In his 1962 book The Structure of Scientific Revolutions, physicist and science historian Thomas Kuhn argued that a series of small, successful challenges to a conventional wisdom eventually lead to a dramatic change in how scientists view that world.
He dubbed such scientific revolutions a paradigm shift. The phrase has since become a colloquialism.
While most of Kuhn’s examples were drawn from the natural sciences, an analogous movement is taking place today in healthcare. The paradigm shift involves the appropriate locus of care. It has implications for every healthcare provider.
For most of the past century, the best place for complicated surgery was a hospital. But as surgical techniques and technology improved, some invasive procedures moved to outpatient clinics. Four-day stays were replaced by in-and-out service.
As cultural preferences shifted, more end-of-life patients opted for hospice and palliative care. Heroic hospital interventions declined as more people realized they were more likely to erode quality of life than meaningfully extend it.
The post-acute care world is undergoing a similar transformation. Nursing homes are shutting down as the frail elderly and their families opt for assisted living and home care. Rehab facilities are scrambling for patients, who find it is less costly and easier to visit the local gym.
For most of the past half century, the best place for a physician visit was at their office or clinic, which had replaced the house call. Today, why wait days or even months for an appointment when you can visit a retail clinic or pharmacy to get what you need?
With the advance of new technologies like video conferencing, telehealth and remote monitoring, many patients are realizing the best access point for physician care is once again their home. Many home-based interventions can be delivered by a physician assistant, nurse or home health aide, who, needless to say, get paid a lot less than doctors.
HHS Secretary Alex Azar recently told the National Kidney Foundation that he plans to speed up a similar evolution in how Americans suffering from kidney failure are treated. Currently, about 88% of the more than half-million Americans on hemodialysis travel three days a week to specialized facilities for their four-hour blood-cleansing sessions. The total cost to Medicare for patients with chronic kidney disease is $113 billion, or about one-fifth of all spending in the program in 2016.
In other countries, most patients get dialyzed at home through daily peritoneal dialysis, or PD, a daily procedure that takes significantly less time and is less taxing physically. Though it requires investment in machinery and supplies for each patient (dialysis centers can use the same equipment for multiple patients), a CMS pilot program saved an estimated $2,000 per patient a year.
Peritoneal dialysis is more effective, too. The medical literature shows patients on PD live longer and have a better quality of life than patients on hemodialysis.
The two major dialysis providers are preparing for the coming dialysis paradigm shift in their own ways. Fresenius Medical Care is purchasing a home dialysis equipment manufacturer. The merger was narrowly approved last month by the Federal Trade Commission.
DaVita currently gets only 16% of its revenue from PD, about the national average. But it has divisions dedicated to caring for patients with chronic kidney disease, or CKD, and offering home-based dialysis. It supports expanded use of PD, which is more profitable since it receives the same bundled payment as clinic-based dialysis.
Most people who wind up on dialysis experienced decades of untreated or badly managed hypertension and diabetes, which impair kidney function and lead to CKD. To improve their treatment and reduce the ranks of those entering any form of dialysis, the CMS should switch to an episode payment for CKD that includes dialysis if necessary.
When it does, this service line—one of the most expensive in medicine—will be at the point where the paradigm shifts.
An earlier version of this editorial misstated that dialysis patients cost Medicare $113 billion. That figure refers to total costs for Medicare patients with chronic kidney disease, including those on dialysis.