The Clinical Therapeutics Journal is publishing a new paper, "The Financial Implications for Medicare of Greater Peritoneal Dialysis Use" by Nancy Neil, PhD, Steve Guest, MD, and several associates. The paper details the use of in-home versus in-center dialysis, including the patterns of dialysis utilization and the results of a budget-impact analysis that indicate if the peritoneal dialysis (PD) share of total dialysis were to increase to 15%, Medicare could yield over one billion dollars in savings over five years.

Dr. Steve Guest, Medical Affairs, Baxter Healthcare, Renal Division, McGaw Park, IL, spoke to DOTmed about the issues and findings in the paper. Dr. Guest first explained that providing care to patients with end stage renal disease (ESRD) is very costly due to the therapy itself but also for the care required to manage the oftentimes concurrent advanced co-morbidities. The overall impact to Medicare is significant as the ESRD Medicare patients represent less than 1% of Medicare enrollees but consume approximately 7% of Medicare resources as measured by payments for medical care billed to Medicare in a given calendar year.

"However, in reality," Dr. Guest said, "the differences in Medicare expenditures between peritoneal dialysis and in-center hemodialysis are very complex with resources being applied to a variety of cost centers."
For example, Dr. Guest described peritoneal dialysis as being most dependent upon disposable resources such as the dialysis solutions and supplies, used to perform the therapy at home. By comparison, in-center hemodialysis is most dependent upon fixed resources, in which investments have been made in bricks and mortar facilities, water treatment capabilities, hemodialysis machines and in-center staffing requirements. "The cost of an unused investment is high and so as not to waste those investments, they must be used to repay the capital outlay." The article is an analysis of these more comprehensive fixed resources used for in-center hemodialysis that include:

-- the facilities in which the hemodialysis is performed;
--the capital investment in the machines themselves;
--the supporting equipment necessary to treat municipal water to become medical grade water and the equipment needed to prepare the dialysate from this treated water;
--ongoing maintenance of the facilities and machines;
-- health personnel, including nurses, technicians, medical assistants, receptionists, etc.

PD does not have the same requirements for a special facility as the home is the site of care. However, Dr. Guest points out that while there is less of a capital investment for peritoneal dialysis, there are significant costs for PD therapy nonetheless: "These costs impact the dialysis providers if they are supplying the patient's dialysis supplies for peritoneal dialysis. But other economies can be realized with home therapy, such as a ratio of 20 patients to 25 patients per nurse for peritoneal dialysis compared to four to six patients per staff member for in-center hemodialysis."

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