The Big Business of Dialysis Care

NEJM Catalyst http://catalyst.nejm.org/the-big-business-of-dialysis-care/

June 9, 2016
Ron Shinkman
Health Care Editor and Journalist

NEJM 的Catalyst 這一期談到美國的透析治療，其中有些有趣的數字和比較，提供大家參考。

According to the U.S. Renal Data System, 468,000 patients underwent dialysis in 2013. That’s a nearly 47-fold increase in 40 years, driven in part by the rise nationwide in diabetes, hypertension, and other chronic conditions.”

拜慢性病（尤其是糖尿病患者增加之故），美國洗腎患者在40年內，增加了47倍，目前約468,000位透析患者。

在1973年，透析治療納入美國的Medicare給付項目。一開始約10,000個透析患者，當時一年花費 $200 million。

目前2015, Medicare每年花$34 billion透析費用。

透析死亡率下降 36%，between 2001 and 2013。

The Corporatization of Dialysis Delivery

美國也是有愈來愈多，私人的透析院所，在shopping mall也有。

前二大透析器材供應商占了70%，Fresenius Medical Care and Colorado-based DaVita Healthcare Partners。

這二大供應商共有3,900透析點，幾乎是以下超市的數量總合(Target, Best Buy, and Publix Super Market stores)

It currently costs about $88,000 a year for a patient to undergo dialysis, according to the USRDS. That’s about 60% more than what the average U.S. household earns in a year.”

根據USRDS，目前每位透析患者年花$88,000費用(透析+住院+急診），這數字超過一般美國家庭平均收入的60%。Fresenius的資料，美國透析患者，一季大約住院10天，(more than double the hospital days for its patients in Asia or Latin America)。(筆者註：台灣透析患者還是照顧得比美國好）

The two leading dialysis companies, German conglomerate Fresenius Medical Care and Colorado-based DaVita Healthcare Partners, control about 70% of the U.S. market.”

有non-profit 和 for-profit 經營者，non-profit的患者死亡率較低。

The big for-profit operators have also been shown to have much higher mortality rates than nonprofit dialysis centers in the U.S. A 2010 article inHealth Services Research tallied a 19% higher risk of death at Fresenius facilities, and a 24% higher death risk at DaVita facilities, than patients receiving care at the biggest nonprofit chain. 

美國的透析患者死亡率比歐洲和日本高，原因可能是：營養不良，和工作人員的訓練不足。

2009, “Why Is the Mortality of Dialysis Patients in the United States Much Higher than the Rest of the World?”  U.S. one-year mortality rates were among the highest in the world: 21.7% in 2003, versus 15.6% in Europe and 6.6% in Japan. The authors fingered patient nutrition and staff training as particular causes of the discrepancy.

Cost Growth, and Cutbacks

透析費用逐年成長，Medicare 2011年開始包裹給付，每次$240。

2011, Medicare began bundling dialysis care payments in an attempt to better control expenses, paying about $240 per treatment, or around $37,000 a year.

透析患者若是有私人保險，則一開始透析前30個月由私人保險給付，後來才由Medicare接手（私人保險給付透析的金額較高，約2倍）。

Private payers typically pay at least twice Medicare rates

Home dialysis isn’t always feasible: Patients must be able to take care of a lot of the dialyzing themselves, or have the means for a home caregiver, among other variables.”

Home dialysis可以節省透析費用支出，目前Fresenius’ and DaVita’s home dialysis rates hover around 20% and 10%, respectively. 

Empowered Dialysis

1) 教病人透析時做瑜伽，增加循環。

Richard Gibney, MD,  in Waco, Texas, Fresenius-owned dialysis centers
Yoga classes for patients as they’re being dialyzed — a response to the rising rates of diabetes among the patients and a need to increase their circulatory performance.

Gibney’s most radical approach toward dialysis is the notion of “empowering” patients by having them perform some or much of the setup and monitoring of their treatment.”

2) Gibney醫師，讓病人自己準備透析用品，設定，打針，以及自己監測透析、回應警報發生時處理，目前他有280位病人是"empowered dialysis"，和傳統由護理人員操作透析相比，這群"empower dialysis"病人，有較少的死亡率和住院率。（瑞典首創‘hunker-down dialysis.’，據說可以減少33%透析費用和增加病人滿意度）

另一家醫療公司試圖用科技來幫忙透析：Outset Medical, based in San Jose, California

Tablo這台機器，設計成讓透析就像在ATM領錢或是自行結帳的商店一樣方便，照螢幕指示，一步一步完成。

A marker of success for Tablo would be in making dialysis pleasant enough for patients to reduce missed treatments, which average more than 13 per year and lead to higher hospitalization rates.”

Tablo 會減少工資支出，減少medical complications (?)，減少病人因故沒有至院所透析的機會，和透析技術人員的工作機會?（因為病人都可以自己操作機器了）

Technician staffing are going to lose their jobs?

“I said ‘No, that’s totally wrong. We’re transitioning from you being a worker bee, a madman like you’re running cattle through a chute, to becoming teachers, mentors, and cheerleaders,’ ” he says.

筆者註：我怎麼覺得最後一段是在安慰透析從業人員的？當機器可以和病人配合把透析這件事做好，那還需要那麼多的員工嗎？時事評論一下：華航空姐這次罷工，成功得獲得所要求的權利固然可喜，然而華航高層目前會不會在想，「是不是該請鴻海郭董研發個機器人空姐了呢？」

Ron Shinkman

Los Angeles–based health care editor and journalist specializing in economics and public policy