Keep them in dialysis until they die

A few years ago I found myself taking a small role in helping a friend survive kidney failure. The story had many twists and turns, but for the purposes of this post, what matters is that before she was lucky enough to receive a transplanted, healthy kidney, she spent several months on thrice weekly dialysis. Dialysis is a procedure which pumps out the toxic byproducts of normal metabolism usually removed by your kidneys by drawing out your blood, filtering it, and pumping it back into you. If that seems nasty and drastic, it is.

The commercial dialysis center where she went for the procedure was in a dreary urban shopping center, across from a rundown Safeway, some fast food outlets, and some liquor stores. This plaza used to serve the core of the San Francisco Black community back before Blacks had been largely driven out of San Francisco by too much tech money chasing too little housing. Many, perhaps most, patients at this center were still older Black people. We saw the same folks, week after week.

My friend escaped this sad facility, through a combination of grit, luck and a measure of white privilege.

Most people don't escape. Anne Kim at the Washington Monthly provides a devastating picture of who commonly suffers from kidney disease, how they mostly end up sentenced to years of dialysis, and even some suggestions about how this corrupt, discriminatory system could be made more just -- and more kind -- for sick people.

Of the 661,000 Americans with kidney failure, about 468,000 people—more than a third of whom are black—are on dialysis. In the District of Columbia, where the prevalence of kidney failure is the highest in the nation, according to the Centers for Disease Control, there are twenty-three dialysis centers, mostly in Northeast and Southeast Washington, the predominantly black parts of the city that are also ground zero for diabetes and high blood pressure, the two conditions most linked to kidney disease. Another 100 dialysis centers are within a twenty-five-mile radius of the city, again concentrated in the suburbs with the largest minority and low-income populations. ...

Like check-cashing outlets and payday lenders, dialysis centers—the vast majority of which are for-profit, like DaVita and U.S. Renal Care—are now fixtures in the urban commercial landscape. “We used to say there’s a liquor store on every corner,” said Clive Callender, a transplant surgeon and professor of surgery at Howard University. “Now we say there’s a dialysis unit on every corner.”

The prevalence of dialysis centers in minority neighborhoods is a reflection of policy failures that encourage—indeed institutionalize—class and racial disparities in American health care. These failures include more than just disparate access to the primary and preventive services that could help high-risk patients stave off kidney disease. Public policy effectively steers low-income and minority patients with kidney disease toward dialysis and away from superior options, particularly transplants.

***Everyone with kidney failure, also called end-stage renal disease, is covered by Medicare. And Medicare guarantees payment for every dialysis session. As a result, the treatment of kidney failure is a volume-centered business aimed at keeping dialysis centers running. “You fill up a facility with so many stations, you make sure somebody is sitting in each of those chairs around the clock,” said Dennis Cotter, president of the Medical Technology and Practice Patterns Institute. “It’s the Henry Ford production model.”

This system creates an incentive for clinics to keep patients on dialysis until they die.

That’s one reason why low-income patients have a tougher time getting transplants, which is the best treatment for kidney failure: their clinicians may not tell them it’s an option. And the longer they stay on dialysis, the poorer their health is likely to be, making them less viable as transplant candidates.

... Medicare currently pays dialysis clinics $231.55 per treatment. That means a clinic like the one in the Southeast D.C. strip mall, with twenty-five chairs, can make $5,788.75 every four hours if all chairs are filled. Assuming three shifts a day, six days a week, that’s $5.4 million per year.***
... the most tragic consequence of a system that incentivizes keeping people, especially poor people and minorities, on dialysis is that it also keeps them from getting what is beyond doubt the best treatment for kidney failure: a transplant.

“A successful transplant gives you almost a normal life expectancy, particularly if you’ve never been on dialysis,” said GW transplant surgeon Joseph Melancon. Between 76 percent and 85 percent of transplant recipients survive five years after transplant, compared to just 42 percent for patients on traditional hemodialysis.

In 2014, of all patients suffering from end-stage renal disease, fewer than one in five black patients with kidney failure were transplant recipients, compared to just over one-third of white patients.

What to do to replace this racist and cruel system? That's not so hard to imagine once we become aware of the economics involved. It might even reduce medical costs in the end:

... give low-income and minority patients a fairer shot at getting a kidney transplant. That means, at a minimum, making sure Medicare pays for lifetime coverage of immunosuppressant medications for transplant patients, instead of just thirty-six months. The original rationale for the current policy, established decades ago, was that transplant patients would eventually get jobs and private insurance, but the instability of work in the modern labor market and the price of coverage make this reasoning far less plausible today.

A likelier explanation for the policy’s continued existence is lobbying by the dialysis industry, which benefits from keeping patients on dialysis and not “losing” them to transplant.

... Democrats who want to move toward single-payer or a robust public option must figure out how to lower the cost of delivery to have any chance of succeeding. Fixing how Medicare treats end-stage renal disease, which accounts for 7 percent of its budget, would be a good place to start.

I knew nothing about this system until I saw it through my friend's experience. The least we can do is spread the truth about this racist distortion of "health care."