1336: Dialysis | Skeptical Sunday

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All it takes is a yes. Welcome to Skeptical Sunday. I'm your host, Jordan Harbinger. Today I'm here with Skeptical Sunday co-host writer and researcher Jessica Win. On the Jordan Harbinger, you know it was funny, Jessica, I was doing comments on Spotify.

You can look at people's comments and stuff and I like to engage there. I like to engage wherever people come in about the show and people were like, "I don't know what it is with Jordan, but he just sucks up to this guest Jessica." And I was like, "You do? You know, what am I weird thing to say about somebody that you work with that you've known for a long time?" Like, I would get it if it was like a celebrity, no offense.

I would get it if it was like a celebrity or something like that. Like, oh look at this guy. And I'm like, "Is it weird to get along with people that you, I don't know, that's the age of the internet that we're in right now where it's actually weird?" Right. Be mean to me.

Yeah. You shut up, Jessica.

“Who said you could talk on this episode of the show where I pay you to talk?”

I mean, what am I supposed to do? Like, I'm supposed to talk down to you and make you look stupid on this show. Yeah, please. Yes. That's entertainment, Jordan.

It is. That's what passes for entertainment. And the other thing that's weird about it is it's like, "If I were rude to you, I would like to think I would hope that I would get more comments about how I'm not treating you well." But treating someone too well, I don't know, and people, like, someone was like, "I agree with Tom or whatever.

I agree with Nick." I agree with Nick. So that sucks. And I'm just, I was thinking, 'cause of course, me being the neurotic podcast host that I am. I'm like, "Well, now I have to think about every single thing I've ever said to you and what the vibe of that might be."

I don't know. I just thought that was such a funny, I mentioned share that with you earlier, but I think it's a funny thing to share with the audience as well, because I don't know. I guess we're not supposed to get along. I don't know. Let's be more combative today.

Yeah. Let's do that. That's a good idea. Finally, that a good idea. All right.

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junk science, crime, and cults, and more that'll help new listeners get a taste of everything we do here on the show. Just visit jordanharbanger.com/start, or search for us in your Spotify app to get started. Today on the show, we're talking about something most people never think about until it becomes everything they think about. Dialysis. It's one of those words that lives somewhere in the back of your brain.

You kind of know, maybe it's kidney related. You know it sounds serious.

You hope you never need to know more than that.

And then one day, it's your life on the line, or that of somebody you love. And suddenly, that word isn't medical trivia. It's a machine you're hooked up to three times a week. There's something about this that feels very American. Look, we can build a device that keeps you alive, and also quietly bankrupt you.

I mean, it's just a miracle of modern science. Here to help us filter the stream of info on dialysis is writer and researcher Jessica Wind. So, quick heads up, by the way, we're going to be discussing some medical stuff that's going to make some people squeamish.

So, if you're one of those people who's like, I'm listening while I'm eating and if it's going to be gross, you got to tell me, this might be one of those. Dialysis. I'll be honest. I kind of know that it has to be with kidneys and blood cleaning and there's a machine

involved in that's a French, there's franchises.

“That's kind of where my knowledge ends, which I think that puts me in with about 99 percent”

of Americans. Yeah, definitely. And the invisibility is the whole story. So, I didn't know much about dialysis until a good friend's entire life changed after their diagnosis.

Wow. A dialysis operates in this weird space where it's simultaneously a genuine medical miracle and a massive industry, but you don't see it until you're inside it. And by then, you know, you're not in a position to really ask hard questions. Right.

Yeah. I would imagine you are not shopping around or reading reviews online, you're just trying not to die.

That ignorance matters because dialysis affects hundreds of thousands of people.

“It costs tens of billions of dollars and it shapes how long and how well people live.”

Okay. So, bring me up to speed. What are we actually talking about here? Okay. So, let's start with what kidneys do.

You know, they're incredible organs. They're about the size of your fist and they filter your blood. Every day, they process about 200 cords of blood to remove waste and extra water, which becomes urine. They balance electrolytes, regulate blood pressure, they even help make red blood cells.

So they're basically like your body's water treatment plant. And they run 24/7 in the background. I don't know.

You know, whatever they've learned about organs, I'm always like, this is amazing.

You know, every single thing. You know, everybody. Yeah. They're first of all. They're busy.

They never take breaks. Really. And so hard on whatever, like my stomach or whatever, your stomach has it easy. Your stomach's hanging out most of the time. Yeah.

You put some food in it. Holds acid. That's not an easy job. But your kidneys. They're just running the marathon all day, every day in the background.

And yeah. Making you pee. Right. It's nice to take it for granted. It is nice to take it for granted.

“And I guess that's why when they fail, you got a big problem.”

Right. And when they do fail. And that's about 800,000 Americans that are living with kidney failure right now. So your body can't clean itself, waste builds up, fluid accumulates. And without intervention, you die, usually within weeks.

Yeah. I was going to ask how long that took. I'm going to imagine that the last few weeks are really bad. How many days do you need where you're not cleaning the thing that you're usually cleaning 24/7 before you start feeling terrible?

It's awful. It's hard. Maybe awful. Yeah. Okay.

So this is not like I don't feel good. I should probably make a doctor's appointment. Okay. This is a ticking health time bomb. So all right.

Let me slow this down just a little bit more for a second here.

When we say dialysis, what are we actually talking about? Well, so dialysis is an external version of that filtration system. So the most common type is hemodialysis. You go to a clinic. They stick to needles in your arm.

Usually in a surgically created like fistula. Okay. That's a really gross word. It's a really gross word.

“That makes my stomach turn and I don't know what it means.”

What is that? It sounds like something. Yeah. God. I don't know.

Tell me what that means before I. So fistula is just the passage between your organ and the body surface. It's just the name for the hollow, you know, surgically made passage. That sounds way grosser than it is. Okay.

It sounds like pustula or something, right? It sounds like it would be gross and oozy. But it's not. Okay.

It's literally the passageway.

That makes me feel a little bit better. All right. I think I'm probably not alone there. Okay. That's.

So we can say the surgically created passageway, if you want. You can say fistula. How did I know what it means? It's not as gross as it was when it was in my head. It was like something out of alien.

Right. Okay. So that's where, you know, they've connected an artery to a vein to make it strong enough to handle repeated punctures. Then your blood flows out through one tube through a machine with a special filter and

back into you through the other tube. How long does this take? How long are you sitting there when you do this? Yeah. It's a long time.

Typically three to five hours per session. Oh, my God. And that's three times a week every week, forever, or until you get a transplant or, you know, you die. Wow.

Okay. Three to five hours, three times a week. You're getting a part-time job filtering your blood. Oh, my God. So when you say forever, well, you mean forever unless you get a transplant or die,

that's not hyperbole, because you can't just stop doing this and you, yeah. Wow. Yeah. Welcome to dialysis. Yeah.

Yeah. 15 hours a week. And that's minimum. And that's 52 weeks a year. So after a year that adds up to, you've spent a full month of your life sitting in

a chair hooked up to a machine. Wow. Man, that's a lot of candy crush, or perhaps listening to this podcast. And this is, this is just keeping you alive. You're not curing anything.

This is your treading water when you do this. That's pretty much it. Right. Your kidneys are still out of commission. So the machine does the kidneys job, but it's not even doing it that well.

You know, natural kidneys work continuously and are perfectly calibrated. So dialysis happens three times a week. So you get this soltooth patterns in your blood chemistry. Oh, yeah. Sure.

Right. After treatment, it's perfect. Then increasingly toxic by day three. So it's like, instead of your heart beating constantly, it just be really, really hard three times a week.

Yeah.

moving. Yeah. That's makes sense. Yeah. You're right.

I never thought about it.

“When I'm sleeping, you know, if I get up in the morning, I have to go to the bathroom.”

I'm probably have to go to the bathroom, even in the middle of the night, right, because I'm well hydrated guy, TMI. But my kidneys are working that whole time. So I don't have to go anywhere and do it because it's working while I'm watching to run on my iPad or when it's just going well and see, wow.

So this whole go to a place and do it manually sounds profoundly suboptimal. So I mean, medically emotionally existentially suboptimal. OK, before we go further, who ends up needing dialysis? Do your kidneys randomly fail because your luck is bad. How does, who does this happen to?

It's absolutely not random. So the two biggest causes are diabetes and hypertension. And together, they account for about 70% of kidney failure cases. The rest are caused by a variation of sort of rare conditions or maybe addictions. And here's the really sobering part, fewer than 40% of dialysis patients survive more

than five years. What? Wait a minute. Yeah.

That's like a cancer statistic.

“That's not something people think of as a routine treatment.”

OK, so wow. So by the time you're on dialysis, your health is not good at all. You're not OK. Yeah, you're not OK. I mean, being on dialysis is that serious.

Yep. Most people have no idea. So what is actually killing these people? So it's lots of things. It's heart disease.

It's a lot of complications from diabetes. But here's the one that really stopped me. Infections are responsible for 36% of all dialysis deaths. And the most common cause of death after that with draw from dialysis. So this isn't the disease instead of killing them.

This is people saying, I can't do this anymore. I don't want to do this anymore. And they just stop doing dialysis and let the illness take its course. Yes. Oh my god.

About 21% of dialysis patients die after choosing to stop treatment. So it's most common in patients over 60. And to be clear, this usually happens with doctors and families involved. It's a huge end of life decision when the treatment itself has just become too burdensome. Yeah.

OK, I see. By the way, I misspoke earlier because I said, this isn't the disease killing them. What I meant was this isn't the disease overrides the treatment. They just stop getting treatment. So I can't really identify the patients.

But it sounds like the treatment can become harder than the disease or at least it overrides your will to keep doing this nonsense right every week. Oh, god. Yeah, for a lot of patients, absolutely. I mean, I don't want to romanticize any of this, you know, dialysis keeps people alive.

But it can also mean hours in a clinic every week. There's exhaustion afterward, there's serious complications, not to mention the financial burden. And dialysis patients say, you know, I'm not living, I'm just not dying. And that calculation where death feels preferable to the machine. I mean, that tells you something really profound about what people are going through.

OK, you mentioned infections break that down for me because again, that number has been

and is it's over one third of people who die from an infection that seems like it shouldn't

happen. Yeah, it's horrific, but dialysis requires vascular access. So either a fistula, like we talked about a graft or a catheter is used. And every time you stick needles in someone or have a catheter line going into their bloodstream, you create an infection risk.

And dialysis patients get this three times a week, week after week, year after year, I mean, the statistics are staggering. So sepsis mortality and dialysis patients is 1 to 300 times higher than in the general population.

“Way, way, way, way, 100 to 300 times higher or percent higher, percent higher, right?”

Like one. Himes higher. Oh, my God. That's ironic. That's ironic.

It's hard to comprehend. Yeah. And bloodstream infections from staff bacteria occur a hundred times more often in dialysis patients than in adults not on dialysis. You're right.

It's hard to wrap your mind around 300 times higher. That's like, oh, my God. Yeah. It's wild. And these aren't freak accidents.

These are predictable consequences of the treatment model. And infection rates vary wildly between clinics. So some have excellent protocols and low infection rates. Other clinics are infection factories. But patients often have no way of knowing which kind of clinic they're walking into.

Yeah, shouldn't there be ratings or something like some kind of this place will not kill you scoreboard because right now it feels like dialysis clinics should have those big letter grades in the window, like restaurants in New York, you know, you get a or a B or a C posted

This clinic is a solid B plus a keeping your blood infection free instead of instead of

dumplings, it's your bloodstream. I don't know, I'm just not knowing what you're going to get and then being subject to a staff infection that kills you. It's the dice roll here is crazy. It's just terrible. Yeah, plus you have a lot of other things on your mind.

You know, you're putting a lot of trust into these clinics. But there actually are ratings, you know, Medicare gives dialysis clinics star scores based on outcomes and safety measures. And I'm guessing these are not posted on the window next to the inspirational happy kidneys, mildly face poster.

They're not, but they do exist. They're just not prominently displayed and the methodologies complicated. So most patients go to the closest clinic because, you know, logistics dictate it. You need treatment three times a week. You can't really shop around.

“Yeah, if you need dialysis, you need dialysis and you're probably not like, you know what?”

That's it. I'm driving three hours away because it's cheaper and cleaner down in Modesto. Right, exactly. Which brings us to the second type, Peritennial Dialysis, where you do it at home. So you have a catheter in your abdomen and you fill your belly with special fluid that draws out waste through the lining of your abdominal cavity.

So you drain it out, you refill it, repeat. You know, some people do this manually several times a day. So there's hook up to a machine at night that cycles the fluid while they sleep. Okay, so that sounds better than the clinic, you know, immediately better, but again, it also makes me feel a little bit sick to my stomach.

I feel bad saying that because these people have to live with it and it's like, oh, Jordan's getting crazy hearing about it. But I think hopefully I'm coming across here is sympathetic because honestly, this just seems like such a terrible thing to have to go through and I feel right. I feel for anyone who has to deal with this.

This is just a terrible way to live and I mean, I just, I can't believe that, well, one,

the technology is amazing, but I'm also like, how do we not have everybody at home?

I don't know. Maybe we'll talk about that in a bit. Yeah, I mean, it's wild. People are just live this way and so the home machines are better for many people. There's more freedom.

It's gentler on the body and you're not tied to a dialysis chair in one specific clinic every week. So some home dialysis systems are even portable, so people can travel with the equipment or ship supplies to where they're going and continue treatment there. But infection risk is also lower when it's done properly.

But for some reason, only 12% of U.S. dialysis patients use it. Yeah, you don't even think about travel. How do you manage that?

“So why are only 12% of people using this if it's so much better?”

Well, now we're getting to the interesting part. So let me ask you something, if you were running a dialysis company, which would you prefer? Patients who come to your clinic three times a week where you control everything and bill for every visit or patients who do it themselves at home where you make less money. So home dialysis, particularly peritoneal dialysis, is gentler.

It's more flexible and cheaper. And Medicare pays about $60,000 per year for home dialysis. And it pays $90,000 for in clinic. After 15 straight minutes of kidney horror, even your anxiety needs a snack break. We'll be right back.

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“So, okay, are the diseases that lead to kidney failure or those predictable?”

Yeah, very much so. So they cluster in communities with less access to healthy food, preventative care, and safe environments.

There's a disproportionate impact on older adults, low-income patients, black and brown

communities, and people managing diabetes and hypertension without the resources to manage them well. I know somebody who had to do dialysis and I remember she had a lot of, she had diabetes and things like hypertension. I remember even just when I was younger, she had health problems and when she got older,

she had to do this. So okay, so by the time the machine shows up, these people had problems for years, the system has failed them in many ways repeatedly, right, if they live in a place where they can't get healthy food or health care, et cetera. Yeah, absolutely.

And black Americans are three times more likely to develop kidney failure than white Americans. Okay. Heart of that might be genetic variant that's more common in people of West African descent. It's called APOL1, but genetics isn't destiny. So the bigger factors are things like living in food deserts where fresh produce is scarce,

working jobs without health insurance, breathing air near industrial sites, drinking water with lead contamination, you know, by the time someone's on dialysis, they've usually been dealt a bad hand for decades. Yes, I feel like we need to do an episode on food deserts because this is one of those things, and I know I'm going to sound like such a privileged PLS right now, but I'm like,

come on, man, like, is that real? You can't get healthy food. They sell chicken everywhere, but I don't know, like I'm talking to my ass, really. I don't know that. There can be many swear miles where there's not one regular grocery storage, just botegas.

You know what, actually, now that you mentioned it, when I worked in downtown Detroit, I remember my boss was saying, you know, a lot of the people in this neighborhood, they do their shopping at the convenience store where they have no business doing all their shopping, and I was like, that's so silly. Why don't they go to the grocery store and he's like, well, they either walk downstairs

and walk into this convenience store and spend an extra $10 buying milk and cheetos and microwave

“stuff because that's what they have at the convenience store, or they take the bus 15 minutes”

that way, they go to the grocery store, they get a ton of bags, they get back on the bus with all of those bags, maybe they have to stand on the way home, and then they walk back up to their place with all the bags of stuff. And I was like, that does sound like a pain in the butt, because I was thinking, oh, you just drive the store, man, what's the big deal, but like, if you don't have a car, you live

in a walk up with the elevator, and yeah, you're doing it little at a time.

Yeah, just stuff I never really think about anyway, so yeah, because my knee jerk reaction

is okay, eat healthier dummy, it's not that hard, but it's, I guess, yeah, it's not that simple. Let the meat cake. What I sound like right now. Let them go to Whole Foods.

Yes, why don't they just go to Aeroon and buy, yes, an organic bean burrito, yeah, that's, I know, I sell $45. Yes, that's exactly how I feel, saying these things right now, but yeah, I just, because food desert sounds, it just sounds fake to me, and I can't be alone in that. I can't be the only person who's like, food desert, come on.

Of course, but the huge part of the population lives that way, and because you're living

“that way, and this is crucial, you know, the consequences don't go away.”

So let me give you a really typical case drawn from documented patient interviews. So I read about a 62-year-old woman. She worked as a public teacher and Detroit for 30 years. She developed diabetes in her 40s. She struggled to afford her medications. She rationed her insulin a few times when money

was tight. Oh, my God, you're not supposed to do that for people who don't know. Not supposed to do that, and by her mid 50s, guess what, her kidneys were failing. Because she couldn't afford insulin.

Insulin is not, it's, it's not even expensive, while in most places, like it's not. This is one of the cheapest, easiest to obtain medications nowadays. I mean, it's just no one should have to ration it. That is, that's disgusting. Yay, American healthcare.

Right. But now she's on dialysis, and it's three days a week. She has to take a bus 40 minutes each way to the clinic. She sits in that chair for four hours. By the time she gets home, she's exhausted.

She's been interviewed saying, quote, the days I have dialysis, I don't have a life, I have a treatment. Yeah, she's.

Yeah, what, what else are you going to do when you take the bus, and it's basically an hour

to get ready and go, and then you sit there for four hours, and then you come home. I mean, that's your whole productive day, plus you probably feel like crap after doing that. I can't imagine you feel good doing that.

“Yeah, and here's the thing, Medicare now pays for all of her dialysis, you know, every”

session, it's one of the only diseases where Medicare covers you regardless of age. The same system that wouldn't reliably help her afford insulin, which, as you mentioned, is not expensive. Now spends about $90,000 a year keeping her on dialysis. I had not thought of that, so we won't pay for the thing that would have prevented this,

which is so cheap as to almost not incur cost at all, but we will pay forever. For the extremely expensive treatment, because I'm going to go out on the limb here and say a public school teacher in Detroit does not make $90,000 a year. So we're actually paying $90,000 for her treatment instead of keeping her working for an extra 20 years for, I mean, the government cost of insulin per year has got to be, I don't know,

a couple hundred bucks at most, probably not even. Yeah, that's crazy. Maybe we could pay our teachers more, you know, or like give them insulin, so they don't die. I mean, come on.

Both care right, exactly. Okay, how much are we talking about here total for the dialysis for everybody in America?

“It's a lot, you know, dialysis is about a $50 billion a year industry in the United States.”

Medicare spends about 36 billion a year on it.

That's roughly 7% of the entire Medicare budget, and it's going to less than 1% of the population. So on a per patient basis, it's the single most expensive condition Medicare covers. For sure. Yeah, I can, I mean, the numbers are staggering $50 billion every year.

That is, that is serious. Yeah. And follow that money. You know, two companies, DeVida and Fresenias control about 70% of all dialysis clinics in America.

Two companies control 70% that is not much of a market. I'm not going to say that they collude and make the prices higher, but I'm going to go ahead and imply that they collude and make the prices higher. Yeah, you're not wrong. I mean, it's effectively a duopoly.

Yeah. So DeVida has about 2,800 clinics. Fresenias has about 2,600.

And together, they treat roughly half a million dialysis patients.

So this level of concentration is extraordinary, even by American healthcare standards. I want to be clear for legal reasons. I've absolutely no facts or information whatsoever. And I don't have any reason to believe that they do that other than if I were running a duopoly or half of a duopoly. I would probably be enough, scummy enough to call the other guys and say, hey, you know,

we should do. Right? Because we'll all make more money. So yeah, that just means I'm a terrible person.

“Moving on, how did it happen that there's only two companies?”

Because if there's this much money in it, how is this not like smoke shops where there's a zillion of these things? Yeah, I mean, it's consolidation over decades. So dialysis requires expensive equipment, train staff and regulatory compliance. So small independent clinics, they just, they got bought up and economics of scale kicked

in. And once you're that big, you know, you have enormous power to shape regulation, negotiate with suppliers and just influence payment rates. And patients, again, can't shop around you're just trying not to die and you're, it's so long that you're just going to go to the one that's near you kind of.

Right? Yeah, I mean, that's the key. If you need dialysis, you need it three times a week on a schedule. So most people go to the clinic closest to them because, like we said, anything else is logistically impossible.

You know, you can't skip treatments to, you know, wait for that better deal and, you know, you can't delay. It's not like choosing a gym or whatever. Yes. This is life or death.

I want to buy electronics. My brother and those like wait for black Friday and it doesn't matter if it's December. It's like wait for black Friday and it's like, no, I kind of just want this thing like in the next 10 months. So I'm going to go ahead and buy it.

But yeah, this is, so this is life or death.

I'm going to hold off till Monday. Right. Waiting for that group on. Right. Doesn't happen.

And that lack of choice matters when you look at who controls the industry.

So David is market cap is around 11 billion and their longtime CEO Kent Theory, who

was known internally as mayor. He built this really intense corporate culture. You know, internally employees called themselves citizens of David a village and they did these company chance at meetings, all this weird stuff. Chance.

Okay. So I'm going to withhold judgment because I don't know if you're doing something like this,

“maybe you need to be cheered up and feel good about it.”

But I think I saw this guy dressed up is a night on John Oliver. Is that this guy did? Yeah. He did. Yeah.

Yeah. Yeah. I can't imagine doing that. But I guess, you know, when you're making a hundred million dollars a year. Yeah.

Yeah. But it's David Ate, it's Italian for giving life. So there's a right sentiment there, I guess. But yeah. Managers would lead these synchronized chance with everyone putting their hands in the air.

It was meant to build unity and mission, but none of these people are on dialysis. Well, we don't know that. But yeah, that's true. But also, I don't know. And I'm on the fence because a lot of organizations do that sports teams do that.

Non-profits do that. The Red Cross could chant and nobody would think twice. And also, I don't know, man, you're probably, it's a little bit depressing because you're seeing these people and they're not well. And then you're like, oh, where's Tom?

Oh, I have to cancel Tom's appointment. He passed away. Like, that's sad.

“But you probably need a little bit of a morale boost to work in a place like this.”

I don't know. Yeah, I suppose. It just seems to me when I was reading about the corporate side of this. Not what's going on in the clinics, but like, what's happening in this corporation. It seemed a little corporate Colty to me, I guess.

That's a good point.

A lot of these people, they work in a building and they've never seen a dialysis patient in their

life. They're not the nurses working. Because I'm always so, I'm so hesitant to crap on a health care worker or a nurse or a medical tech. Like, it's their job.

That's not exactly who I'm describing. Okay. Got it. No, that makes more sense. Yeah, you're right.

When we think of these companies, we're thinking of the nurse who's like, you'll be fine. Do you want me to change the channel on the TV? We're not thinking of the person who's like, deny this person's coverage because I'm not Korean and a bad mood. Yeah.

The issue I suppose is when chanting is happening inside a multi-billion dollar company who's primary customer is Medicare. That's a problem. That's the problem. Because when the rhetoric is about mission and community, you know, the economics are enormous.

So theory made more than 17 million in his final year running the company, which is impressive for a company whose primary customer is Medicare. Yeah. The government. Right.

Funded by taxpayers. Yes. So our government is cutting enormous, enormous checks to these companies. These two companies. Yeah.

As 1972, that's when Congress passed a law making kidney failure. The only disease where Medicare covers everyone, regardless of age. Okay. 30 years old with kidney failure, Medicare pays. You know, it was seen as a moral imperative.

We're not going to let people die because they can't afford dialysis. Which in its face? I mean, that sounds great. I want people who have health problems to not die because they can't afford their medicine or their treatment.

Right. It sounds great. But it also created something unique in American health care guaranteed in definite payment. So this creates stable, recurring revenue and financial success becomes tied to keeping

patients on dialysis, not necessarily getting them off it. And to be clear, this isn't doctors and nurses wanting people to suffer. I have to go back to my earlier statement that I just don't want people to think like, how dare you? I work so hard in this dialysis clinic.

It's what I'm talking about you. We're talking about the Pennsylvania pushers. Of course not.

“I mean, it's important to remember doctors want to help patients.”

But this system quietly rewards stasis over resolution. So if you're a dialysis company, you have a customer base that cannot leave and a payer that cannot refuse. So you were right. That's not a market.

That's a captive revenue stream. So the incentive is to keep people alive. Yes. It's not necessarily to get them off dialysis. So nobody's saying this out loud.

I suppose, but the system works best when people never leave.

It's better. I'm not saying this, but in theory, it's better to never get off dialysis. You should not get better. You shouldn't get a transplant. You should just stay until you die.

Like that's the ideal business, the ideal customer for them. Right. That math is undeniable. So a patient on dialysis is worth $90,000 a year, every year, indefinitely. The patient who gets a kidney transplant costs Medicare, about $110,000 for the surgery,

Huh. Okay.

“So from a business perspective, once again, transplants are actually bad.”

Yeah. From a pure revenue perspective, yes. A transplant means a dialysis provider loses a customer. So dialysis companies aren't actively preventing transplants. It's more subtle than that.

The system simply doesn't incentivize them to prioritize getting patients off dialysis. Okay. So how does that play out? What does that look like? So through the transplant waitlist, about 90,000 people are on it.

So we discussed it at length in the episode on transplants, which was episode number 1253. Yeah. Organ donation. Organ donation. Right.

The average weight time is three to five years. So some people can wait eight, ten years and during that time, they're on dialysis. Wow. Because they're on enough kidneys to go around to people who need them. Right.

That's the idea. Right. That's partly it. We do have an organ shortage about 17,000 kidney transplants happen each year, but demand far exceeds the supply.

And here's what's sticky.

The referral process to even get on the waitlist is complicated. How is it complicated? Remind me. I don't remember this. You need a referral from your dialysis clinic, and you need extensive medical evaluations.

You have to prove you can afford the anti-rejection drugs. Now that's some bullshit right there. That's some bullshit. That is insane to me. Oh, you're too poor to get this life-saving treatment.

I'm sorry. You're just going to have to stay here and do dialysis until you kill yourself.

“And remember, there's even a stipulation where you have to demonstrate you have social support.”

Why? That's just part of the requirements to get on the transplant list. I get it, but I hate that because it's like you don't have enough friends and family that care about you to live. If you're a loner, sorry.

I get it because, I mean, here, the sad reality is though they have to do that because they want to maximize the success of the transplant, right? And the people with more social support have better outcomes, I assume. Correct. Oh, gosh.

This is some dystopian-ish, man.

So it just ends up that clinics aren't always aggressive about pushing people

through that process. Okay. I'm going to say why not, even though I already know the answer, but go ahead. Why not? There's no financial incentive.

Okay. So in fact, evidence suggests clinics are slower to refer patients for transplants. Colomies surprised. Yeah, right? There was a study in the journal of the American Society of Nefrology, which found

patients at four-profit dialysis clinics were 64 percent less likely to get on the transplant weight list compared to the patients at non-profit clinics. Wow, 64 percent less likely. That's not subtle. That might not be an accident, Jess.

Yeah, right? Even after controlling for patient health, demographics, everything. So the difference was profit motive. It's a system that just makes suffering profitable. So far, the lesson is if something in America is tragic enough, somebody will eventually

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“Yeah, so if you're at a for-profit clinic, they're just quietly not really wanting to help”

you leave. And a non-profit clinic, it makes sense, right? We need as many people to get transplants as possible because then we have a slot open and we can get another person in here. Because their goal is theoretically helping as many people get through as possible.

Whereas a for-profit clinic, they don't really care if they're full, they're full, it's like a hotel. They don't really care. All guests are kind of creative equal, right? Right.

They're just numbers. Yeah, they're a nut entry and a spreadsheet. That's just a gosh. This is black mirror without the cool unique technology on screen. Right.

Exactly. Well, I guess it does.

It dials as machine is pretty cool tech.

So maybe it's just black mirror. It's pretty close. And, you know, these for-profit clinics, they're not blocking you, but they're not exactly shepherding you through either. So remember, these clinics are often understaffed, they're stretched thin, social workers

who handle transplant referrals or juggling huge caseloads. Clinics are understaffed. And if the company's revenue depends on keeping chairs filled, you know, what gets prioritized. Yes. The chairs.

“That's all we're just sort of implying earlier, right?”

It's the chairs that get prioritized. Of course. You know, there was a whistleblower lawsuit filed in 2015. It was one of several.

Where a former DeVita employee alleged the company systematically discouraged transplant referrals.

So DeVita denied it and settled. But the allegation was that staff were told not to educate patients too much about transplant. I'm fuming over here quietly. Don't tell them there's a way out. That's so bleak, man.

I can't believe what I'm hearing right now. I know. It's subtle. You know, it's not a written policy. No, because they would be suited to oblivion.

And if it were written down anywhere, of course. It's about what gets emphasized, what gets resources, you know, what gets rewarded. So if you're a clinic manager and your bonus depends on build treatments, are you celebrating when patients leave? Now, but it's, this is psycho, Jessica, this is psycho nonsense.

They know it's really hard to swallow, but it's systemic. And here's an even more maddening part in the U.S. Medicare system. The plants are actually cheaper, you know, Medicare saves about $270,000 over, you know, like 10 years per transplant patient versus dialysis. Wow.

So even if you strip away morality, pure maths says transplants win.

“But since they don't benefit the people currently making money, correct?”

Yeah. The savings go to Medicare, meaning taxpayers, the losses go to dialysis companies. So the system is optimized for corporate revenue instead of patient outcomes or fiscal efficiency. Our non-profit clinics better because it seems to me, like I said before, their outcome

is like, get as many people out of here. Yeah, because they seem to be, they seem to be for sure. So studies show non-profit clinics have lower mortality rates, they have higher transplant rates, and just better patient satisfaction, but they make up a shrinking share of the industry. So for-profit chains have been consolidating dialysis care for years and non-profits, they just

don't have the capital to expand at the same pace. So the consolidation continues and the profit mode of growth. Yeah. So that reinforces why home dialysis isn't pushed, yeah? Right.

It makes less money for clinics, and when patients dialize at home, they're more independent. You're not coming to the clinic three times a week. The company has less control, less opportunity to build you for add-ons, and less ability to keep you just in their ecosystem. By the way, you said add-ons, what are add-ons?

This should not be add-ons. This is a medical treatment thing. Don't tell me they're grifting these people in the clinic as well. I mean, why wouldn't they? There's upselling at the dialysis clinic.

Oh, my God. I hate this episode as terrible. For medications, they want to sell you vitamin supplements, iron infusions, things like that, and dialysis clinics have gotten very good at finding billable services. For a while, there was a major issue with over prescribing a drug called Epigen, which is

for anemia. So since dialysis patients often become anemic, Epigen makes sense, but Medicare used to pay for it separately on top of the dialysis payment. Oh, no. No way.

This is going. Oh, gosh. So suddenly, Epigen doses, they skyrocketed. It became just a profit center. And these higher doses increased risks of heart attacks and strokes, divita, and for

Zenias were among the biggest purchasers of Epigen in the world. And that manufacturer, Amgen, was making billions.

And also the risk of heart attack and stroke, I don't want to sound unkind, but I'm

“going to go ahead and guess that somebody who's diabetic and on dialysis is already at”

sky high risk of heart attack and stroke. Yeah, exactly. So giving them a drug that they don't need, that increases that risk is either killing people doing this period. I don't even need to know that that has happened as a fact to know that that has happened.

Right? I don't need a documented instance because if you're raising the risk profile, somebody who's high risked over the course of 800,000 Americans doing this three times a week, someone has died from this. Oh, yeah.

It's incredibly depressing. So the manufacturers making billions off of selling this drug to these clinics that are up selling it. So I'm giving it out when people don't necessarily need it because they can bill Medicaid for it or Medicare for it.

So what happened? So Medicare changed how it paid for the drug. So they bundled it into the overall dialysis payment.

“So there is no incentive to over-prescribe and clinics couldn't bill extra for higher doses.”

And guess what, usage dropped immediately. Funny how that works. That's disgusting. Yeah. That's disgusting.

And at the same time, the FDA issued safety warnings because studies showed that higher doses increased the risks of all these health concerns, like the heart attacks, blood clots, and like you said, even death. So when the financial incentive disappeared, suddenly patients didn't need as much of this drug.

And both companies have paid massive fraud settlements.

Over the past 15 years, DeVida has paid around $1 billion for various allegations.

Wow. Imagine being that general counsel in your job is just to deal with fraud allegations. And you're like, OK. So we definitely did this. Let's negotiate the fine.

Yeah. I'm sure they have a chant for that. Oh, yeah. Yeah, the legal department is those guys are busy. A billion dollars in fraud settlements, not wrongful death, not tax fraud.

Like this is you have done, you are a bad actor, you have committed actual fraud. You're getting fined a billion dollars. That is crazy. That is a crazy high settlement. I know.

And crazy that they can afford it and stay in business. Yes, right.

“No cost to doing business is how that's why they still exist.”

Otherwise, this would be, oh my gosh.

Yeah, there was a $495 million in just one case for allegedly billing Medicare for drug

waste. Oh, my God. 34 million, just in 2025 last year, free legal kickbacks to nephrologists. Presentious has been sued for allegedly performing unnecessary, vascular access surgeries to generate additional revenue.

They'll also claim these surgeries weren't medically necessary, but they were really profitable. Oh, my gosh. So they're paying doctors, defrologists as a kidney doctor. So they're paying doctors, I don't know, probably to refer to a specific clinic or to get some treatment or something and then they're giving people unnecessary surgeries.

Again, not to beat this dead horse, but if you are already high risk for medical complications and you are, I don't know, diabetic and you have high blood pressure going into surgery unnecessarily could and will in some instances definitely kill, like again, someone has died from this. Absolutely.

Depending on how widespread that fake, or I should say, unnecessary surgery, this is like some Nazi kind of crap, like we're just going to do surgery on you because it makes us money. I mean, it's not quite the same thing, but it's out there. This is that is up there.

It's terrifying. Allegedly. Yeah, allegedly. Sorry, sorry. Yes, allegedly.

Allegedly, they're doing this. The case is ongoing, and this is the environment we're talking about, you know, when billing is the business model, pressure to maximize what you can bill for follows. Who's regulating all this? So CMS, the Centers for Medicare and Medicaid Services, they oversee dialysis clinics.

And there are standards for water quality, infection control, and staffing. The clinics do get inspected, but here's the issue. The regulatory burden has exploded, but outcomes haven't improved proportionally. What do you mean? So there's a quality measures manual for dialysis, clinics, and it doubled in size from

150 pages in 2016 to 280 pages in 2025. And the patient survey that required to administer is 62 questions long. And so that's insane in less than 30% of patients, even respond to it. And that doesn't actually help patients. Of course not, because the standards focus on compliance, not outcomes.

So a clinic can check every box and still have terrible outcomes. They can meet every technical requirement and still have patients who are miserable or dying at astonishingly high rates. There was an investigation by Pro-Publica a few years ago that found wide variation in mortality

And some had death rates, 50% higher than the national average. Oh my gosh, that's significant. Okay.

“So how is that possible, though, if they're all regulated?”

Because the regulations don't measure quality of life or long-term outcomes very well. They measure things like, is the water clean? Our infections log, our treatments happening on schedule, you know? Yeah. Okay.

This almost sounds like soft regulatory capture. Yeah, soft is right, meaning not like cartoon, villain, corruption. Just regulators may be slowly over time getting too cozy with the industry. They're supposed to oversee same language, same incentives. I mean, if they're, if they do properly, so there's two companies.

And it's just this lucrative, there's kind of no way that you don't end up with big problems. And when these two giant companies with enormous resources are running the show, they have sway over how the rules are written. Yeah, that's what I mean. Yeah.

So they submit comments on proposed regulations. They're the ones funding studies. They hire former CMS officials as consultants. They spend about $2 million each on federal lobbying. And so over time, the regulatory environment just becomes comfortable for them.

That is bleak. That is complicated, but bleak.

Also, I, I don't know, side note here, but is amazing, hello, that number is $2 million each.

It kind of sounds like a lot, but give me a break. You only need to, or whatever, four million dollars to get the government to let you charge the taxpayers billions of dollars. That is really great ROI. Our Congress people are pathetically cheap dates.

If that's really what this cost. Yeah. Which shouldn't surprise anyone? I would have thought you had a zero on the end to the amount that they had a lobby to get this stuff.

I mean, I guess it's every year, but still come on. Wow. And so they fund patient advocacy groups, you know, organizations that ostensibly represent patient interests, but are financially supported by dialysis companies. So when legislation comes up, that might hurt the industry, these groups will oppose

it, you know, framed as protecting patient access. Yeah, that's sinister, but it's also super common, so I don't even know if we can act surprised that that's happening. Right. I know.

But lower reimbursement could cause some clinics to close, which would hurt access.

But the framing is always about protecting the current system, never about redesigning

it. Okay. I need to understand the patient experience more. So let's come back to the human side here. What does this feel like?

Do we know what this feels like? I can't imagine you feel great after dialysis, even though it's cleaned you up. Well, and people try to describe it. So I'll tell you about another patient. There was this guy I read about named Marcus.

He was 54. He worked in construction and he had kidney failure from untreated hypertension. He described dialysis as, quote, "Imagine the worst hangover you've ever had."

“That's how I feel when I wake up on treatment days because the toxins have built up.”

Then I sit in a chair for four hours while the machine sucks out my blood, cleans it, and pumps it back. Afterward, I'm wiped out, not just tired, wiped, brain fog, nausea, muscle cramps. I go home and sleep. The next day I feel almost human, then the cycle starts again.

Wow, three times a week. Three times a week, you go through that.

And here's what people don't realize.

You can't travel easily, right? You can't take a spontaneous trip. If you want to go somewhere, you need to arrange dialysis at a clinic near your destination. That's, you know, if they have an open chair, and it has to fit your schedule. So this man, Marcus, he missed his daughter's wedding because they just couldn't arrange

dialysis where she lived. See, that sucks. I'm sorry to hear that. That's awful. So he misses his daughter's wedding.

I don't really know how that's, it seems like that shouldn't happen. I don't know. But I guess if they don't have enough chairs in appointments, like that's it, you just can't go.

“And I think, in his case, there was a lot of optimism, like, of course, of course, this”

is going to happen for you. And then at the last minute, it just, it couldn't make it work. You know, and dialysis doesn't just replace your kidney function, right? It reorganizes your entire existence. Your job has to accommodate your schedule, which is what puts people into, yes, Medicare

covers it. But people go into financial hardship because you can't really work while you're doing this. Social life revolves around it, imagine trying to date while you're on dialysis, you know, who wants to date someone who's exhausted half the week and big life events become logistical

puzzles because clinics or machine rentals are just not available. So you might miss things like walking your daughter down the aisle. I know someone's thinking, it's so I'm just going to say it. I guess if you date somebody who's on dialysis, you should also maybe be on dialysis, right?

You think your appointments up and you, yeah, you go and you say, hey, we want to cherish

next to each other and you bust out the sorry or trouble or some or monopoly or something like that and you just, you have four hours of uninterrupted, I don't know, I'm joking. But I, I'm going to guess while you're doing this, maybe you don't feel like having a great time. You might just be sitting there with a slamming headache or something.

I don't, I don't know. I didn't read about what it does here, libido, but it can't be good.

“Yeah, I just, in, in just like, do you, can you just lay there sort of like on an airplane?”

You're watching a movie and you feel dehydrated and gross, you know, that's kind of what I'm imagining. Right. It's sad that this is just accepted as normal for these people. This is just their life now.

That's depressing. And dialysis is invisible.

I mean, most patients, they don't talk about it because there's a stigma, there's exhaustion,

and there's this constant emotional math of gratitude, verse, suffering. Sure. Just to be grateful because the machine is keeping you alive, which it is, but that doesn't mean the system is okay. Right.

You can say this keeps people alive and still say, hey, the way we built this is insane. Exactly. And that's where criticism gets shut down, because if you say, hey, the dialysis industry has problems, someone will respond with, oh, so you want people to die. It's like, no, I want people to live well.

There is a difference.

“So what are the clinics like, what is a day of dialysis like in this place?”

Yeah. So I mean, it varies. But the typical setup is a large room with maybe, you know, 20 to 30 reclining chairs, syringe and rose. Each chair has a dialysis machine next to it.

Patients come in. They get weighed. They get their blood pressure taken. The needles are inserted, and then they sit for four hours. What do people do?

Like I said, you bust out a game or you watch TV. I mean, I don't know. What do you do? I mean, they watch TV, they sleep. If you can focus, I guess you could read some people bring their laptops.

But a lot of patients, they just feel too crappy to concentrate on that. That's what I'm thinking. Yeah. I mean, there is a strange community that forms, and I think this happens with chemo patients, too.

You know, you see the same people three times a week for years. So some people make friends, others just indoor. You know, statistically speaking, someone is almost certainly listening to this right now while undergoing dialysis. So if that's you, I hope it's going well for you, and we're thinking about you right

now. Thinking of you. And we hope you feel better soon, and go find out how to get a transplant. If you haven't done that already, because we want you to survive and not have to do this crap anymore, what about staffing at the clinics?

So this is a major issue. Nurses and texts are often stretched thin. In some clinics, one nurse is managing six or seven patients simultaneously. And turnover is high because the work is really hard, and the pay isn't great. And when staffing is thin, you know, that's when corners get cut.

And patients don't get as much attention. That's when the infection rates go up. And remember those infections statistics we talked about. That's 36% of deaths of people on dialysis are from infection. So this is an abstract, you know, understanding kills people.

So people are dying because clinics save money on labor. I mean, that's the implication. So you maximize profit by minimizing labor costs. And in health care, that means worse outcomes. Yeah, of course.

There's kind of no way around that. I'm curious if you know what happened when COVID hit because that must have just been like a bomb going off in this industry. Oh my gosh. Yeah, COVID was catastrophic for dialysis patients.

So even though dialysis was still available during lockdown, 25% of dialysis patients who got COVID, they died. That's one in four. So it exceeded death rates in the general population by a huge margin.

And there was actually a decline in the U.S. dialysis patient census for the first time

because of all these excess deaths. One in four dialysis patients who got COVID died, wow, because of their super high risk for exactly this kind of thing. And also, oh man, yeah, I mean, it was a perfect storm. So they're immunocompromised.

They're in clinics with other sick people three times a week. They can't isolate. The one positive outcome from it was that it accelerated the shift to home dialysis. So suddenly there was, you know, urgency around getting people out of clinics. So a global pandemic with a lethality of one in four in the target population that we're

talking about now had to happen. Or the system to prioritize the thing that was better and cheaper for patients all along.

“That's yeah, okay, if you weren't angry before, you should be now.”

Yeah, and Medicare started pushing harder for home dialysis, but progress is slow because the financial incentives, they haven't fundamentally changed. Nothing says modern health care like we can keep you alive, but only in the most expensive

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“Tell me about other countries, does anyone do this better?”

Denmark probably has a device that fits in the palm of your hand that you can walk around during the day doing this, right? It's free. Right, they just have a kidney-vending machine. Yeah.

That's Japan. But yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah, yeah.

The problem is in Japan, it's someone else's kidney.

(laughs) It's got a nice God. But several countries do it better. So in the Netherlands, about 40% of dialysis patients use home dialysis, compared to just 12% here in Hong Kong, it's over 70%.

Wow, 70%. That's incredible. Because they prioritize it. They train patients, they provide support, and they make it the default option unless there's a reason, not to.

Right, okay. And their outcomes are better. They have lower mortality. They've better quality of life. Yeah, because you're at home with your family, chillin, watching it's a wonderful life or something,

with this little thing beeping next to you. You don't have to slap over someplace with a bunch of strangers and get an infection. Why can't we do that again in America?

“I don't understand what the, so is it really just, hey, the clinics get, it's got to be incentives, yeah?”

Yeah, I mean, we could do it. But it would require changing the incentives. So Medicare could pay more for home dialysis or pay bonuses to clinics that transition patients home. They've started doing this actually.

There's a push to increase home dialysis rates, but it's slow because companies are resisting the shift when they see they're going to lose money. What about transplants? Do other countries do that stuff better? I know that's a different episode.

Yeah, we talked about that in the organ donation. And a lot of countries are much better at transplants. So Spain uses that opt-out system, so you're a donor unless you say otherwise. We're in America. We're opt-in.

And their transplant rates are among the highest in the world. We have opt-in here. Yeah, you have to elect to do it. Right. We have opt-in.

And even then, families can override that decision, which is a whole other issue. So we have chronic organ shortages as well. There are also innovations like paired kidney exchange programs where incompatible donor recipient pairs. They swap kidneys with other pairs to make compatible matches.

Okay. There's all kinds of issues. And these are growing, but they're logistically complex and really underfunded.

“What about artificial kidneys speaking of vending machines?”

Is that science, I mean, this vending machine thing is fake obviously. But artificial kidneys, is that science fiction still at this point? Well, inter we, how's that looking at it? It's actually real, but it's slow. So there are researchers working on implantable artificial kidneys, like some kinds of wearable

devices. They're even talking about bioengineered kidneys that might be possible to grow from stem cells. The science is promising, but development is expensive. The path to FDA approval would be really long. We're just not there yet.

I see. And the dialysis industry, I'm guessing they're not involved in funding all this research. Right. Why would they? If someone invents a portable artificial kidney that you wear like an insulin pump,

that's the end of the dialysis clinic model, there's no incentive for incumbents to disrupt the system. So innovation is happening despite the industry, not because of it. Mostly yes. You know, there are some companies exploring new technologies, but the big players are focused

on optimizing the current model, not replacing it. Okay. So because the quietest tragedy and all this is lack of prevention, right? Yeah. I mean, this is the part that makes me angriest.

I think, I don't know, a lot of this makes me angry. But chronic kidney disease is often preventable, or at least delayable. So if you catch it early, if you manage your diabetes well, control your blood pressure, you can slow progression dramatically.

In fact, many people with early stage kidney disease never progress to kidney failure

if it's caught early, but we don't invest in that. We barely invest in that. Nefrologists, the kidney doctors, they're among the lowest paid specialists.

So primary care doctors are overworked and often don't catch kidney disease until it's advanced.

“The screenings really inconsistent, the education is really minimal.”

You know, we're back to patients, like rationing and saline.

Because prevention doesn't really make money, and you can't build Medicare for something that never happens.

Right. Prevention means nothing dramatic happens. There's no emergency, there's no machine, there's no chair, there's no $90,000 year treatment. You know, it means someone stays healthy and never enters the system, and there's no billing code for that.

So prevention pays society with fewer sick people and lower costs, but dialysis pays companies. So we have this perverse setup where the most profitable outcome is late intervention in definite treatment and no cure. By the way, I want to say real quick, I know someone's going to be like,

no Medicaid also pays for part of doubt. I know we're saying Medicare. It does that is what pays for the bulk of it, and it's just easier than saying both of those things at once. So for people who are ready to fire that often in email, we know it's just we're trying to keep it simple.

Okay. What would proper prevention look like here?

It would just be aggressive screening for high risk populations. You know, better diabetes management access to healthy food would help treatment for hypertension. So no phrology consultations for anyone with early stage kidney disease would stop a lot of people from going into dialysis. You know, it's not some exotic idea.

We know how to do this. Right. We just don't. Right. We don't fund it. There's no lobby for prevention. But there's a massive lobby for dialysis, spending millions on political campaigns, funding patient groups, shaping the conversation.

“You spend a lot of time on this when you talk to patients. What do they want?”

And they want their lives back. You know, that's the consistent theme with people. They're grateful for dialysis. Most of them would be dead without it, but they also don't want to live this way. They want to travel. They want to work full time. They don't want to feel like shit half the week,

and they want to feel like the system is trying to get them off dialysis, not keep them on it. Well, do they feel like the system is trying? Mostly no. They feel like they're in a holding pattern.

And here's what's really hard.

Many patients blame themselves. You know, they think if I just managed my diabetes better, I'd just gone to the doctor sooner. If I'd eaten better, all of these things you would say to yourself, and sure personal choices matter,

but these are people who often didn't have good options available to begin with. You know, they couldn't afford medications.

“They couldn't get doctors appointments or insurance,”

even if they were working two jobs, or they lived in neighborhoods where the only nearby food was fast food. So the system failed them, and then they blame themselves. Right. It's hard-breaking. And then the system locks them into this permanent treatment while profiting from it.

So it's hard not to see it as exploitation. I'm sympathetic to the whole personal choice thing, but I don't know. When you talk about the food desert thing and the medical thing, and there's also the genetic thing, it's like,

it's a bad hand, like you said earlier in the episode. I suppose somebody could say, "Hey, you guys are being anti-medicine or you're being extreme saying it's exploitation. Come on, guys." I know, but we don't want to look at it,

but the industry hides behind the fact that it's providing necessary care, which it absolutely is. But the dialysis system, it's not optimal, and it's certainly not ethical. So we can acknowledge that dialysis saves lives while also demanding it does better.

Okay. And what does better look like? So it looks like this aggressive prevention. So fewer people need the dialysis. It looks like incentivizing home dialysis and transplants. Let's break up this duopoly, so there's actual competition.

It would look like regulation that focuses on outcomes, not just compliance, better staffing ratios to reduce those horrific infection rates, and it looks like funding research into alternatives into those portable kidneys, those bio-engineered organs,

whatever works. All of which would reduce revenue for the current players. Exactly. So it won't happen without political will. No Medicare could change payment structures tomorrow. Congress could fund prevention programs.

The FDA could fast track artificial kidney research, but all of that requires overcoming industry resistance. And industry has money and lobbyists and patient groups that they fund. Right. And nobody wants to be accused of rationing care,

letting people die, so the conversation doesn't happen. We just keep writing checks and the system continues.

I mean, honestly, visibility podcasts like this. You know, most people don't know this is happening. Dialysis is invisible until it's personal. And if people understood this scale of this,

that half a million Americans trapped in a system

optimized for profit, not outcomes, or 60% won't survive five years, where infections kill more than a third of the patients, or people are choosing death over continuing treatment. You know, maybe if people realize that there'd be pressure for reform.

But it requires people to care about something that maybe doesn't affect them directly at the moment. I know for now, but kidney disease is growing. Diabetes is growing. High-pretension is growing. So more people are going to face this,

but the system isn't designed for them. You know, it's designed for shareholders. Yeah, that's bleak, man.

“Yeah, but it's realistic. And here's the thing.”

It doesn't have to be this way. You know, we built this system through policy choices. We can unbuild it the same way. So we just need to decide that keeping people alive isn't enough. You know, we should want them to live well.

You would think that would be part of the baseline, but I get it. There's numbers involved, but it's like, man, we are really focused on those numbers. Yeah, I mean, you think, but when profit is the organizing principle,

a live becomes the acceptable outcome. Everything else seems optional. So what do we tell people? What's the action item here, the takeaway? I mean, you know, if you have diabetes or hypertension,

manage it aggressively, get your kidney checked regularly. It's just a blood test, any urine test. If you have chronic kidney disease, see a nephrologist early. You know, don't wait until you're in crisis.

“And if someone you care about is on dialysis,”

support them, encourage them to talk with their doctor about transplant eligibility or whether home dialysis might be an option. Sometimes patients just don't realize those conversations are available to them.

And politically, I mean, politically, we have to support policies that fund prevention and expand transplant programs. We could demand that Medicare reward outcomes, not just volume.

And we have to be skeptical when patient advocacy groups oppose reforms. You know, look at who's funding that and address those infection rates. I mean, 36% of dialysis deaths involving infection. It's unacceptable. Yeah, that's insane to me.

And that's where we are. We've built a system that rewards keeping people alive. But not really necessarily helping them live well at all. That's just not, that's an afterthought. Right.

I mean, I want to emphasize here, dialysis saves lives. But the business model was built for permanence, not prevention, mobility, or cure. Yeah, that's a strange place for medicine to end up. Yeah, and it doesn't have to stay this way.

The system was built through policy choices. It can be rebuilt the same way. Ethical medicine requires asking how people live, not just whether they live. You know, dialysis isn't a scam.

It's not malicious. It's a necessary medical intervention. It's just trapped inside a system that puts profit first. Thank you, Jess.

I feel depressed discovering kidneys have a $50 billion industry built

around them or failed kidneys. Yeah, you're welcome. I'm happy to contribute to the existential dread here. But people do need to know about this and to anyone listening who's on dialysis or loves someone who is.

This system is hard. It's complicated. So filter the facts as carefully as your kidneys are supposed to. And if you haven't, maybe go get your kidneys checked by a doctor. Hopefully he's not being paid under the table by one of the dialysis companies.

Maybe get a second opinion. I really feel for you if you're dealing with this. I hope this episode was enlightening for everyone else as well. Jess, this is a really good episode. Oh, shoot.

That's not what I want to say. Jess, terrible work today. Terrible. I'm ashamed of you. I'm sorry to disappoint you.

And thank you all so much for listening. suggestions for future episodes of Skeptical Sunday to meet Jordan at Jordan Harbinger.com. Advertisers deals discounts, ways to support the show. All at Jordanharbinger.com/deals. I'm @jordanharbinger on Twitter and Instagram. You can also connect with me on LinkedIn. You can find Jessica on her multiple substax between the lines and where Shadows linger.

We'll of course link to those in the show notes. Her work is also on Instagram at Never Met Jessica.

That's plural for some reason. This show is created in this association with podcast one. My team is Jen Harbinger, Jason Sanderson, Tottis Alaskas, Robert Fogretty, Ian Beard, Gabriel Mizrahi in the house as well. Our advice and opinions are our own and Yam Aloyer, but I'm not your lawyer. Of course, we try to get these as right as we can. Not everything is gospel even if it is fact checked. So consult a qualified professional before applying anything you

“hear on the show, especially if it's about your health and well-being. Remember, we rise by lifting”

others. Share the show with those you love. If you found this episode useful, please share it with somebody else who can use a good dose of the skepticism and knowledge that we've told out today.

we'll see you next time. You're about to hear a preview about the biggest threats to your health

that most people never see coming from microplastics in the brain to everyday habits that

“quietly chip away at your energy, focus and longevity. I think microplastics are a problem. Most”

people know generally what they are. I mean, these are like small pieces of plastic that come off

larger pieces and they get into our bodies mostly through what we're ingesting. They're in the air

as well. And so they get smaller and smaller and smaller, they're called nanoplastics. And as the

“smaller, they become more dangerous in a way because we can absorb them easier. It's in our water”

sources. It's on the plants that we eat. So vegetables and fruits because it's in the soil and they get on the plants as in the plants. It's in meat. It's in every it's all over the place. Air is a big source of microplastic pollution as well. It's getting everywhere in our organs,

“but dietary fiber seems to prevent absorption in a couple different ways, particularly soluble”

fibers for meantible fiber, prebiotics, right? Those are all sort of interchangeable ways of saying soluble fiber. Fruit spruits is a big one. The skins of fruits. Some vegetables as well. But you can supplement with it like inulin. You know, there's a lot of these prebiotic fibers people take as well. The beta glue cance is another one. The point is is that if there's something you can do to prevent your body from absorbing it, that's the best. And try to eliminate these microplastics as much as they

can. And the number one thing you can do is get a water filter for sure. Air filters in your house,

water filters in your house. Those are the two top things that you can do. The reality is is that

microplastics, it's just everywhere. Catch the full conversation with Dr. Ronda Patrick for the science behind it all and the practical changes that can actually make a difference on episode 1267 of The Jordan Harbinger Show. [MUSIC]