||The Peer Kidney Care Initiative: Improving Dialysis Care in the US
Posting from the AJKD blog. Free, full-text, supplement issue of American Journal of Kidney Diseases on the Peer Kidney Care Initiative.
Editor's note: One would usually want to applaud such an effort by so many experienced physicians. Unfortunately, it fails to address the greatest shortcomings and blind spots of U.S. dialysis care.
U.S. dialysis care has trailed far behind other fields of medicine in improving patient outcomes and has trailed other first-world countries in dialysis care for decades. U.S. nephrology has always focused solely on hospitalizations and mortality statistics as the way to improve the patients’ quality of life. This Peer effort continues and solidifies that mistake. It also continues a very limited search for solutions that will improve morbidity and hospitalization rates, as the solutions must fit the infrastructure, dialysis machines, and mindset that U.S. nephrologists have invested in over the last several decades.
Usually, only the top specialists in a field of medicine make astronomical amounts of money. The Stark law, which permitted nephrologists to own the clinics to which they referred patients, made it possible for most U.S. dialysis-care nephrologists to become multi-millionaires. A nephrologist's net worth was based on the number of patients they had in their dialysis clinics. Not unlike cattle farmers, they found a herd medicine approach was best for them. There was no need to be a great physician or even an engaged physician. With fixed reimbursements per treatment, the cheapest and fastest dialysis treatments were the primary goal of most nephrologists’ care and business. There were no centers of excellence that focused on patients’ life and health goals. As patients had no other options, U.S. nephrologists could ignore patients’ needs and concerns and still become rich. This is the revered tradition of U.S. nephrology, where this easily-gained wealth ─ unfortunately ─ seems to equate with being right.
Does any other field of medicine avoid patient engagement like U.S. dialysis care? Major organ replacement therapy must include, as was expected forty years ago when federal funding was approved, major emphases on rehabilitation, psychosocial wellbeing, and patient employment. U.S. nephrology has ignored all of these with disastrous results. Patients become enslaved to a life called dialysis. Without focus on the meaning and purpose of patients’ lives, too many patients become depressed, lose hope, as well as the will to survive. Nephrologists admit that virtually none of them would accept the therapy that over 85% of their patients receive. According to the USRDS, less than 10% of working-age patients are employed. Why won’t U.S. nephrology leaders address this? Is it because the money would come out of their own pockets?
Due largely to their ownership positions, U.S. dialysis care nephrologists continue to cling to the image and power of being "captains of the ship." Dialysis care will be greatly improved when they finally realize that while they can continue to be the captain for acute care, for long-term chronic care they should simply be the ship's doctor … on the patient's boat.
The Stark law keeps U.S. nephrologists firmly aligned with business interests. As a result, this Peer group, the Renal Physicians Association, and Kidney Care Partners can and will never act as effective patient advocates to policymakers and lawmakers.
I have watched this Peer movement evolve since the 2009 Boston meeting. From the beginning, they did NOT attempt to include patients, address their psychosocial needs, or consider the impact of their financial interests in caring for their patients.
A message for U.S. dialysis-care nephrology: First, diagnose (and demote) thyself. Acknowledge that you can’t serve two masters. Change the system so you can be physicians -- and effective patient advocates -- once again.