The for-profit model in the U.S.
Dialysis in Australia and New Zealand (ANZ) is provided free of all charge to patients by accredited renal units established through the public, tertiary hospital system. For example, Dr. Agar has been the director of his institution’s central renal unit for the past 30 years; the director is always a practicing nephrologist. In this “hub and spoke” setup, each central in-center service administers and staffs multiple suburban, regional, and—where appropriate—remote satellites.
Except for a small number of barely profitable or even loss-producing private satellite services in one or two Australian states, Dr. Agar notes, companies do not provide dialysis services there. Conversely, in the United States, dialysis services are provided by for-profit companies. “Companies are, in the end—and as companies should be—beholden to profit-making for their shareholders,” Dr. Agar says. “This is a huge and fundamental difference. Again and broadly, we in ANZ provide, prescribe, and support dialysis as we believe it to be best suited to each individual patient.”
Whereas the U.S. dialysis patient is responsible for a 20% copayment—which may be covered under a Medicare Advantage Plan or Medigap policy (www.medicare.gov/publications/pubs/pdf/10128.pdf) —dialysis is free to the ANZ patient. “This is also true in the main for their physicians and dialysis teams who are salaried and, as a result, make their decisions about their patient’s best interests—home or otherwise—with the patient and his/her family but without the income pressures that might occur if a ‘fee’—read income—is gained or lost depending on the site of dialysis,” Dr. Agar adds.
But not only is home dialysis better for the patient, Dr. Agar says, it is far less expensive for the government. “The costs of home HD and home PD have consistently been shown to come in at anywhere from 15% to 30% cheaper in a range of studies here [ANZ], in Canada, and elsewhere,” he states. “If it is better for the patient and better for the national accounts, why wouldn’t you encourage, support, and even incentivize it?”
On the other hand, Dr. Agar argues, “If funding is for-profit, and profits are best likely to be made in a center under a ‘Henry Ford’ production-line model of care and are not likely to be made at home under a patient self-care program model, where is the incentive to devise and support the home-care model?”
Dr. Agar believes that about half of dialysis patients are capable of home self-care. “In ANZ, many dialysis services sustain a comfy 40% to 50% of patients at home, with some units doing even better than that.”