The North American Domestic Market-A Small But Vital Niche

Mr. Tighe Wilson, President of Wil-Med Global in Broken Arrow, OK, specializes in dialysis equipment, providing service and sales for Fresenius, Gambro, B-Braun, NxStage, and Baxter machines, the major manufacturers. Wil-Med deals with domestic and international customers. Wilson has twenty years experience in business and biomedical ventures and was drawn to dialysis as a niche market because of its growing necessity, as evidenced by the continuing rise in patient numbers.

Wil-Med offers installation and on-site training for preventative maintenance to hospitals and end-stage renal community providers-the acute and chronic clinics. When hospital acquisitions or mergers occur, Wil-Med can supply equipment, support equipment and assist in liquidating a surplus. The clientele supply ensures Wil-Med acquires late model high end and wellmaintained machines.

In Wilson’s observations, dialysis equipment has reached a plateau for the most part in terms of basic patient care. The most significant advancement in dialysis units is delivering therapy on an individual patient prescription basis. The machines can handle specific programming for patients’ therapeutic needs.

Mr. Sudarshan Meenakshi, Director of Maple Consultants in Scarborough, Ontario, Canada, has 80% of his business in dialysis equipment, with the remainder in accessories and parts.

Meenakshi has an electronics background specializing in biomed engineering and a Canadian post graduate diploma in Dialysis Technology. He is one of the few Certified Nephrology Technologists in Canada. Using this background, he educates and instructs, technologists, and tech assistants.

Maple Consultants has a unique position in seeing the market from both a North American and Asian perspective. Meenakshi says that in Canada, using high-tech equipment in hospitals is a common practice. However in the Indian market, clients are looking for simpler dialysis units with competitive cost.

If Maple supplies the units to a dealer, a basic preowned refurbished dialysis machine will be approximately $4,000. If the company is supplying to the end user, it provides two or three year warranty. In that case, the price will be higher around, $7000. The economy has had some effect on prices and costs, adding to the overhead that can raise expenses, the hike in oil prices for example, particularly affecting shipping costs.

Wil-Med has a detailed reconditioning process utilizing the manuals for rebuilding pumps and hydraulics. Wil-Med’s techs examine the equipment mechanically and cosmetically with a checklist as they recondition. “It is important that when the user sees the equipment, it is clearly well-maintained, and functions well and looks right. A machine has to be ready to perform when it arrives at a medical center, and the down time kept to a minimum,” says Wilson.

Wilson says the most important element is starting with well-maintained equipment. This means finding good sources from which to buy the units. If you are familiar with the sources, then you are familiar with those who are using the machines and how well they are maintained (i.e. optimally used and stored in a climate-controlled environment). A dealer should know the background of the supplier, and then institute a rigid test process with trained techs (Wil-Med has factory certified techs), and uses OEM parts. Dealing in obsolete equipment is not a good practice; the equipment should be currently supported by the OEMS.

For Maple’s refurbishing requirements, the units should be clean and free of any external damage. Dialysis units are a combination of electrical/ mechanical parts and hydraulics. If the equipment has not been used for a few months the hydraulics compartment or the pumps tend to seize and crystallized parts can stick tubes and valves. The machines should not be stored for a long time, and they should be rinsed and disinfected regularly to avoid any bacterial growth.

“In developing expertise in reconditioning, it’s all about knowing the model and manufacturer, getting to know the machine and being able to pass along the quirks of the machines to the domestic and international customers,” Wilson says. If those customers come in for questions and answers, Wil-Med can help them to learn more about the mechanical issues and operational aspects and offer an update on the additional features and the subtleties of a unit. Because scheduled preventative maintenance is so important, Wil-Med will also provide recommendations for good techs in the end-user’s area.

Dialysis providers, like other medical centers, have to deal with budgetary cuts and the rising costs in medications and overhead and labor. A good dealer takes the budget needs into account when working with a client. Wil-Med takes a close look at a facility’s programs to see how to stretch the dollar. One particular question in debate recently is the reuse of dialyzers. From Wilson’s standpoint, the choice is unique for each clinic. For a clinic with a tight budget, reuse can save four to six dollars per treatment, allowing more budgeting for staff, dieticians and other care that improves the quality of life for patients. Wil-Med works with medical facilities to determine if reuse may be an option.

The International Market-Tight Budgets, Tough Transport, Enormous Need

Maple’s Indian clients have similar problems, and do not want to invest money on machines and wait for two to three months to bring the equipment from overseas, or deal with difficult customs and government procedures at the local level. The economies of Southeast Asia are booming increasing the need for better medical treatment. Moreover, medical tourism takes clients to these countries for treatment. Aging is not contributing to the growth of treatment centers in India, rather, it is the newer affluence that is enabling people medical treatment affordability. “Political and local issues are always a factor,”

Meenakshi says. “However, knowledge of local issues, being fluent in the vernacular plus the commitment and dedication of meeting the clients’ requirements are factors that can improve growth of the industry.” Meenakshi says, “When the unit reaches Maple’s warehouse in Chennai, we carry out preventive maintenance and other quality control measures to meet Indian standards.” Maple has a fully-equipped technical lab in Chennai. Maple’s clients in India are local dealers and nephrologists who have their own hospitals and nursing homes. Meenakshi and his business partner Mukesh Gajaria use their extensive experience and technical know-how to assist any customers who require clinical information. The service for Indian customers ensures that the area is getting better equipment, with quciker delivery.

Another view of the international dialysis market comes from Rajagopal Geethu of Zigma Meditech India Private Limited, also located in Chennai, India. Zigma has just entered the dialysis market, and currently provides about 2% of total business. “Over a period of time we felt that we were missing out on an opportunity in the market and hence have started supplying units to our customers,” says Geethu.

Zigma sells refurbished Fresenius units primarily to hospitals and specialty dialysis centers in the South India market. The refurbished units sell for around $3000 – $4000. Geethu says the units should last a minimum of five years, if not more. In the refurbishment process for Zigma, the physical components of the unit are examined. Then the condition of the tubing and connectors is checked. A good deal of preventative maintenance is performed. The unit also undergoes a complete cleaning, followed by testing to ensure that there is no residue in the system. Special attention is given to the springs and seals, as they have constant interaction with acidic fluids. The most common problems are tubes and seals breaking or the pumps malfunctioning, in addition to any electronic/electrical failure that may occur due to voltage fluctuation.

Geethu has found the needs of the Indian market to be quite complex. Dialysis treatment is very expensive in India, even with a growing affluent class. A typical dialysis treatment in Southern India excluding the consumables (catheter and medication) can run from $20 to $80, according to Geethu and Meenakshi; however, the cost can be difficult to afford for the majority of the population, as the per capita income is at about $750. Even a middle class family cannot afford to have dialysis for more than a year. “Affordability is a major issue and most places tend to re-use the filters in order to reduce costs for the patient,” Geethu explains. “The volume of patients undergoing dialysis is quite high and it’s common to see dialysis centers working three to four shifts a day. Therefore, while cost is a big concern, the ruggedness of the unit and its ability to keep working without trouble or breakdown is a requirement.”

When Geethu consults with clientele for the best solution, the customers look at reducing the overall cost of ownership of the equipment. “As long as the equipment does not compromise even a very small percentage in delivering as it is supposed to, they are ready to take used or refurbished machines without the slightest hesitation,” he says. In India, the savings amount to about half the cost of the new equipment. The cost of maintenance is also lower.

An OEM Solution For Home Health Care And Critical Care: NxStage’s System One And A New Home Dialysis Registry

NxStage of Lawrence, MA, manufactures a home dialysis unit, the System One. NxStage also has a critical care division selling to hospitals, with seven out of the top ten kidney care and teaching institutions in the U.S., including UCLA and Johns Hopkins.

Mr. Joe Turk, Senior Vice President, Commercial Operations of NxStage, says that in 2005 the use of home dialysis was well under a half-percent of dialysis-user population, continuing a decades-long trend. However, in the last couple years, home dialysis has begun to revive as an industry. During that time, NxStage has doubled patient numbers. Yet the numbers are still fairly small, around one percent of the total dialysis population.

NxStage has also created a unique online registry with information about the patients who use NxStage’s home dialysis. Advisors to NxStage felt that the company had the opportunity to provide a needed service in collecting demographic information. NxStage took up the challenge. “We have been diligent about capturing information in a registry format concerning treatment and mortality,” Turk says. As an example, the data from the registry shows that men slightly outnumber women in using NxStage home dialysis, and the average age of a NxStage user is 52. On a very positive note, the mortality rates have turned out to be 50% lower than expected.

Turk says the System One is popular with its users due to the emphasis on compact design and ease of use for the home patient, including a simple interface. The System One is designed to be infrastructure independent; it can be plugged into any grounded outlet. There does not need to be adjustments for changes in electricity or water. The device is small and can be checked for air travel. “The device frees the patient in a number of different ways. The patient having home dialysis does not have to have life centered around appointments with the dialysis center, having to plan trips around treatment,” Turk says.

Turk believes the System One is an innovation. “We are the first to make it smaller and incorporate traditional functions in the cartridge for the user to maintain. The system makes the process simpler smaller and safe.” The System One can be purchased or rented. It costs around $19,000 to purchase and about $1500 per month to use. “The availability of home use is important because quite frankly there is a limit as to how many can be treated in a center, due to the lack of nurses and space. Home treatment can be cost effective, and physicians believe it is appropriate for about 16% of patients, around 40-60,000 who need hemodialysis.” Dialysis is another section of the medical equipment industry that continues to thrive despite current economic struggles. Worldwide, it provides a lifesaving measure to a rising health care crisis, which means a market for more dedicated dealers of quality equipment. As Meenakshi says, “The medical service providers are doing a yeoman service facilitating delivery of services in a timely and cost-effective manner. Used medical equipment is like used cars. There is a device for every need and pocket. Service, commitment, current knowledge in the field and dedication are the key factors. This then, becomes a ‘win-win’ situation.”

Maximizing patient comfort can be done simply—with adjustments such as adding comfortable waiting rooms for family members, improving ventilation and providing patient control over temperature, adding space between dialysis chairs, or offering additional privacy. These changes do not all necessitate a large investment; in fact, the simplest alterations can bring the facility revenue worth many times the cost of the modification.

Tangible Changes

DaVita, for example, offers new dedicated self-care facilities, which incorporate a unique design to improve patient satisfaction. The company’s treatment options represent a continuum of care, said Terry Rowe, vice president of center development for DaVita. “These options include home hemodialysis (HHD), peritoneal dialysis (PD), nocturnal dialysis, in-center self-care dialysis and traditional chronic hemodialysis. The traditional modalities—HHD, PD, chronic and nocturnal—are familiar to most in the renal community, but in-center self-care is relatively new. At DaVita, in-center self-care means a patient is actively involved in a significant portion of his/her care, and is supported by the DaVita clinical care teammates and, in some cases, the patient’s care partner,” he added.

To facilitate the patient’s ability to move along the care continuum, DaVita has created two innovative partnered-modality facilities, which they call “In-Center Self-care—Multi-Modality Centers.” Each of these centers supports HHD, PD, nocturnal, in-center self-care and traditional chronic hemodialysis. The facilities were created to enhance each modality by offering special features and the convenience of one central location. They are also meant to foster patient independence in a relaxing and rejuvenating environment.

The most recent of these centers is located in Las Vegas. “It features a stacked stone veneer entrance and lobby area, soft paint colors and wall coverings, wood-look floors and solid surface countertops,” said Rowe. In addition, in order to foster their independence, the facility does not require self-care patients to check in or wait; instead, they have a separate entrance that opens to their patient lockers. To the left of the patient locker area is the patient prep area, which includes a sink for washing hands and accesses, and also includes the scale. In the self-care treatment area, patients have access to individual self-care suites. These are private glass suites, larger than traditional dialysis spaces, to reinforce independence, accommodate learning and allow room for a care partner if the patient chooses to have one.

The HHD training suites in the Las Vegas center also facilitate individual training and feature retractable partitions for group sessions, added Rowe. And in the nocturnal suites, patients may choose to use the oversized dialysis chair that accommodates a nocturnal sleeping pad or the Murphy bed available in every nocturnal suite.

All of these suites have indirect lighting and, with the exception of the nocturnal suites, each has its own window. Every suite has an individual flat-screen TV and is wired for high-speed Internet. Even though the in-center self-care suites are designated as HHD, PD or nocturnal, they are all multi-functional and can accommodate any treatment modality as necessitated by the day’s census. Additional features of the self-care part of the center include a nutrition bar area with refrigerator, a medication prep area and a telemetry monitoring station.

“Every part of these new centers is designed to encourage independence and create benefits for patients to become increasingly involved in their own care,” Rowe explained. “In addition to providing the most comfortable care experience possible, we believe the centers empower patients to take part in their own care, which helps us provide them with industry-leading clinical care.”

Intangible, but Priceless, Add-Ons

Not every change has to be something patients can see and touch. Tighe Wilson, president of Wil-Med Global, Inc., said that the main point of interest he discusses with patients — and sees in facilities — is the concept of patients getting clear answers and feedback with their treatments. This doesn’t have to cost the center a penny. Instead, if staff members can simply take the time to provide individual attention to each patient, they will find that the patient’s satisfaction improves dramatically.

Wilson believes firmly in that personal attention. “The patients appreciate larger staff-to-patient ratios, dietitians and that personable touch,” he added. “But so many of our customers—both large and small—must watch overhead and try their very best to stretch the dollar.”

Clinic design can always be improved upon, too. If possible, Wilson suggested, give the patients access to newer technologies. “The extra space and the wiring for cable and the computer hookups are wonderful, [because they improve the provision] of information and/or communication during treatment. The extra space allows some additional privacy and adds to the comfort level for the patients,” he said.

The most desirable clinics, he continued, are the ones with positive and caring staff members who go that extra mile for the patients when possible. “I take my hat off to all of the ESRD staff in North America who work so very hard to truly give the best patient care and the long days everyone puts in to accomplish this goal,” he said.

Renal Business Today asked the American Association of Kidney Patients (AAKP) if some of their members would be willing to share their own insights for facility improvement. Following are some of their suggestions.

A Word from the Patients

David O. Stapel, who receives in-center hemodialysis in Halton City, Texas, told us he would like to see automatic self-opening pocket doors (doors that slide sideways) in the entrances to the waiting room and the treatment areas of dialysis facilities. “This is to accommodate wheelchairs, walkers, etc.,” he suggested.

Stapel also would like to see lockers made available for patients to store blankets, pillows and other supplies. In addition, he requested comfortable chairs for dialysis patients. “The old reclining chairs (La-Z-Boy style) with an abundance of padding are best! Chairs that vibrate would be an added feature,” he added.

Not only that, but each treatment station should have a small table equipped with telephone, Kleenex, etc., similar to a bedroom nightstand. And finally, he said, the walls of a dialysis center should be painted in cool, relaxing colors. “Avoid white and gray, and use attractive wall hangings, which add to the soothing atmosphere,” he proposed.

Ruth, a 60-year-old hemodialysis nurse and patient in Alabama, had some other ideas that would be inexpensive and easy to implement. “It would be nice to have a covered area for patients to drive under when the weather is bad,” she suggested. Another positive addition might include a welcome sign to let patient know that they are more than just someone to sit in a chair.

“It would be nice to have a dialysis patient-friendly vending machine for snacks pre- and post-dialysis treatment,” she added. “Of course, individual TV sets with ear equipment for privacy [are desirable]. The most important thing is to have staff members who are well-educated on clearance, patient compliance, and have some compassion and empathy—someone to encourage and not fuss at patients all the time.”

AAKP president Roberta Wager, RN, MSN, also asked patients what their ideal dialysis center would look like, and in addition, received responses from nurses and technicians who work with dialysis patients every day. First, the staff members suggested, each patient should have his or her own computer in their area—to input treatment, data, etc. (an infection control issue). Second, they should have sinks with a good flow of water—not water just sprinkling out a little at a time. Third, the nurses and technicians would like to see plenty of space between patients. This improves privacy and is helpful in case a patient codes, because equipment can get in and out of the area more easily, they said.

Another surprising tip was the addition of individual trash cans to each station, so that staff members do not have to move one trash can around to different patients. And new chairs would be a bonus—the right size chairs for patients that are not too low, so nurses and technicians do not have to stoop so far to stick patients’ access sites, etc.

And another tip that might require some rearrangement of each patient station is making sure that electrical sockets in the walls are easily accessible to staff.

As for the patients Wager spoke to, “Most of them commented on quantitative needs—such as why the clinics must look at the patients as numbers—and albumin numbers, KT/V numbers, phosphorus numbers, Hgb numbers, and potassium,” Wager said. “The clinic staff is so concerned about meeting ‘the numbers game’ that they forget the human aspect of the patient. If patients do not meet the goal (numbers), then they feel like they are being lectured, talked down to, etc.,” she added.

Additional input was provided by Brenda Dyson, past president of AAKP and patient services coordinator for Network 8 Inc. in Jackson, Miss. She is a transplant recipient and, in the past, has experienced home hemodialysis and in-center hemodialysis.

Dyson suggested, “I would like heated chairs (big La-Z-Boys in any color except brown or orange) or at least heating pads supplied for each patient (along with whatever blankets the patient can bring). I would also like individual TVs,” she said. In addition, she proposed “They need to keep extra earphones, since I had a problem keeping up with mine.”

Not only that, but she believes that there should be at least one RN for each pod area, and at least one LPN, along with the PCTs. Further, Dyson said, “The waiting room should have two TVs (if the room is big enough to separate them without too much interference), and a soft drink machine and free coffee should be available to family members waiting for their loved ones. The staff should be friendly but professional and treat the patients as adults, not naughty children.”

Finally, RBT heard from Floyd Lambert, a 58-year-old hemodialysis patient from Alabama, who said, “The waiting room should be medium-sized, with bathroom facilities, water and coffee. It should be for the convenience and comfort of those waiting on patients. Patients should spend very minimal waiting time in this room.”

On the dialysis floor, there should be a nurse’s station that is centrally located, Lambert suggested. “Each technician should have a station (desk) located where their patients can be seen at all times and where patients can see their technician. Many times, the technicians are in other sections talking with their peers because they have nowhere to call ‘home,’ and do not respond as quickly as desired by their patients. A division wall between sections would allow for some privacy, and if privacy is needed within the section, curtains can be drawn to obscure vision from other patients. Supplies should be in every section for each technician.”

Televisions should be individual with patient earphones so as not to interrupt others including technicians, other patient, or RNs.

Lambert, too, prefers seats for patients that are “La-Z-Boy” style, and that also allow the patient or technician to raise and lower legs with a lever. “The back should have the capability of multiple adjustments with the patient just lying back or sitting up. Of course, adjustable beds would be great!”

Finally, Lambert said, a separate floor should be in the building for positive patients, and should include two to four chairs (depending on average need) in the area, with at least one RN and one technician on staff at all times. Also necessary is a separate area for home dialysis patients’ training and checkups, with individual rooms for training, similar to the home environment.

Although some of these changes can be quite expensive, many others can be implemented with a minimum of cost to the clinic while maximizing their return in customer satisfaction.