Inertia is strong. Why make a change, any change, when somebody can rise up to warn: Tread carefully. Beware the unforeseen consequences. The status quo works well enough. And when moneyed forces back the status quo, inertia wins.
Consider the case of dialysis. When kidneys, which filter waste from the blood, fail, the person dies — unless s/he has either a transplant with a new kidney, or undergoes dialysis. Since the wait for a new kidney is three to five years, most patients go on dialysis while they wait.
The dialysis machine is a filtering device. Two needles will slowly remove blood from the patient. That blood goes to the machine where a liquid filters the waste. The filtered blood returns to the body.
Dialysis can take place either in a clinic or at home. In a clinic, typically the patient goes several times a week for three to four hours at a time, where a clinician administers the procedure. At home, the patient controls his own dialysis, doing it him/herself (inserting the needles), and controlling the frequency and the timing. Sessions can be shorter or longer, more or less frequent, and may happen at night. The patient decides. Although a partner may oversee the procedure, a patient can do it alone.
Today the majority of patients with kidney failure in the United States undergo clinic-based dialysis. The majority in New Zealand and Australia undergo home dialysis.
Home dialysis offers benefits. Studies suggest that patients take less medication to keep phosphorous under control, have less nerve damage, feel better during dialysis, have more energy, sleep better, have fewer and shorter hospital stays. Home dialysis can offer patients not just a better qualify of life, but may enable them to live longer.
In the United States, clinic-based dialysis is the norm. Patients undergo high spurts of dialysis a few times a week — what one nephrologist called a “bazooka approach” that works efficiently, but is not tailored to each patient.
To understand the divergent approaches, look to the money.
In “How to Make a Killing: Blood, Death and Dollars in American Medicine,” Tom Mueller argues that in 1972, when Medicare insured dialysis for all Americans, regardless of age, income, or work-status, it opened the financial floodgates for Big Dialysis. At the start, the country had many small dialysis centers, but over time DaVita and Fresenius — the big ones — bought up practices. Since the purchases fell below the cap that alerted the anti-trust police, the two corporations steadily expanded. Today they cover the majority of patients in the United States. Dialysis is profitable. The clinics collect from Medicare, and if the patient is privately insured, they negotiate a higher fee from the private insurers. One estimate of the dialysis market: $24.7 billion.
The consolidation of private clinics not only eliminated competition, but resulted in a now familiar tale of corporate greed: chains have replaced skilled with less-skilled staff, and have increased the patient load per staff member. Data, moreover, show fewer transplants, higher rates of hospitalization, and lower survival rates. This saga echoes the experience when for-profits enter the market in hospices, home health associations, hospitals, nursing homes.
The bigger concern, though, is not the character of Big Dialysis. As Tony Soprano remarked about the mob, it does what it does. Big Dialysis serves patients, but also serves stockholders.
The concern is the reliance on clinic-based dialysis when evidence from Australia and New Zealand points to the success of home-based dialysis. It is better for the patients, less costly for the payers.
Why not wean America’s kidney patients from the clinics? Why not sever the dialysis machines from their tethers to Big Dialysis?
The clinics — the way we have always operated — have inertia on their side.
But in this season of New Year’s wishes, let us wish that patients’ health can prevail over corporate wealth, that change can prevail over inertia.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email joan.retsinas@gmail.com.
From The Progressive Populist, December 15, 2023
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