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PHYSICIAN & DIALYSIS ECONOMICS MATTERS

Umesh Khanna, Mumbai

ABSTRACT

Physicians should have adequate training in nephrology and should be able to look after acutedialysis in ICU if they have critical care facilities. Maintenance hemodialysis in smaller cities orextended suburbs of metro could be looked after jointly by a physician and a nephrologist. Althougheconomically a dialysis unit is not directly a profitable venture, indirect revenues do help in makingit cost effective. A complete physician with a good medical set up should have dialysis machine as a

part of his facility and preferably should do a special course in dialysis medicine so as to be able tohandle kidney failure patients effectively.

PHYSICIANS AND DIALYSIS UNIT

There are 3 aspects of this topic which need discussion

a. Should physicians manage dialysis patients?

b. Is it economically pro table?

c. Are we ready to have a diploma in dialysis medicine course?

1. Should physicians manage dialysis patient?

In a population of more than 120 crores there are hardly 1000 nephrologists in our country and

most of them practicing in metros & tier one cities. Thus nephrology services in India are woe-fully inadequate. With the growth of tier 2 & tier 3 cities & their rising population, health careservices have mushroomed with moderate sized hospitals & physician owned nursing homeslooking after the bulk of health care in private sector. Acute Kidney Injury (AKI) affects 5-7%of all hospitalized patients and up to 25% of patients admitted to any ICU could have AKI withthe overall incidence varying from 1-25% depending on the criteria used for the de nition ofAKI and the population surveyed. Also 4-6% of these ICU patients having AKI would needdialysis or Renal Replacement Therapy. Further with the increase in life style diseases the inci-dence and the prevalence of CKD is ever increasing with an addition of nearly 2-3 lakhs newend stage renal failure patients needing dialysis every year. Thus both AKI and CKD cases may

be rst seen by physicians before the Nephrologist arrives on the scene.

Hence facilities for renal replacement therapy are increasing by leaps & bounds in our country& just about 1000 nephrologists in our country cannot handle this ever increasing load /

FACILITIES FOR RRT (RENAL REPLACEMENT THERAPY) IN INDIA 4

1000 dialysis centers/ Units.

9000 Dialysis machines.

54,000 60,000 Dialysis patients.

1200+ Nephrologists.

200 Transplant centers.

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Is it cost effective? - The answer is no!

One can charge Rs. 1500-2500 Rs per dialysis sitting & yetnot make a big profit but there are a lot of indirect benefits toyour ICU. The dialysis unit can improve the prestige of yourICU making it a well equipped full fledged ICU, a modern& complete set up, able to handle critical care & hence the

number of ICU cases referred to your centre increases thereby bringing remuneration indirectly. Secondly you have thesatisfaction of treating all types of critical cases including thosecomplicated by renal failure and multi organ damage. Thirdlythe economics of bed charges, ventilator charges, laboratorytests, procedures visit charges, surgery etc compensate for thecapital cost & justify the economics of acute care dialysis.

Chronic dialysis centre for maintenance Hemodialysis.

As discussed 1000 nephrologists in India are woefullyinadequate to handle lakhs of ESRD patients in our country.Hence supply can never meet the demand. Thus there is a needfor more trained nephrologists, along with the qualified ones,to match the ever increasing need for dialysis units.

Concept of free standing dialysis unit or Satellite DialysisCentre

These are independent satellite dialysis units with no admissionor indoor facilities typical of a hospital. They have around10 or more dialysis stations, managed by experienced nurses& technicians who are trained in resuscitation. An RMO isin telephonic consultation with Nephrologist for day to day

problems. The Nephrologist only visits as and when possible / .

A physician can team up with a Nephrologist & look after dayto day care of dialysis patients & share the emoluments with

Nephrologist. Alternately if he has extra space in his nursinghome or hospital, then he can set up a dialysis unit jointlymanaged by him & Nephrologist

Is it economically viable to run a dialysis unit for chronicdialysis?

Capital Cost:

1. Premises variable cost but that asset will appreciateover the years giving you good returns. If taken on rentthen cost of premises is Rs. 100-200 per dialysis

2. Dialysis machines Rs. 6.0 lacs per machine

3. R.O. plant Rs. 2.5 lacs

4. AC & Plumbing & carpentry 5.0 lacs

Running cost of a dialysis unit as shown in the table.

Consumables 300

Electricity 50

Water treatment & Maintenance 50

Repairs (wear & tear) 50

Depreciation 100

6000 Transplants / year

8000 pts on CAPD.

Dialysis restricted to Metros & tier-1 cities.

Only 6% machines in Stand Alone units Vs 60% inUS.

State of RRT (Renal Replacement therapy) in India 4

Zone centersMa-

chinesNo. of

dialysisCost ofdialysis

Tx cent-ers

No Tx/month

North 229 1900 95,000 1600 26 120

South 306 2050 100,000 1400 88 117

East 108 1050 52,500 1300 15 25

West 400 2400 1,50,000 1100 37 80

Delhi 79 750 38,000 1600 10 80

Mumbai 180 1200 80,000 900 20 20

Chennai 44 350 17,500 1200 17 34

Calcutta 36 300 17,500 1100 10 20

Thus we need physicians to get exposure in nephrology &dialysis, thereby enabling them to shoulder this burden ofincreasing dialysis facilities and renal failure load.

One can make a case for setting up a special dialysis courseor diploma for a year thereby imparting theory & practicaltraining & also safeguarding physicians from medico-legalissues. In fact such a course has already been sanctioned andwould be starting by the next few months by IGNOU (IndiraGandhi National Open University).

PHYSICIAN & ACUTE DIALYSIS

A good critical care unit is incomplete without dialysis facility.Large number of ICU cases would have acute kidney injury& many of them would need dialysis . Their numbers willdepend on the size of hospital, the criticality of cases beingadmitted in that set up & whether it is a secondary or tertiarycare set up. In the absence of dialysis facility transferringcritical cases in shock on ventilators & ionotrops is not easy& fraught with implications. Thus having a dialysis machinein ICU today is as essential as having a ventilator was someyears back. You do not need a CRRT machine & modernday hemodialysis machines can do slow & low efficiencydialysis (SLED) which is shown to be as effective as CAVHD/ CVVHD. A small one machine Reverse Osmosis (RO) Plant

is easily available to give pure water required for dialysis.Costing of Acute Dialysis Set up.

You need a capital cost of Rs. 7.0 to 7.5 Lacs initially. Thedialysis machine is kept bedside like a ventilator. A smallwater connection & drainage pipe is required near the machine& a water tank of 500 liter with a small portable ReverseOsmosis (RO) plant can be installed in the terrace or in adedicated area. Thus one can have a small one bedded dialysisunit in physicians set up.

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Physician & Dialysis Economics Matters

Honorarium to Nephrologist 100-200

Staff Salary 100-200

Interest on capital and rent 100-200

TOTAL COST OF 1 DIALYSIS: RS. 1000 APPROX. /

Dialysis expense is approximately Rs. 1000 per session &hence not very cost effective unless you have large numbers of

patients or you cater to richer clientele who can pay more thanRs. 1500 per session. Finally indirect income from laboratory

procedures, surgery admissions & of course income from pharmacy can compensate for the lack of income.

How to prepare a physician to run a dialysis unit.

1. More undergraduate training required in medical col-leges

2. Compulsory rotational residency in MD medicine withhands on experience of dialysis during that period

3. More nephrology updates and CMEs in such fora as

APICON4. Nephrology & dialysis workshops arranged by dialysis

centers and nephrology units.

5. Starting diploma course in dialysis medicines e.g. IG- NOU course.

IN CONCLUSION

Acute Dialysis set up is a must for running a good critical careunit even though it is not profitable. It raises the stature of a

physician & his hospital. It could be a life saving service in asmaller town or distant suburbs of a metro. Running a chronicdialysis centre is not profitable and has its own set of problems

including medico legal cases. Unless you are interested inthe subject and have reasonable hands on experience or adiploma in nephrology and dialysis, it may not be worth itfrom your perspective. You could of course team up with your

Nephrologist and together look after the satellite dialysis unitsin the large cities or metros but in smaller cities, physician witha diploma in dialysis medicine may be the need of the hourand a practical solution to the social problem of commutingand long distances travel of a CKD patient 3 times a week.

REFERENCES

1. Uchino S, Kellum JA, Bellamo R, et al. Acute renal failure in cri-tically ill patients, a multinational, multicentre study. JAMA 2005;294:813-818.

2. Clandio Ranco, Rinaldo Bellamo, John Kellum. Etiology of ARFin ICU. Textbook of Critical Care nephrology 2 nd Edition 2009.

3. Modi GK, Jhav. The incidence of end stage renal disease in India,a population based study. Kidney Int 2006; 70:2131-3.

4. Khanna U. The economics of dialysis in India. Indian J Nephrolo- gy 2009; 19:1-4.

5. Kher V. ESRD in developing countries nephrology forum. Kidney Int 2002;62:350-62.