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Alwin Hawkins is a critical care nurse and therefore is on the front lines of the health care battles. He offered some interesting pushback on the article I published recently on the proposed Medicare bill that would increase the level of payment to dialysis centers at the expense of home dialysis.

I didn’t suggest that the reimbursement rates should be cut, just that they shouldn’t be increased, and not at the expense of home dialysis. The corporation that owns the dialysis center I use is looking at an annualized profit (based on Q1 financials) on the order of US$160 million this year.

Here’s how I would support an increased reimbursement rate (subject to change after the Philadelphia subpoena of DaVita records runs its course):

A higher dialysis dose and special dialysis filters provide no additional benefit to ESRD patients; the minimum dialysis dose recommended by current treatment guidelines is adequate. That’s the finding of the first major National Institutes of Health (NIH) clinical trial for dialysis in more than 20 years. The study was conducted primarily because of the high death rates and frequent hospitalizations of hemodialysis patients.

Dr. Garabed Eknoyan, the study’s lead investigator, announced that the study indicated that hemodialysis patients who received a higher dialysis dose than the minimum recommended dose or who used high-flux dialysis filters neither lived longer nor stayed out of the hospital longer than hemodialysis patients who received the minimum recommended dialysis dose.

Appearing to contradict the conclusions of the study’s researchers are two interesting findings:

• Higher dialysis doses appeared to reduce the risk of death and hospitalization among women.
• High-flux dialysis filters appeared to reduce the risk of death among patients who had been on hemodialysis for more than 3.5 years.

This week, two congressional committees—the House Ways and Means committee and the House Energy and Commerce committee—are scheduled to vote on a new Medicare bill. If passed, the bill would move to the full House of Representatives for a vote. The draft bill includes a provision that would increase the level of payment to dialysis centers. The payment increase would be funded by lowering the payments for home dialysis by 20 percent. Currently more than 340,000 people are on dialysis or have a kidney transplant in the United States and total treatment costs are US$17 billion each year.

The proposed payment level increase is problematic for hemodialysis patients for a variety of reasons. Most of us currently dialyze in dialysis centers—only about ten percent of U.S. end-stage renal disease (ESRD) patients dialyze at home—but the home dialysis technology improvements are promising. Most disturbing is that lower home dialysis payments will likely create a disincentive for dialysis centers to continue their home dialysis programs. Such a situation would, in turn, create a disincentive to the continued development of innovative home dialysis technologies.

While I have no plans for home dialysis, it’s important to me as a treatment option, especially since I’ve seen the level of care I receive at the dialysis center steadily decrease over the past two years. Dialysis technicians that six months ago seemed grossly incompetent—and obviously so—now bring relief when I find they’re on duty. It’s not because they’re suddenly competent, it’s just that some of the newer technicians are even more incompetent.

Aksys Ltd.‘s Personal Hemodialysis System (PHD System) has received approval by the U.S. Food and Drug Administration (FDA). Home hemodialysis has been around for a while, so some coverage of the company’s announcement has been overblown.

What sets the Aksys PHD System apart is that it’s the first dialysis machine designed specifically for home hemodialysis. This is important for several reasons:

• End-stage renal disease (ESRD) patients can dialyze themselves overnight. No dialysis center in my area, for example, offers overnight dialysis sessions.
• Some studies indicate that home hemodialysis is safer than in a dialysis center.
• Some studies indicate that daily dialysis is more beneficial to the patient.

Is it possible for a health care system, when organized by institutions with primary objectives that are more tied to their own economic growth than to patient outcomes, to be a truly healthy system? Medicine acknowledges that cancer cells grow in total disregard of the cells around them. We’ve known since the early eighties that health care was becoming just another commodity in a free market with its marriage to the bottom-line of potent institutions. So, should we be surprised to discover that the typical forces that produce the Enron’s of the world are alive and well in the health care industry? A recent article in the New York Times suggests to me that kickbacks have evolved into a fine-art form with stock or options being offered to executives at Premier, one of two powerful buying groups that serve as middlemen for supply purchases for half the country’s non-profit hospitals. It looks like I’m not alone with that thought.

Larry R. Holden, president of the Medical Device Manufacturers Association, according to the Times article by Walt Bogdanich, Barry Meier, and Mary Williams Walsh, had this to say: “Billions of dollars are being controlled by two companies, and nobody knows who they are. Nobody looks at their books. Nobody knows what companies they are investing in.”