COST OF RUNNING DIALYSIS IN FREELY ASSOCIATED STATES FNU & PIHOA JOINT STUDY background Non-communicable diseases as one of the top priorities for the entire world. (World Health Organization, 2012) Seoul Declaration and Honiara Communique on the crisis of non-communicable diseases in the region, emphasise the importance of collective and intensive efforts for the prevention and control of these diseases. (World Health Organization, 2012) Prevalence of renal diseases among the indigenous people of Oceania is also on the increase. (Weil & Nelson, 2006) Non-communicable diseases are becoming a leading cause of disability and death in the Western Pacific Region. (World Health Organization, 2012) Western Pacific region is predicted to contribute as the most deaths due to non-communicable diseases by 12.3 million deaths in 2020 followed by South-East Asia with 10.4 million deaths in the same year. (World Health Organization, 2012) Age-standardized prevalence of insufficient physical activity in adults 15+ years, comparable estimates, Western Pacific Region, 2008 Total adult (15+ years of age) per capita consumption of pure alcohol (litres) for both sexes, Western Pacific Region, 2008 Age-standardized prevalence of obesity in adults aged 20+ years, comparable country estimates, Western Pacific Region, 2008 Age-standardized prevalence of raised blood pressure in adults aged 25+ years, comparable country estimates, Western Pacific Region, 2008 Age-standardized prevalence of diabetes mellitus in adults aged 25+ years, comparable estimates, Western Pacific Region, 2008 Age-standardized prevalence of raised total cholesterol in adults aged 25 years, comparable country So what? FAS has a rampant NCD crisis. One of the outcomes of NCD crisis is that there will be large number of people requiring complicated healthcare services such as interventional cardiology, advanced nephology, operative ophthalmology, vascular surgery etc. One of the most serious burdens of disease due to NCDs is renal disease. Jurisdiction based evaluations REPUBLIC OF PALAU CURRENT SITUATION Belau National Hospital currently offers dialysis services Currently there are 30-35 patients receiving haemo-dialysis There The are 9 machines in the dialysis center center offers twice a week dialysis at 4 hours per session HAEMO-DIALYSIS PROCEDURE COMPETE BLOOD COUNT SERUM POTASSIUM SERUM SODIUM EPOGEN (ERYTHROPOETIN) BLOOD TRANSFUSION AVF INSERTION BLOOD UREA NITROGEN SERUM CREATININE SERUM PHOSPHORUS SERUM CALCIUM ALKALINE PHOSPHATASE TOTAL COST PER PATIENT PER YEAR TOTAL NUMBER OF PATIENTS in 2013 TOTAL COST PER YEAR $231.00 $50.00 $12.10 $12.10 $85.06 $180.40 $304.50 $11.00 $12.10 $12.10 $12.10 $17.60 8 2 1 1 2 2 2 1 ANNUAL COST PER ITEM PER PATIENT AVERAGE MONTHLY FREQUENCY AVERAGE ANNUAL FREQUENCY COST PER ITEM DESCRIPTION 96 $22,176.00 24 $1,200.00 12 $145.20 12 $145.20 24 $2,041.44 2 $360.80 $0.00 24 $264.00 24 $290.40 6 $72.60 12 $145.20 8 $140.80 $26,981.64 32 $863,412.48 Total cost of materials = $ 869,502.48 Total overhead cost + labor = $ 478,226.36 Therefore total annual cost of dialysis = $ 1,348,726.84 new machines needed 0 2015 42 $1,768,894.11 11 2 $28,000 2016 49.2 $2,072,133.10 12 1 2017 56.4 $2,375,372.09 14 2018 63.6 $2,678,611.08 2019 70.8 2020 $1,483,055 9.89% $28,000 $1,896,894 12.65% $14,000 $24,600 $2,096,733 13.98% 2 $28,000 $28,200 $2,403,572 16.02% 16 4 $56,000 $31,800 $2,710,411 18.07% $2,981,850.07 18 2 $28,000 $45,900 $3,127,750 20.85% 78 $3,285,089.06 20 2 $28,000 $39,000 $3,324,089 22.16% 2021 85.2 $3,588,328.05 21 1 $14,000 $42,600 $3,630,928 24.21% 2022 92.4 $3,891,567.04 23 2 $28,000 $46,200 $3,937,767 26.25% 2023 99.6 $4,194,806.03 25 3 $42,000 $49,800 $4,244,606 28.30% 2024 106.8 $4,498,045.02 27 2 $28,000 $53,400 $4,551,445 30.34% 2025 114 $4,801,284.01 29 2 $28,000 $57,000 $4,858,284 32.39% 2 3 Cost of RO $17,400 cost of new machines % of budget spent total machines needed 9 Total cost on dialysis Total recurrent cost on dialysis $1,465,655.12 Maintenance Projected number of patients 34.8 Total RO plants needed Year 2014 100,000 100,000 Jurisdiction based analysis STATE OF POHNPEI CURRENT SITUATION Pohnpei is the only state to offer dialysis services in FSM Currently there are 10-14 patients receiving haemo-dialysis Pohnpei State Hospital offers services through 4 machines Pohnpei offered thrice a week dialysis at 2.5 hours a session Now I learn that Pohnpei follows twice a week 4 hours a session dialysis AVERAGE MONTHLY AVERAGE ANNUAL ANNUAL COST PER ITEM DESCRIPTION PRICE FREQUENCY PER PATIENT FREQUENCY $147.60 12 144 $21,254.40 COMPETE BLOOD COUNT $15.00 2 24 $360.00 SERUM POTASSIUM $10.00 1 12 $120.00 SERUM SODIUM $10.00 1 12 $120.00 HAEMO-DIALYSIS PROCEDURE BLOOD TRANSFUSION $180.40 2 $360.80 AVF INSERTION $600.00 9 $5,400.00 BLOOD UREA NITROGEN $10.00 2 24 $240.00 SERUM CREATININE $10.00 2 24 $240.00 TOTAL COST PER PATIENT PER YEAR TOTAL NUMBER OF PATIENTS TOTAL MATERIAL COST PER YEAR TOTAL OVERHEADS TOTAL COST FOR DIALYSIS Total cost per patient per year $28,095.20 12 $337,142.40 $40,851.36 $313,193.76 $26,099.48 Total cost on dialysis % of budget spent Maintenance 14,000 11,487 461,181 5.76% $498,552.27 6 0 0 12,735 511,287 6.39% 2018 21 $547,410.49 7 1 14,000 13,983 561,393 7.02% 2019 23 $596,268.72 8 1 14,000 15,231 611,499 7.64% 2020 25 $645,126.95 8 0 0 16,479 661,606 8.27% 2021 27 $693,985.17 9 1 14,000 17,727 711,712 8.90% 2022 28 $742,843.40 9 0 0 18,975 761,818 9.52% 2023 30 $791,701.63 10 1 14,000 20,223 811,924 10.15% 2024 32 $840,559.85 11 1 14,000 21,471 862,031 10.78% 2025 34 $889,418.08 11 1 14,000 22,719 912,137 11.40% total machines needed new machines needed 0 2015 15 $400,835.81 5 1 2016 17 $449,694.04 6 2017 19 Cost of RO 1 $351,977.59 4 Total RO plants needed 5.14% cost of new machines 10,239 411,074 Total recurrent cost of dialysis 14,000 Projected number of patients 4.51% Year 360,968 2014 13 8,991 If Pohnpei adopts the twice a week 4 hours a week schedule ANNUAL COST PER ITEM PER PATIENT AVERAGE ANNUAL FREQUENCY AVERAGE MONTHLY FREQUENCY PRICE DESCRIPTION $118.80 8 96 $11,404.80 COMPETE BLOOD COUNT $15.00 2 24 $360.00 SERUM POTASSIUM $10.00 1 12 $120.00 SERUM SODIUM $10.00 1 12 $120.00 HAEMO-DIALYSIS PROCEDURE BLOOD TRANSFUSION $180.40 2 $360.80 AVF INSERTION $600.00 9 $5,400.00 BLOOD UREA NITROGEN $10.00 2 24 $240.00 SERUM CREATININE $10.00 2 24 $240.00 TOTAL COST PER PATIENT PER YEAR TOTAL NUMBER OF PATIENTS (average) TOTAL MATERIAL COST PER YEAR TOTAL OVERHEADS TOTAL COST FOR DIALYSIS Total cost per patient per year $18,245.60 12 $218,947.20 $40,851.36 $259,798.56 $21,649.88 % of budget spent Total cost on dialysis Maintenance Cost of RO Total RO plants needed cost of new machines new machines needed total machines needed Total recurrent cost of dialysis Projected number of patients Year 2014 13 $291,970.28 3 0 0 6,743 298,713 3.73% 2015 15 $332,498.86 4 0 0 7,679 340,178 4.25% 2016 17 $373,027.43 4 0 0 8,615 381,642 4.77% 2017 19 $413,556.01 5 1 14,000 9,551 423,107 5.29% 2018 21 $454,084.58 5 0 0 10,487 464,572 5.81% 2019 23 $494,613.16 6 1 14,000 11,423 506,036 6.33% 2020 25 $535,141.73 6 0 0 12,359 547,501 6.84% 2021 27 $575,670.31 7 1 14,000 13,295 588,965 7.36% 2022 28 $616,198.88 7 0 0 14,231 630,430 7.88% 2023 30 $656,727.46 8 1 14,000 15,167 671,894 8.40% 2024 32 $697,256.04 8 0 0 16,103 713,359 8.92% 2025 34 $737,784.61 9 1 14,000 17,039 754,824 9.44% Cost for 3 cost for 2 Year times dialysis times dialysis Annual savings 2014 $360,968.25 $298,713.28 $62,254.97 2015 $411,074.48 $340,177.86 $70,896.62 2016 $461,180.71 $381,642.43 $79,538.27 2017 $511,286.93 $423,107.01 $88,179.93 2018 $561,393.16 $464,571.58 $96,821.58 2019 $611,499.39 $506,036.16 $105,463.23 2020 $661,605.61 $547,500.73 $114,104.88 2021 $711,711.84 $588,965.31 $122,746.53 2022 $761,818.07 $630,429.88 $131,388.18 2023 $811,924.29 $671,894.46 $140,029.83 2024 $862,030.52 $713,359.04 $148,671.48 Jurisdiction based analysis STATE OF CHUUK Current situation Chuuk does not offer haemo-dialysis services There are two dialysis machines in Chuuk The two machines in Chuuk are to be transferred to Pohnpei Estimated number of patients requiring dialysis is 40 41 $887,948.18 10 2015 43 $928,476.75 11 1 2016 45 $969,005.33 11 2017 47 $1,009,533.90 2018 49 2019 10 140,000 1 100,000 % of budget spent Total cost on dialysis Maintenanc e Cost of RO Total RO plants needed cost of new machines total machines needed new machines needed Total recurrent cost of dialysis Projected number of patients Year 2014 24,007 1,151,955 14.40% 14,000 21,443 963,920 12.05% 0 0 22,379 991,384 12.39% 12 1 14,000 23,315 1,046,849 13.09% $1,050,062.48 12 0 0 24,251 1,074,313 13.43% 50 $1,090,591.06 13 1 14,000 25,187 1,129,778 14.12% 2020 52 $1,131,119.63 13 0 0 26,123 1,157,243 14.47% 2021 54 $1,171,648.21 14 1 14,000 27,059 1,212,707 15.16% 2022 54 $1,169,959.52 14 0 0 27,020 1,196,980 14.96% 2023 58 $1,252,705.36 14 0 0 28,931 1,281,636 16.02% 2024 60 $1,293,233.93 15 1 14,000 33,367 1,440,601 18.01% 2025 62 $1,333,762.51 15 0 0 30,803 1,364,566 17.06% 1 100,000 Jurisdiction based analysis STATE OF KOSRAE Current situation Kosrae as at now does not offer haemo-dialysis services There has been noticeable motivation at the level of policy makers to make efforts towards providing dialysis Therefore, even though Kosrae was not a part of this study initially, it was included subsequently There are 7 known patients requiring dialysis in Kosrae at the moment % of budget spent Total cost on dialysis 8 $173,502.14 2 2 $28,000 2015 10 $214,030.71 2 0 0 $4,943 $218,974 10.95% 2016 12 $254,559.29 3 1 $14,000 $5,879 $274,438 13.72% 2017 14 $295,087.86 3 0 0 $6,815 $301,903 15.10% 2018 16 $335,616.44 4 1 $14,000 $7,751 $357,367 17.87% 2019 17 $376,145.02 4 0 0 $8,687 $384,832 19.24% 2020 19 $416,673.59 5 1 $14,000 $9,623 $440,297 22.01% 2021 21 $457,202.17 5 0 0 $10,559 $467,761 23.39% 2022 23 $497,730.74 6 1 $14,000 $11,495 $523,226 26.16% 2023 25 $538,259.32 6 0 0 $12,431 $550,690 27.53% 2024 27 $578,787.89 7 1 $14,000 $13,367 $606,155 30.31% 2025 29 $619,316.47 7 0 $14,303 $633,619 31.68% 0 1 $100,000 Maintenance Cost of RO Total RO plants needed cost of new machines new machines needed total machines needed Total recurrent cost of dialysis Projected number of patients Year 2014 $7,507 $309,009 15.45% Jurisdiction based analysis REPUBLIC OF MARSHALL ISLANDS Current situation At the moment RMI does not offer dialysis services RMI has a history of providing dialysis services There are three dialysis machines in the RMI warehouses The estimated patient load is 60 20 $280,000 2 $100,000 % of budget spent Total cost on dialysis Maintenance Cost of RO Total RO plants needed cost of new machines total machines needed new machines needed Total recurrent cost of dialysis Projected number of patients Year 2014 61 $1,320,945.78 20 $47,676 $1,748,622 7.95% 2015 63 $1,361,474.35 21 1 $14,000 $41,924 $1,417,398 6.44% 2016 65 $1,402,002.93 22 1 $14,000 $43,172 $1,459,175 6.63% 2017 67 $1,442,531.50 22 0 $0 $44,420 $1,486,952 6.76% 2018 69 $1,483,060.08 23 1 $14,000 $45,668 $1,542,728 7.01% 2019 70 $1,523,588.66 23 0 $0 $46,916 $1,570,505 7.14% 2020 72 $1,564,117.23 24 1 $14,000 $48,164 $1,626,281 7.39% 2021 74 $1,604,645.81 25 1 $14,000 $49,412 $1,668,058 7.58% 2022 76 $1,645,174.38 25 0 $0 $50,660 $1,695,834 7.71% 2023 78 $1,685,702.96 26 1 $14,000 $51,908 $1,751,611 7.96% 2024 80 $1,726,231.53 27 1 $14,000 $53,156 $1,793,388 8.15% 2025 82 $1,766,760.11 27 0 $0 $54,404 $1,821,164 8.28% Scenarios The scenarios to be considered Keep things as they are and let off shore services cater to the demand/increasing demand Provide dialysis services in the jurisdictions to cater to the impending demand Hybrid time solution of providing services to buy Keep things as they are and let off shore services cater to the demand/ increasing demand CONNS PROS Will make the people No additional burden very unhappy on the system Severe out of pocket People will obtain expenditure on services overseas services despite the government Patients who cannot afford transfer will not Will not create new receive services inequities Make people relocate overseas Maintain the inequities between the haves and have-nots Will not sustain after 2017 Provide dialysis services in the jurisdictions to cater to the impending demand PROS Patients are going to be very happy Will reduce affordability driven inequities Best way to reduce out of pocket expenditure for patients Most convenient for patients Will create jobs in the health sector Reduce fund outflow from domestic economies in sourcing overseas care CONNS Will push the health ministries towards severe constrains Will burden the already human resources Lead systems towards sever inequities Very soon dialysis will consume lion share of healthcare budgets Severely compromise the essential services Will create resource allocation inequities Hybrid solution of providing services to buy time Buy time for what and how? None of the sites can sustain dialysis services on their own If they are to sustain dialysis, there should be an additional grant to support medium term service provision Each site should develop an exit strategy by then to successfully control NCDs and reduce the demand to a manageable level Once the grant is over, the demand should be so low that the sites could sustain The sites need support for innovative NCD prevention and support to develop policy to implement this solution The response need to be mainstreamed that it really works PROS Best of both worlds Most sustainable solution Healthy populations CONNS Cannot afford to get it wrong! Thank you
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