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We get paid much more to keep someone on dialysis than to keep them off of it. If we don’t achieve dialysis metrics—like avoiding dialysis catheters or providing a certain dose of dialysis—known to best result in long-term benefits, we are financially penalized. But create a fistula in a little old lady that usually requires interventions to make it work and keep it working and make her stay on the dialysis machine as long as it takes for the numbers to look right, then essentially get a bonus. If we see an in-center hemodialysis patient four times in a month, we stand to make 50 percent more money than if we only saw her once. And the nephrologist really only has to see the patient once each month—if a physician assistant sees the patient the other times, we still get paid. We would have to document a comprehensive medical history and examination over the better part of an hour with a patient returning to clinic twice to see the same money—and good luck trying to justify why that was clinically necessary to do. The second, third, and fourth in-center hemodialysis patient visits can be more like drive-bys—a simple documentation that we (or the physician assistant) “saw” the patient, with no notation of time required. Private insurance companies and the Medicare ESRD program pay top dollar for dialysis care, not clinic visits. It’s profitable to build another dialysis center, but we haven’t figured out how to build comprehensive outpatient palliative care services.
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Vanessa Grubbs (Hundreds of Interlaced Fingers: A Kidney Doctor's Search for the Perfect Match)