How much does hemodialysis cost in India?

      13 Comments on How much does hemodialysis cost in India?

There are a number of studies on the comparative cost-effectiveness of hemodialysis (HD) and peritoneal dialysis (PD) from many parts of the world. These studies show that when provided at equal level of quality and standard, PD is consistently more cost-effective to the healthcare system. A position statement issued by opinion leaders from Hong Kong, Australia, China, Italy, France, Japan, Korea, Macau, Malaysia, Singapore, Spain, Taiwan, Thailand, and the United States reiterated that in-center HD is more expensive than PD. According to the recently published Global Kidney Health Atlas, out of the 124 countries surveyed, more provided free PD (51%) than HD (42%) from public funds.

Dialysis is expensive. The annual costs of providing dialysis to one patient is US$ 89,900 in USA, AU$65,000 in Australia, US$12,100 in Thailand and US$9,112 in Brazil.

The actual cost of delivering HD in India is not known. Just because the out of pocket payment made by the patient for hemodialysis is relatively low compared to elsewhere in the world, there is a widespread belief that hemodialysis delivery is cheap in India. The main reason for this is a lack of health economic study on the cost of the two forms of dialysis.

Part of the reason for the perceived low cost of HD is the failure to consider many hidden costs in delivery of HD, and cost-cutting by omitting several measures needed to deliver HD of a reasonable standard. No formal comparative health technology assessment of various RRT options has been done. Recent data suggest that the actual cost of HD is at least 4-8 times higher than estimated previously.

In a public-sector tertiary hospital, the mean out-of-pocket expenditure on HD was estimated to be INR 2,230. Another study reported median direct costs for HD at INR 2,628. In a private tertiary care hospital in South India, the cost per HD session borne by the patient was found to be INR 4,428.

In a study published about 5 years ago, Dr Tarun Jeloka from Aditya Birla Hospital Pune showed that the out of out of pocket cost of HD and PD for self-paying patients was not different as widely believed.

This week, the most comprehensive study carried out in a public-sector hospital using rigorous methodology was published. This study was done at PGIMER by a team led by the noted health economist Dr Sankar Prinja. They calculated the overall average cost incurred per HD session at INR 4,148.

The cost calculation was divided into two parts – costs to the health system (human resource, building, equipments, consumables, and overheads) and the out of pocket expenditure by the patient (medicines, travel, stay, food, diagnostics). Importantly, they dis not consider loss of earnings, which will raise the cost even higher. The out of pocket expenditure was about 68% of total costs.

These types of studies need to be welcomed, as they suggest that simply covering the health system cost by health insurance is not going to remove barriers to sustainable access to long-term dialysis since there is a substantial out of pocket cost component. This data should inform development of public policy and funding models for dialysis delivery in India.

Having said all this, a question can be asked – how do centers provide dialysis for much less than this amount? Maybe their infrastructure costs are covered from other sources – like charity or donation. Another possibility is that certain processes and standards, normally considered essential, are being done differently. Clearly, cost reduction by simplifying redundant processes are welcome, but the essential principle of any medical procedure (including dialysis) should be to do no harm. So any cost cutting that results in compromise with quality should be unacceptable for dialysis providers, administrators, patients and their care givers.

We now need a multi-centric properly designed health economic study – a type of health technology assessment that looks at different options, their costs, tradeoffs in terms of outcomes and can inform the choice of dialysis modality for public funded dialysis program.

Having discussed dialysis, we should not forget that transplantation is the most cost-effective RRT modality and we should do all we can to reduce the financial barrier to promoting transplantation. It would be a pity if patients choose to say on dialysis because it is free rather than get a transplant because it will lead to lots of out of pocket expenditure.

13 thoughts on “How much does hemodialysis cost in India?

  1. Dr. Amrita Rao

    Many people who need transplants of organs and tissues cannot get them because of a shortage of donations. Of the 230,000 Americans currently on the waiting list for a lifesaving organ transplant, more than 101,000 need a kidney, but only 17,000 people receive one each year. Every day 12 people die waiting for a kidney. Organ and tissue donation helps others by giving them a second chance at life. Dr. Amrita Rao manipalsurgery0@gmail.com

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  2. PDR

    Went through the – emerging data –

    Nice start – congrats

    Failed to include the no. of dialysis per week
    Nature of admission n dialysis acute care vs maintenance
    Type of access
    Access interventions
    Reuse of dialysers
    Reasons for the diff in oope based on -social factors-
    Cost provider dependent including profit expectations – not income source of patient – unless billing done based on social stratum
    No nephrologist or dialysis nurse perspective

    This data may not be representative base for pricing in the dialysis program
    The assumption of leased machines
    Procurement in high volumes
    Cheaper labour
    Occupancy of the unit (idle hours per day than a presumed -percentage capacity of facility-)

    Reply
    1. Percy Morel

      Last year I did around 10 dialysis sestion in madra hospital in chennai it cost me around less than INR 2000.00 per session
      I can say that dialyser and other logistic are cheap stuff with poor quality so I did not got good dialysis like at MOH which i been for the last 20 year

      Reply
  3. Basant Pawar

    I am surprised that the costs were lower in the public hospital as compared to the private hospitals. In a study done (unpublished, as permission to do so was not granted) the cost of most procedures ( non dialysis procedures) in the government was much higher.

    The reimbursements rates offered by the government (CGHS rates etc) were so low as to discourage acceptance by private providers.

    The reimbursement rates should be realistic and should be coupled with tangible end points that must be achieved by the unit. These should include URR, Kt/v, HB, performance scores, adherence to dialysis ( as in some countries), reporting of morbidity and mortality, which should be reported in a fair around transparent way so that patients can choose where to go.

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  4. Chandra Mauli Jha

    While preparing for a talk few years back, I had calculated cost of dialysis delivery at Oman. It may take some time to find exact figures but as far as my memory permits, my findings were:
    1. Approximately 12’000 USD PER PATIENT PER YEAR WAS EXPENDITURE OF DIALYSIS including epo analogues, iv iron and Investigations etc.

    2. Cost of dialysis to a patient was cheaper than cost of statin treatment to prevent one stroke by its prescription to the population at risk (based on data from UK, lancet)

    This was to impress that “obviously very costly” dialysis therapy indeed was cheaper than some other therapies considered “not so costly”.

    Compared to India, in Oman dialysers were used once and profit as well as pricing of materials at several point of material supply chain was higher too.

    Coming to the point of how centres could provide dialysis cheaper than cost estimated in the study, I would say that some costs are virtual from zero to several. .. For example if one has invested in a hospital and its bed occupancy is only 50%, It may utilize 50% space for outsoucing to dialysis provider at a very nominal rent which would still be adding something positive to tge balance sheet of hospital and save dialysis provider from costly investment. ….. By reducing profit at supply chain nodes, cost may be reduced by not less than 25 to 30%. … In the last, in commercial hospital practice, as a hospital manger, I may chose to provide dialysis at no profit or as a loss so that my “Client base” remains wide”. After all it is net profit or loss which matters than segmentwise profit and loss.

    For example, coronary angiography, PTCA etc are covered by insurance but not any modality of dialysis. The hospitals regularly chose to bill for angiography and PTCA with free dialysis during hospital / ICU stay.

    Very stimulating paper indeed! May be that more such studies at different practice pattern are carried out.

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  5. navdeep

    We must also include travel cost and the cost due to loss of work of the 1-2 attendants that routinely accompany the patient.

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  6. Col Dr D Mukherjee

    Sir perhaps so many Govt schemes for dialysis reimbursement in pvt hosp fail because of unrealistically low rates.

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  7. Col Dr D Mukherjee

    Sir perhaps so many Govt schemes for dialysis reimbursement in pvt hosp fail because of unrealistically low rates.

    Reply
  8. Surendra rathore

    The proper methodology of calculation is not given.
    I think actual rate of HD are cheaper than this study because
    1. Land prices are different among cities. At public sector and charity hospitals this burden is taken care of by goverment/ trusts. So it can not be counted in cost calculations.
    2. We do not discard machines as per manufacturer instructions. Instead they are used till they can’t be further repaired.
    3. The machine technician ratio is never ideal. One staff for 10-12 machines is a common finding.
    4. MRP and cost of iv set, needles, normal saline, EPO is not same across the country and hospitals. In mumbai one can get epo for 200- 220 rs while the MRP is arround 1500.
    4. Dialyzers are almost universally reused which further brings down d cost.

    I my opinion we are reducing price of HD session because of quality compromise.

    Reply
    1. vjha Post author

      Yes – you are right that prices will vary from place to place. However, the taxpayer has paid for the land/building/electricity etc when the underwriting is done by the government so it is a mistake to say this should not be included in the cost calculation. The other calculations have been done taking into account local practice.

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  9. Vinod K Bansal M.D.

    In USA dialysis cost is borne by Medicare .It pays alt fee for each hemodialysis session depending on the county that one gets treatment.For example in Cook County,Illinois which is considered a high cost area the payment is $261 per session and it is limited to 13 sessions in a month .Included in this are all cost except very few such as antibiotics which are not related to dialysis related issues .Erythropoeitin , activated VIt analogue and are any dialysis related infection antibiotics are all included in this bundle.The access related cost is separated and is reimbursed under existing codes and payment.\In USA all aspect of dialysis hemp or peritoneal is very tightly regulated by Medicare.Hope this help to camper the cost structure.The physician component is also capitated and is $ 216 to 260 a month per patient.

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  10. Arvind Canchi

    An important study. Thank you. Surprising that the figure is as high as Rs 4148, but then we’ve never looked at it in this manner. More surprising is that the out of pocket expenses for the Pt, amounting to Rs 2820 per dialysis session. Were MRP prices taken into account when the calculation was made or the actuals? This means that out of pocket expenses will be much higher in Pvt/corporate hospitals. Thanks for the link to the study from Kochi in a journal I would not have looked at otherwise, interesting points in that study too.

    Now if the building is free, the machines bought from donations, etc I find low cost/ charity centres charging Rs 500 to 700 per session. Can they break even if numbers are large? The mind is boggled.

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