Kidney disease in war-torn Sudan

 The Lancet brings us this news from Sudan.

Kidney failure in Sudan: thousands of lives at risk by Hatim A Hassan, Mohamed Hany Hafez, Valerie A Luyckx, Serhan Tuğlular, and Ali K Abu-Alfa, The Lancet, August 09, 2023DOI:https://doi.org/10.1016/S0140-6736(23)01370-3

"Sudan is one of few countries in Africa that has provided dialysis and transplantation under universal health coverage for several decades.2 Before the war, around 8000 patients required ongoing dialysis and around 4500 were living with kidney transplants (appendix). Haemodialysis was provided twice per week instead of three times per week to permit access to more patients within budget constraints.3

Haemodialysis requires continuous water, electricity, staffing, and disposable supplies. Since fighting began, dialysis services, which are mostly located in Khartoum, have been severely disrupted (appendix). Patients who can, have fled to dialysis units in other cities. Despite some units reducing haemodialysis frequency to once weekly, shortening sessions at times to 2 h, and offering appointments all day and all night, they are struggling to cope with demand. Most haemodialysis staff continue to work without being paid and are at high risk of burn-out. Egypt is accepting patients needing dialysis, but the cost and risk of the journey are prohibitively high for most.

Dialysis supplies have mostly run out by early August, 2023, despite dialysis sessions being reduced to weekly. A donation of supplies for a third of the patients for 3 weeks was obtained from one company. Reliance on donations of the large quantities of dialysis supplies needed for around 8000 patients is unrealistic. Dialysis supplies are not only expensive, but are bulky and costly to transport. Patients with kidney transplants are experiencing dangerous interruptions in their access to immunosuppressive medication. A reliable source of financing is urgently required to meet the needs of patients requiring dialysis and people with kidney transplants.

Support is needed to prevent adding a further layer of tragedy to this war if dialysis services cannot continue and transplant medication is not provided. Wars elsewhere pose similar threats to dialysis provision. The global health agenda must address the urgent need for transparent decision making and affordable access to vital treatments such as dialysis and transplantation during crises. Finding solutions to meet the needs of patients with kidney failure who depend on these therapies in low-resource settings in times of peace is also long overdue."

Crowdsourcing organ transplant ethics

 In Slate, an upbeat article about the ethical issues associated with deceased organ allocation and (before that) access to dialysis, and the benefits and difficulties with crowdsourcing the solutions.  

The Kidney Transplant Algorithm’s Surprising Lessons for Ethical A.I.  A more democratic approach to A.I. is messy, but it can work.  BY DAVID G. ROBINSON

This article is adapted from Voices in the Code: A Story About People, Their Values, and the Algorithm They Made, out Sept. 8 from Russell Sage Foundation Press.

" in the world of organ transplants, surgeons and data scientists have an unusual habit of being brutally honest about the human lives behind their work—of inviting others into the impossible choices their field confronts. For better and worse, the organ transplant system is itself a real-life laboratory of more inclusive, accountable techniques for building and using A.I.—approaches that are now being proposed in U.S. and EU legislation that could cover courtrooms, hiring, housing, and many other sensitive domains.

...

"Where did this culture of moral humility—one that’s now shaping the design of a high-stakes A.I. system—come from?

"Collaborative decision-making about hard ethical choices in kidney medicine began before the digital revolution. It began before there were many kidney transplants. "

After the development of dialysis there were..."just a handful of dialysis machines, ...Whom to save? Scribner and his team were inundated with pleas from dying patients and their doctors.

"Faced with this quandary, Scribner and his colleagues chose to do something extraordinary: They shared their moral burden with the Seattle community they served. Rather than pretending that their technical expertise gave them special moral standing, they chose to be morally modest, and to widen the circle. The doctors still decided who was medically eligible for dialysis. But then, they established a second committee, a group of seven laypeople chosen by the local medical society, who would make the non-medical decision of how to allocate the few available slots among the many eligible patients. The committee members were given some basic education about kidney medicine, but weren’t told how to make their moral choices.

“They Decide Who Lives, Who Dies” was the headline of a 1962 Life magazine article about this new group. Its members, who were anonymous, were photographed in shadow. A clerical collar can be seen on one. The lone woman of the group, a homemaker, clasps a pair of reading glasses in her folded hands. The article reported that the committee’s approach was based on “acceptance of the principle that all segments of society, not just the medical fraternity, should share the burden of choice as to which patients to treat and which ones to let die.”

"The Life story described some biases that played out on the committee—they favored male breadwinners who had children to support—and it triggered widespread revulsion. A pair of scholars wrote that the committee was judging people “in accordance with its own middle-class suburban value system: scouts, Sunday school, Red Cross. This rules out creative nonconformists … the Pacific Northwest is no place for a Henry David Thoreau with bad kidneys.” The original Life story never mentioned race, but later reporting suggested the committee had been biased in favor of white applicants. The committee only ran for a few years. Other dialysis facilities used different rationing strategies—including first-come, first-served—and in 1972 Congress passed an extraordinary law to provide dialysis at public expense through Medicare to all patients who needed it. That proved to be a humane, if extremely costly, escape route from the rationing problem that Scribner once faced.

"Along with all its faults, I think the Seattle committee also gave us much to admire. It was profoundly, even uncomfortably, honest about the hard choices at the center of kidney medicine. It refused to pretend that such choices were—or ever could be—entirely technical. And it tried, albeit clumsily, to democratize the values inside a complex, high-tech system. The Seattle physicians and their lay colleagues were rationing a scarce supply of dialysis treatments. But even after Congress provided dialysis for everyone, the shortage of transplantable kidneys was destined to spark similar questions, ones we still face today."

HT: Tom Riley

SCOTUS on dialysis and DaVita

 The Supreme Court delivered a number of decisions recently, and the news coverage has rightly focused on the decisions that will increase guns and decrease abortions.  

But another decision has implications for how dialysis is financed for patients with kidney failure. It's going to take some time for all the adjustments that will now start to be made to determine what this means for the financing of kidney care.

Briefly, all kidney failure patients are eligible for Medicare coverage for dialysis, but private insurers covered the first 30 months (and pay much more than Medicare rates).  The case concerns a health insurance program that sought not to pay those rates, and in the case of MARIETTA MEMORIAL HOSPITAL EMPLOYEE HEALTH BENEFIT PLAN ET AL. v. DAVITA INC. ET AL.  the Supreme Court ruled in favor of the health plan.

Here's the story from Reuters:

U.S. Supreme Court rules against DaVita over dialysis coverage  By Nate Raymon

"June 21 (Reuters) - The U.S. Supreme Court on Tuesday rejected dialysis provider DaVita Inc's (DVA.N) claims that an Ohio hospital's employee health plan discriminates against patients with end-stage kidney disease by reimbursing them at low rates in hopes they would switch to Medicare.

"In a 7-2 decision authored by conservative Justice Brett Kavanaugh, the court ruled that Marietta Memorial Hospital's employee health plan did not violate federal law by limiting benefits for outpatient dialysis because it did so without regard to whether patients had end-stage renal disease. A lower court had ruled in favor of Denver-based DaVita.Following the ruling, shares of DaVita, one of the nation's two largest dialysis providers, closed 15% lower. Shares of German rival Fresenius Medical Care (FMEG.DE) dropped 9%."

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Here's a blog from the law firm that won the case, Vorys, Sater, Seymour and Pease LLP :

6/21/22 Vorys Wins 7-2 at U.S. Supreme Court in Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc 

"On June 21, 2022, the U.S. Supreme Court released its decision in Marietta Memorial Hospital Employee Health Benefit Plan v. DaVita Inc. siding with petitioners (our side) and our client Marietta Memorial Hospital, its employee group health plan and health plan third-party administrator, for which Vorys argued the case.  The Court found that the group health plan does not impermissibly “‘differentiate in the benefits it provides’ to individuals with end-stage renal disease or ‘take into account’ whether an individual is entitled to or eligible for Medicare.”  The Supreme Court decision overturned a split decision by the U. S. Court of Appeals for the Sixth Circuit.

...

"The case began on December 19, 2018, when DaVita, a commercial dialysis provider, sued Marietta Memorial Hospital, a small community hospital located in Marietta, Ohio; the Hospital’s medical plan, the Marietta Memorial Hospital Employee Health Benefit Plan; and the Hospital’s third-party administrator, Medical Benefits Mutual Life Insurance Company, in the United States District Court for the Southern District of Ohio.  DaVita, a large, for-profit dialysis provider, alleged violations of the Medicare Secondary Payer Act (MSPA) and Employee Retirement Income Security Act (ERISA).  The Defendants, represented by Vorys, filed a motion to dismiss, which the District Court granted. 

"DaVita appealed to the United States Court of Appeals for the Sixth Circuit, which disagreed with the District Court decision.  Marietta appealed the district court decision to the U.S. Supreme Court. 

"On November 5, 2021, the U.S. Supreme Court granted a writ of certiorari, agreeing to hear the case.   In recognition of the importance of the case, the office of the Solicitor General of the United States filed an amicus brief, joined in the oral argument and urged the U.S. Supreme Court to rule in favor of the Marietta Memorial Hospital, its group health plan and the third-party administrator.  Oral arguments took place on March 1, 2022."

Dialysis provider DaVita enters the transplant space

 Here's the press release:

DaVita Acquires MedSleuth, Deepens Efforts to Improve Transplant Experience. Transplant software company helps DaVita bolster its presence along the kidney care journey

" DaVita Inc. today announced its acquisition of transplant software company MedSleuth. Working with transplant centers across the U.S., MedSleuth aims to create greater connectivity among transplant candidates, transplant centers, physicians and care teams to help improve the experience and outcomes for kidney and liver transplant patients.

"With this acquisition, DaVita deepens its efforts to fuel transplant innovation, underscoring its commitment to improve care at every stage and setting along a patient's kidney care journey.

"Kidney transplantation is a life-changing option for most people with kidney failure, one that's limited today by supply and complexity," said Javier Rodriguez, CEO for DaVita. "MedSleuth has built a powerful platform that can help increase patients' access to transplantation. We're looking forward to supporting the team to accelerate innovation and help streamline the transplant process for transplant candidates, transplant centers, physicians and care teams."

"From lack of supply to meet the demand to understanding and staying on top of the complex process from workup to wait list to transplant, the U.S. transplant system can be complicated to navigate.

"MedSleuth's innovative software can help not only streamline the process of evaluating candidates and keep them active on the waitlist but may also help increase the rate of transplantation through living donation. The software can also make it easier for transplant candidates' doctors and care teams to help support them along the transplant journey.

"BREEZE™, MedSleuth's flagship product, helps remove certain barriers for potential kidney and liver donors and recipients by remotely gathering relevant clinical and demographic information and sharing it with participating transplant centers—effectively streamlining the transplant process, from candidate evaluation through donor and recipient follow-up.

"MATCHGRID™, MedSleuth's paired exchange platform, uses optimization algorithms to find chains for paired donation. This helps transplant center clinicians rapidly match living organ donors with recipients who have willing, healthy but incompatible donors."

HT; Martha Gershun

The complex economics of dialysis and insurance, in Freakonomics

 Freakonomics peeks under the rocks to see what crawls out:

Is Dialysis a Test Case of Medicare for All? (Ep. 457)  by Stephen J. Dubner

"But as he dug into their business, he discovered what looked like a suspicious relationship between the two dialysis chains and a charity called the American Kidney Fund, whose mission is to provide financial support to needy patients.

CHANOS: So, the American Kidney Fund will help various patients pay for private policies. 

Private insurance policies, that is, instead of Medicare.

CHANOS: The patient is strongly urged because of quality of care, convenience, whatever the case might be, that they will be treated better as a commercial-policy patient rather than a government-policy patient and that the American Kidney Fund could help them pay those premiums.

On its surface, that does not sound like a terrible thing for a kidney charity to do. But Chanos looked at it from the perspective of the dialysis industry.

CHANOS: If the dialysis companies could push people that would normally be eligible for Medicare into commercial policies, private policies, they could charge those companies often two to four times what the going Medicare reimbursement rate was.

And Chanos believed that pushing people onto commercial insurance is exactly what the American Kidney Fund was doing. It’s helpful here to follow the money.

CHANOS: It will come as probably no shock that the two largest donors to the American Kidney Fund are the two largest dialysis companies, Fresenius and DaVita. 

In 2018, DaVita and Fresenius reportedly donated a combined $247 million to the American Kidney Fund — or about 80 percent of the charity’s revenues.

CHANOS: So, they are basically putting money into the charity. The charity is turning around and using that money to help pay premiums to enroll patients in commercial insurance. And then, the commercial insurers are charged a huge premium to what the dialysis companies are charging the government. 

It’s estimated that for every dollar that DaVita or Fresenius send to the American Kidney Fund, they receive $3.50 in return from private-insurance payments.

CHANOS: And that’s the problem. 

One especially interesting part of this arrangement is who’s losing money: the insurance companies! It’s not often you hear about insurance companies on the losing end — and maybe you don’t have much sympathy.

CHANOS: “Well, it’s the private sector, right? So, why should we care if the insurers make less profits?” Well, the fact of the matter is it’s raising premiums for everybody in the exchanges.

That is, the insurance exchanges, the marketplaces created by the Affordable Care Act, also known as Obamacare.

CHANOS: And the head of California Blue Cross Blue Shield was on the record saying that the dialysis in California was driving up private policy rates dramatically"

Covid-19, kidney failure, and dialysis

Corona virus and kidney failure are a bad combination, whichever way you look at it. On the one hand, Covid-19 is causing kidney failure. On the other, if you are already on dialysis, you are exposed to Covid-19 infection whenever you go to spend a few hours at a crowded dialysis clinic.

Frank McCormick points me to this story from Politico:
U.S. races to stock up on dialysis supplies as kidney failure ravages virus patients
Approximately 20 percent of coronavirus patients in intensive care around the city need the kidney treatment, often for weeks.

"Hospitals in New York City are running out of dialysis fluids as thousands of coronavirus patients develop kidney failure, an unexpected development that could presage the next critical supply shortage nationwide.

"Approximately 20 percent of coronavirus patients in intensive care around the city need the kidney treatment, often for weeks, a development that many providers did not see coming. FEMA held a call Monday with FDA and CMS to discuss the possibility of issuing emergency use authorizations to import more dialysis fluids, according to a document obtained by POLITICO.
...
"Gov. Andrew Cuomo recently said that New York’s ventilator needs are beginning to plateau, and he has begun diverting the equipment to states in greater need. But hospital staff say that the extended nature of dialysis treatment means that shortages of fluids, trained personnel and even equipment there could just be starting."
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And here's a NY Times story on dialysis patients and clinics:

 Dialysis Patients Face Close-Up Risk From Coronavirus
As the pandemic sweeps the United States, patients needing kidney dialysis and employees of the clinics worry about keeping the virus at bay in such tight spaces.

"As the coronavirus rages from state to state, the 500,000 people whose failing kidneys require them to get dialysis are among the most vulnerable. Each clinic may have dozens of patients during a single shift, often sitting less than the recommended six feet apart for hours.
...
"Infection has traditionally been one of the industry’s biggest problems.

“The second leading cause of death among hemodialysis patients is infections,” said Dr. Alan Kliger, a Yale nephrologist who is leading efforts to control the spread of coronavirus among dialysis patients. As many as one in 10 patients die from complications from an infection, often at the site where a patient has a catheter.

The blowback following Trump's executive order concerning dialysis

It turns out that traditional dialysis providers are not rallying behind President Trump's suggestion that home dialysis could serve many more patients.

The Washington Post has the story:

Trump touted a kidney-care initiative in his State of the Union. But things are not going so smoothly. 
By Christopher Rowland

"The Trump administration has delayed a signature health-care initiative to boost the number of U.S. kidney patients who undergo dialysis at home and get transplants, amid resistance from kidney doctors and large dialysis companies whose payments from the Medicare system could be reduced under the plan.

Trump listed his plan to improve kidney care as a key initiative in his State of the Union speech this week.

But doctors and large dialysis corporations are seeking to remove or reduce proposed financial penalties for underperforming clinics. The new plan was supposed to take effect Jan. 1, but now the timetable is unclear."

Transplantation rates for patients in non-profit versus for-profit dialysis centers

From JAMA,September 10, 2019  Volume 322, Number 10:
J::AMA
September 10, 2019 Volume 322, Number 10Association Between Dialysis Facility Ownership and Accessto Kidney Transplantation

Jennifer C. Gander, PhD; Xingyu Zhang, PhD; Katherine Ross, MPH; Adam S. Wilk, PhD; Laura McPherson, MPH; Teri Browne, PhD;Stephen O. Pastan, MD; Elizabeth Walker, MS; Zhensheng Wang, PhD; Rachel E. Patzer, PhD, MPH

"MAIN OUTCOMES AND MEASURES: Access to kidney transplantation was defined as time from initiation of dialysis to placement on the deceased donor kidney transplantation waiting list,receipt of a living donor kidney transplant, or receipt of a deceased donor kidney transplant.Cumulative incidence differences and multivariable Cox models assessed the associationbetween dialysis facility ownership and each outcome.
RESULTS: Among 1 478 564 patients, the median age was 66 years (interquartile range, 55-76years), with 55.3% male, and 28.1% non-Hispanic black patients. Eighty-seven percent ofpatients received care at a for-profit dialysis facility. A total of 109 030 patients (7.4%)received care at 435 nonprofit small chain facilities; 78 287 (5.3%) at 324 nonprofitindependent facilities; 483 988 (32.7%) at 2239 facilities of large for-profit chain 1; 482 689(32.6%) at 2082 facilities of large for-profit chain 2; 225 890 (15.3%) at 997 for-profit smallchain facilities; and 98 680 (6.7%) at 434 for-profit independent facilities. During the studyperiod, 121 680 patients (8.2%) were placed on the deceased donor waiting list, 23 762 (1.6%)received a living donor kidney transplant, and 49 290 (3.3%) received a deceased donorkidney transplant. For-profit facilities had lower 5-year cumulative incidence differences foreach outcome vs nonprofit facilities (deceased donor waiting list: −13.2% [95% CI, −13.4% to−13.0%]; receipt of a living donor kidney transplant: −2.3% [95% CI, −2.4% to −2.3%]; andreceipt of a deceased donor kidney transplant: −4.3% [95% CI, −4.4% to −4.2%]). AdjustedCox analyses showed lower relative rates for each outcome among patients treated at allfor-profit vs all nonprofit dialysis facilities: deceased donor waiting list (hazard ratio [HR], 0.36[95% CI, 0.35 to 0.36]); receipt of a living donor kidney transplant (HR, 0.52 [95% CI, 0.51 to0.54]); and receipt of a deceased donor kidney transplant (HR, 0.44 [95% CI, 0.44 to 0.45]).
CONCLUSIONS AND RELEVANCE: Among US patients with end-stage kidney disease, receiving dialysis at for-profit facilities compared with nonprofit facilities was associated with a lower likelihood of accessing kidney transplantation. Further research is needed to understand the mechanisms behind this association.

Here are the figures. "For-profit large chains" seem to give the slowest access to being put on the transplant waiting list, receiving a living donation, or receiving a deceased donation.

HT: Irene Wapnir

Alex Azar (Secretary of HH&S) writes about possible new kidney policies

In the New Hampshire Business Review, the Secretary of the U.S. Department of Health and Human Services writes about the recent executive order* concerning caring for kidney patients:

President is providing hope for kidney patients
August 29, 2019  Alex M. Azar

"To prevent kidney disease and provide more treatment options, we’re launching new ways for Medicare to pay for kidney care. For example, nephrologists will soon be able to receive bonuses for preventing the progress of kidney disease in their patients. We’ll give providers a financial stake in getting their patients healthy, as opposed to just paying them for performing more procedures.

"We have also proposed a Medicare initiative to give about half of America’s dialysis providers new incentives to provide patients with dialysis at home or even in their beds at night, rather than having them travel to dialysis centers. Today, only 6.1% of kidney patients in New Hampshire receive dialysis at home, an option that’s much more common in other countries.
...
"To provide more kidney transplants, we will be revising how kidneys are obtained from deceased organ donors, allowing better identification of kidneys for transplant. The executive order also calls for us to expand support for the generous living donors who choose to donate organs. Changing how we identify transplantable kidneys from deceased donors, by itself, could produce life-saving organs for an additional 17,000 Americans each year — including some of the 87 individuals currently waiting for a kidney in New Hampshire.
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*See earlier post:

Tuesday, July 16, 2019

President Trump's Executive Order on kidney care

HT: Frank McCormick

Global kidney health atlas from the International Society of Nephrology

Here's the 2019 Global Health Atlas

Kidney transplantation is nowhere readily available to everyone who needs it,  but the wealthy countries of the West provide it most widely:

Annual costs of dialysis are roughly the same as costs of transplantation in the year the transplant is performed (and of course dialysis costs stay roughly constant until the patient dies or is transplanted, while the costs of a successful transplant become largely the costs of immunosuppressive drugs).

Payments for kidney disease in the U.S.

Medpage Today has the story:

Kidney Disease Payment System Draws Medicare Scrutiny
'We do not think the state of kidney disease care is acceptable'

"Medicare needs to change the way it pays for kidney disease treatment in order to get better results, Adam Boehler, director of the Center for Medicare & Medicaid Innovation, said here.

"We do not think the state of kidney care is acceptable," Boehler said Wednesday at the annual meeting of the Healthcare Information and Management Systems Society. "Right now, we're at a place where 10% of patients in Medicare [with kidney disease] are seen at home, while you have Hong Kong, with a 70% rate. That's not OK. The level of transplants is not OK."

"What happens is that end-stage renal disease (ESRD) is siphoned out and [effort is] focused there, instead of viewing the whole spectrum, instead of thinking about chronic kidney disease before ranging from diagnosing it in the first place, to integration of later-stage chronic kidney disease, to ESRD," he said. "Because what you really want is the prevention of ESRD from developing," he said. "If it develops, you want [it] to be transplant wherever possible; if not, [treatment at] home wherever possible, and it should be a last resort that people go to a dialysis center."

...

"Boehler said he wasn't trying to demonize dialysis centers. "It's our fault; we set the incentives," he said, referring to Medicare. "You need to change those incentives. If we want people to do what's best for patients, if we want them to lower costs and improve quality for patients, they need to make money for doing that -- we'll look specialty by specialty to set it up like that."

"Medicare spends about $120 billion a year on kidney care, Boehler noted. "The first thing you may think about in ESRD is dialysis centers ... but that is not the majority of spend. The majority of spend is in other places -- hospitals, complications arising from them, et cetera. That doesn't mean we have to cut the spend there; it means you have to change around the way people make money." Right now, he said, for the dialysis centers, "if somebody gets a transplant, that's a lost customer."

Kidney dialysis on the California Ballot?

An Orange County Register op-ed discusses a likely referendum to control dialysis costs, and some better proposals...

How to help the 18,000 Californians who need kidney transplants
By KURT SCHULER and MARC JOFFE

"The Kidney Dialysis Patient Protection Act, which is likely to appear on the state’s November ballot, is a well-intentioned but inefficient way for California voters to help dialysis patients.  The initiative would try to restrain kidneMy dialysis costs by limiting the profit margins of dialysis corporations to 15 percent. The group has collected more than 450,000 signatures to put the initiative on the ballot and will soon submit them to election officials. A much better policy option, however, is to encourage more kidney donations, which save lives and get patients off dialysis once and for all..."

"Kurt Schuler, a kidney donor, lives in Virginia and belongs to the Organ Reform Group and Network. Marc Joffe is a senior policy analyst at Reason Foundation."


HT: Frank McCormick

Tax credit for adopting a child

Philip Held draws my attention to this oped from the WSJ, by By Jedd Medefind (who is president of the Christian Alliance for Orphans, and formerly led the White House Office of Faith Based and Community Initiatives (2008-09)).

The Adoption Tax Credit Saves Money
The foster system costs over $25,000 a year for each child.

"The adoption tax credit, which provides up to $13,570 to aid families in adopting a child, has teetered on a razor’s edge in tax-reform negotiations. But the bills passed by the House and Senate both ultimately preserved it, and now the conference committee should follow suit. Eliminating the credit would harm children who need families, while hitting America in the pocketbook.

"There are more than 115,000 children in foster care today. About half of them will be adopted, but without the tax credit that number would drop significantly. The rest “age out” of foster care, likely without family for life.
...
"Families don’t adopt to get a tax credit. But the costs of going through the process—and then meeting the needs of a child coming from a hard place—can be a major barrier. After the adoption tax credit first became widely available in 1997, adoptions from foster care nearly doubled in three years.

"A drop in adoptions would mean fewer [children] finding families. It would also push government spending higher in many areas. Government’s replacement for parents—the foster system—costs taxpayers well over $25,000 a year for each child, according to a 2011 report by the National Council for Adoption. That doesn’t count spending on a huge number of other programs that chip in, including food stamps, Medicaid and Temporary Assistance for Needy Families."
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Here's the 2011 report.
"Comparing the per-child cost ofsubsidized adoption from fostercare with the cost of maintaininga child in foster care, one concludes that the child adoptedfrom foster care costs the publiconly 40 percent as much as thechild who remains in fostercare. The difference in cost perchild per year amounts to$15,480."
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I can't help seeing a strong analogy between

• adoption saving kids from foster care;
• kidney transplants saving patients from dialysis; and
• adoptive parents being analogous to kidney donors...

Big Dialysis (or, why we need to increase access to transplants)

Here's a polemical story from the Washington Monthly: it gives a good picture of why it's pretty terrible to be on dialysis, but casts blame too quickly on the big dialysis companies (while downplaying the complex roles of Medicare and organ shortages...)
The Dialysis Machine
How Medicare steers low-income and minority kidney patients toward the hell of dialysis—and keeps two big companies rolling in profits.

Travel while on dialysis

One of the burdens of kidney failure is that, while waiting for the chance of a transplant, patients often have to spend several hours several times a week on dialysis.  This means most patients can't travel without arranging dialysis sessions at their destination.

After my Morishima Lecture in London, Silvina Lindner pointed out to me that there is an emerging marketplace for dialysis travel.

Here's the website of Connectus Medical, which offers to help arrange dialysis in more than 150 countries.

(In another approach, see my post on efforts towards portable dialysis.)

Portable hemodialysis?

When I was in Trento I was approached by a team from an Italian-Californian startup that is trying to develop a portable hemodialysis system that could fit in the overhead compartment on a plane, or could allow a van to become a mobile dialysis provider.  Here's their webpage: EasyDial, and good luck to them.

The big dialysis business

Here's an interesting report that goes well with the John Oliver video a little while ago:
Why DaVita is being regulated, investigated, and sued

In a business where individual patients may pay vastly different fees depending on whether they are being supported by Medicare or by private insurance, there is room for game playing.

Dialysis: Last Week Tonight with John Oliver (HBO)

Laughing through the tears...


The video briefly mentions a new living donor information source and database, Give and Live.

The American Kidney Fund, in the NY Times, and riposte from the AKF

In a nuanced back and forth, the NY Times has suggested that the American Kidney Fund is abusing its status as a charity for patients who can't otherwise afford dialysis by only encouraging applications from patients at clinics which contribute to the AKF. They reply that this isn't the case.

Here's the NY Times story: Kidney Fund Seen Insisting on Donations, Contrary to Government Deal

"The American Kidney Fund is one of the largest charities in the country, with an annual budget of over $250 million. Its marquee program helps pay insurance premiums for thousands of people who need dialysis, a lifesaving and expensive treatment for kidney failure.

"The organization has earned accolades for its efficient use of the money.

"Under an agreement with the federal government, the Kidney Fund must distribute the aid based on a patient’s financial need. But the charity has resisted giving aid to patients at clinics that do not donate money to the fund, an investigation by The New York Times has found. The actions have limited crucial help for needy patients at these clinics. The agreement governing the relationship between the group and the companies forbids choosing patients based on their clinic."

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Here's the AKF's response: Our response to Sunday’s New York Times article

"An article in the business section of Sunday’s New York Times presented a factually incorrect and unfair picture of the American Kidney Fund (AKF) and the lifesaving work that we do through our Health Insurance Premium Program (HIPP). We have reached out to the Times to request corrections on the most serious factual errors and misleading statements. In the wake of this article there are several key points that we feel are essential to emphasize:

• Since we are a charitable organization, we do ask all providers to contribute to our program—but we never require it.
• We have never turned away a patient who is financially qualified to receive a grant, and we never will turn away such a patient.
• We never condition our issuing of grants on whether a provider has contributed to AKF, and fully 40 percent of dialysis providers with patients receiving help from AKF don’t contribute anything to AKF.  
• There is no “earmarking” of donations.
• HIPP has firewalls in place to protect the integrity of the program."

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The agreement linked to in the NY Times article (to put it in context) is  Advisory Opinion No. 97-1  of the Office of Inspector General of the U.S. Department of Health & Human Services.

Many dialysis patients are not referred to transplant centers in their first years on dialysis (incentives matter...)

Too Few Kidney Dialysis Patients Referred for Organ Transplant, Study Finds
Only about one in four in Georgia get further evaluation

"Although a kidney transplant is considered the best hope for people struggling with end-stage renal disease, a new study conducted in Georgia found three-quarters of these patients weren't even evaluated for a possible transplant within their first year of dialysis.

That finding flies in the face of U.S. regulations that require all dialysis centers to fully inform these patients about all available treatment options. Those options include kidney transplantation, a typically less expensive intervention than ongoing dialysis and one that also promises greater longevity and a better quality of life, the researchers noted.

What's more, the team found a huge variation in statewide referral rates. Some dialysis centers failed to send even a single first-year patient for a transplant consultation, while others referred 75 percent of their new patients."
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