2011—Vol 306, No. 6, 650-1) suggests that we face 3 scenarios: doing nothing, participating in rationing, or taking the lead in identifying and eliminating waste. Brook uses an economist’s definition of “waste”. He writes: “Waste to an economist is an expenditure that does not produce commensurate value”. Rationing in dialysis is already there – it’s called bundling. Nephrology needs to change the narrative to one of reducing waste in dialysis, by defining waste like an economist –focusing on outcomes that are cost-effective. I hope that we’ll end up with the original Scribner model of longer home-based dialysis, not because it's more profitable, but because it's less wasteful.