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The Korean Society of Nephrology and Rep. Nam In-soon of the Democratic Party of Korea held a policy discussion on “How to Activate Peritoneal Dialysis to Improve the Quality of Life of End-Stage Kidney Disease Patients” on March 7 at the National Assembly’s conference hall. (Credit: KBR)
The Korean Society of Nephrology and Rep. Nam In-soon of the Democratic Party of Korea held a policy discussion on “How to Activate Peritoneal Dialysis to Improve the Quality of Life of End-Stage Kidney Disease Patients” on March 7 at the National Assembly’s conference hall. (Credit: KBR)
Among the two types of dialysis, peritoneal dialysis—a treatment for end-stage renal disease, which is rapidly increasing in Korea and worldwide—is just as effective as hemodialysis but comes with a lower economic burden and allows patients to continue working while receiving treatment. For these reasons, many countries actively promote its use. As a result, the share of peritoneal dialysis patients in the U.S. grew from 8.3 percent in 2012 to 14 percent in 2022, while in Thailand, it rose from 9.5 percent in 2008 to 30.7 percent in 2016. However, the opposite trend is unfolding in Korea.
Since 2019, Korea has been running the Peritoneal Dialysis Patient Home Management Pilot Project, which provides home healthcare services to help peritoneal dialysis patients manage their treatment at home. However, despite this initiative, the share of peritoneal dialysis in Korea has declined from 6.8 percent in 2019 to 5.4 percent in 2021 and further to 4.5 percent in 2023. While the main project is expected to launch after the pilot ends later this year, concerns are already being raised about its effectiveness in its current form.
In response to this issue, the Korean Society of Nephrology (KSN) and Rep. Nam In-soon of the Democratic Party of Korea (National Assembly Health and Welfare Committee) held a policy discussion on “How to Activate Peritoneal Dialysis to Improve the Quality of Life of End-Stage Kidney Disease Patients” on March 7 at the National Assembly’s conference hall. The discussion highlighted the factors hindering the wider adoption of peritoneal dialysis in Korea, despite its potential to improve the quality of life for the country’s rapidly growing number of end-stage kidney disease patients, boost the domestic productive population, and significantly reduce medical costs. Participants also explored possible solutions to address these challenges.
First of all, end-stage renal disease patients tend to prefer hemodialysis over peritoneal dialysis because hemodialysis is performed in a hospital, whereas peritoneal dialysis must be managed at home.
“The biggest hurdle for peritoneal dialysis is a little anxiety (among patients),” said Professor Kim Jwa-kyung of the Department of Nephrology at Hallym University Sacred Heart Hospital. “They don’t know if they’re doing it right.”
To address this concern, Korea’s pilot project for home management of peritoneal dialysis patients focuses on education and provides continuous feedback to reassure patients that they are performing the procedure correctly.
The number of Covid-19 confirmed cases among patients on dialysis is spiking in Korea.
(Credit: KBR)
However, the pilot project for home management of peritoneal dialysis patients has led to a decrease in the proportion of peritoneal dialysis patients in Korea. The project has shown that registered peritoneal dialysis patients have a lower risk of death than unregistered patients, fewer patients switching to hemodialysis, a lower risk of peritonitis and catheter infection complications, fewer emergency room visits and hospitalizations, and lower overall medical costs. It is puzzling that a national policy aimed at enrolling and managing peritoneal dialysis patients has proven to be more effective, yet the number of patients using peritoneal dialysis is still declining.
Currently, the pilot project provides an educational consultation fee of 42,480 won ($29.2) (limited to two times per year, and four times in the first year) for professional and in-depth education and consultation by a doctor for more than 15 minutes. Additionally, there is an educational consultation fee of 26,770 won (limited to four times per year, and six times in the first year) for education and consultation on disease and health management by a doctor or nurse for more than 20 minutes. There is also a patient management fee of 28,710 won (limited to once per month) for non-face-to-face consultations aimed at periodic patient monitoring and management.
However, the pilot program has made it difficult for healthcare providers to recommend peritoneal dialysis to patients over hemodialysis, despite the availability of pilot reimbursement. “Peritoneal dialysis requires an independent space to manage inflammation, such as peritonitis, but there is no space in the hospital. It also requires a team approach, where doctors know what to check for in peritoneal dialysis patients, but there is no dedicated nurse,” Kim said.
She added that many patients with end-stage renal disease are not even aware of peritoneal dialysis as a dialysis option.
According to Yang Jae-won, Insurance and Legal Affairs Director at KSN, and a professor of nephrology at Wonju Severance Christian Hospital, the total per capita cost of hemodialysis is about 1.4 times that of peritoneal dialysis, which means that in addition to the patient's out-of-pocket expenses, peritoneal dialysis also imposes a higher financial burden on health insurance.
Furthermore, hemodialysis requires four hours of dialysis at the hospital three times a week, making it difficult for end-stage renal disease patients to work, which can disrupt a family's finances. These are some of the reasons why countries are promoting peritoneal dialysis.
So, what are other countries doing to promote peritoneal dialysis? In Taiwan, the government provides about 26 million won ($17,898) to peritoneal dialysis centers for each new patient, according to Yang. This funding covers the costs of starting peritoneal dialysis, including training for doctors and nurses, as well as facility expenses. The cost of continuing dialysis for peritoneal dialysis patients is approximately 3.1 million won ($2,135) for six months and around $606 for 12 months. In addition, Taiwan provides about $309 per month for the management of peritoneal dialysis patients, with the payment increasing to $454 once the treatment goal is achieved.
Hong Kong has prioritized peritoneal dialysis, with the share of peritoneal dialysis exceeding 75 percent.
“More than 75 percent of dialysis patients are on peritoneal dialysis, with hemodialysis covered only for patients who cannot undergo peritoneal dialysis for medical reasons,” said Yang. “The U.S. has a policy of setting the same price for hemodialysis and peritoneal dialysis.”
However, in Korea, except for the educational counseling fee and patient management fee in the pilot project, hospitals cannot get any reimbursement for peritoneal dialysis. Korea operates a “fee-for-service” system, where physicians are paid based on their medical activities. Therefore, if hemodialysis is performed in a hospital, physicians can receive a payment, albeit a low one. However, since peritoneal dialysis is performed by patients at home, it is not considered a medical service provided by healthcare professionals, so no separate reimbursement is set. As a result, there is a lack of motivation for doctors to offer peritoneal dialysis treatment.
“To motivate doctors to bring in peritoneal dialysis patients, they need to be paid for the minimum amount of work they do. Right now, they don't get paid a penny, so there's no incentive for them,” Kim noted.
They need training, facilities, and supporting nurses, but hospitals are not willing to provide these because they do not see any positive benefit from having more peritoneal dialysis patients, she added.
“We need a positive support system to encourage doctors and hospitals.”
Currently, KSN recommends that reimbursement for peritoneal dialysis should be set at 20 to 25 percent of the reimbursement rate of hemodialysis.
“Hemodialysis is priced at 120,000 won per session, and we collect monthly payments and do hemodialysis about 13 times a month. Peritoneal dialysis should be charged for a week's worth of hemodialysis, even if it costs 360,000 won,” Kim said.
In addition, since peritoneal dialysis requires an independent space in the hospital and a dedicated nurse, hospitals should be incentivized to increase the number of peritoneal dialysis patients, she emphasized.
So, would the KSN's request increase the financial burden on the national health insurance program? No, it would not. In fact, it would actually reduce the financial burden.
According to Kim, if the number of dialysis patients continues to increase at the current rate, the total medical expenses for end-stage renal disease patients in 2033 will be about 5.7 trillion won. However, if the share of peritoneal dialysis patients increases by 1 percentage point each year, reaching 16 percent in 2033, the total medical expenses for end-stage renal disease patients in 2033 will be around 5.4 trillion won, reducing the cost by 300 billion won.
At the discussion, Kim Hyun-ah, head of the Payment System Development Department at the Health Insurance Review and Assessment Service (HIRA), said, “To revitalize peritoneal dialysis, we will hold a meeting with the KSN in the first half of the year to listen to the opinions of experts and reflect them in the policy.”
In addition, in the second half of the year, HIRA will consider whether to convert the pilot project into the main project and to activate peritoneal dialysis in Korea, it will consider the results of the pilot project and the need for further improvement, she added.
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Kim Kyoung-Won kkw97@docdocdoc.co.kr
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