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.