1336: Dialysis | Skeptical Sunday

9:02Jordan Harbinger:So that's where, you know, they've connected an artery to a vein to make it strong enough to handle repeated punctures. And then your blood flows out through one tube, through a machine with a special filter, and back into you through the other tube.

9:19Jessica Wynn:How long does this take? Like, how long are you sitting there when you do this?

9:23Jordan Harbinger:Yeah, it's a long time. Typically three to five hours per session. Oh, my God. And that's three times a week.

9:30Jessica Wynn:Oh. Every week, forever.

9:33Jordan Harbinger:Or until you get a transplant or, you know, you die.

9:36Jessica Wynn:Wow. Okay, three to five hours, three times a week. So this is, 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.

9:52Jordan Harbinger:Welcome to dialysis. Yikes. 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.

10:09Jessica Wynn: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.

10:20Jordan Harbinger: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 sawtooth patterns in your blood chemistry.

10:40Jessica Wynn:Oh, yeah, sure.

10:41Jordan Harbinger:Right after treatment, it's perfect. Then increasingly toxic by day three. So it's like, instead of your heart beating constantly, it just beat really, really hard three times a week.

10:53Jessica Wynn:Yeah, yeah. And by the time it's ready to beat again, your blood is slowed to a crawl slash is not moving. Yeah, this 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 and I probably have to go to the bathroom even in the middle of the night, right? Because I'm a 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 Ron on my iPad or whatever, right? It's just going while I'm asleep. Wow. So this whole go to a place and do it manually sounds profoundly suboptimal.

11:24Jessica Wynn:So I mean, medically, emotionally, existentially suboptimal. Okay. Before we go further, who ends up needing dialysis? Do your kidneys randomly fail because your luck is bad? Who does this happen to?

11:37Jordan Harbinger: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.

12:04Jessica Wynn:What? Wait a minute. Yeah. That's like a cancer statistic. That's not something people think of as a routine treatment. Okay, so, wow, so by the time you're on dialysis, your health is not good at all.

12:15Jordan Harbinger:You're not okay.

12:16Jessica Wynn:Yeah, you're not okay.

12:16Jordan Harbinger:I mean, being on dialysis is that serious, yet most people have no idea.

12:21Jessica Wynn:So what is actually killing these people?

12:24Jordan Harbinger:So it's lots of things. You know, 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 percent of all dialysis deaths and the most common cause of death

12:40Jessica Wynn:after that withdraw from dialysis so this isn't the disease and stuff 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 percent of dialysis patients die

12:58Jordan Harbinger: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.

13:15Jessica Wynn:Yeah, okay, I see. So 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 should probably clarify that. Correct, yeah, they just fail. 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.

13:36Jordan Harbinger: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.

14:08Jessica Wynn:Okay, you mentioned infections. Break that down for me because, again, that number is bananas. It's over one-third of people who die, die from an infection. That seems like it shouldn't happen.

14:17Jordan Harbinger: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 in dialysis patients is one to 300 times higher than in the general population. Wait, wait, wait.

14:52Jessica Wynn:100 to 300 times higher or percent higher? Percent higher, right? Times higher. Oh, my God. That's horrific.

15:00Jordan Harbinger:It's hard to comprehend. Yeah. And bloodstream infections from staph bacteria occur 100 times more often in dialysis patients than in adults not on dialysis.

15:12Jessica Wynn:You're right. It's hard to wrap your mind around 300 times higher. That's like, oh, my God.

15:18Jordan Harbinger: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, you know, which kind of clinic they're walking into. Yeah.

15:41Jessica Wynn: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 on the door and like congratulations. This clinic is a solid B plus to 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 being subject to a staph infection that kills you. You know, it's the dice roll here is crazy. It's just terrible.

16:12Jessica Wynn:Yeah.

16:13Jordan Harbinger: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.

16:28Jessica Wynn:And I'm guessing these are not posted on the window next to the inspirational happy kidney smiley face poster.

16:34Jordan Harbinger:They're not, but they do exist. They're just not prominently displayed. and the methodology is 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.

16:50Jessica Wynn: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.

17:00Jordan Harbinger:Right, exactly. Which brings us to the second type, peritoneal 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. Others hook up to a machine at night that cycles the fluid while they sleep.

17:26Jessica Wynn: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 queasy hearing about it. But I think hopefully I'm coming across here as 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'm 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?

17:58Jessica Wynn:I don't know. Maybe we'll talk about that in a bit.

17:59Jordan Harbinger:Yeah. I mean, it's wild. People are just live this way. And so the at-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.

18:33Jessica Wynn: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?

18:41Jordan Harbinger: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, but it pays$90 ,000 for in-clinic.

19:14Jessica Wynn:After 15 straight minutes of kidney horror, even your anxiety needs a snack break. We'll be right back. This episode is sponsored in part by CookUnity. Jen and I have started doing this thing where we eat at home more often, partly because it saves us a ton of time. By the time you deal with traffic parking, waiting for a table, getting home, the meal's a two-hour event. We've also kind of exhausted our local restaurant rotation. You just hit that point where everything feels repetitive. That's why Cook Unity has been a nice charge for us. It keeps meals interesting without us having to leave the house.

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21:43Jessica Wynn:And use code Jordan for 15, pressing off your entire order. Offer ends soon. Don't sleep on it. Don't forget about our newsletter, Wee Bit Wiser. It is a gem from a past episode of the show from us to you. It's an under-two-minute read. Comes out every Wednesday. JordanHarbinger.com slash news is where you can find it. Now, back to Skeptical Sunday. So this is not about what's best for the patients. Color me surprised. So, okay, are the diseases that lead to kidney failure, are those predictable?

22:09Jordan Harbinger: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.

22:29Jessica Wynn: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 then 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, you know, health care, etc.

22:52Jordan Harbinger:Yeah, absolutely. And black Americans are three times more likely to develop kidney failure than white Americans.

22:59Jessica Wynn:Okay.

23:00Jordan Harbinger:Part 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.

23:29Jessica Wynn:Jess, 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 POS 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 out of my ass, really. I don't know that.

23:45Jordan Harbinger:There can be many square miles where there's not one regular grocery store. It's just bodegas.

23:51Jessica Wynn:You know what? Actually, now that you mention it, when I worked in downtown Detroit, right. 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.

24:22Jessica Wynn: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 like, oh, you just drive to the store, man. What's the big deal?

24:37Jordan Harbinger:But like, if you don't have a car, you live in a walk up without an elevator. And yeah, you're doing it little at a time.

24:43Jessica Wynn: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 them eat cake is what i sound like right now let them go to whole foods yes why don't they just go to erwan and buy uh yes an organic bean burrito yeah that's i know i sound like 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

25:12Jordan Harbinger: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 in 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.

25:46Jessica Wynn:Oh my God. You're not supposed to do that for people who don't know.

25:49Jordan Harbinger:Not supposed to do that. And by her mid fifties, guess what? Her kidneys were

25:54Jessica Wynn:failing because she couldn't afford insulin. That makes me so sad and angry because that sentence should stop all of us cold. Insulin is not, it's not even expensive. Well, in most places, like it's, 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.

26:15Jordan Harbinger:Yay, American health care. Yeah, that's 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. You know, she's been interviewed saying, quote, the days I have dialysis, I don't have a life. I have a treatment.

26:37Jessica Wynn:Yeah, geez. Yeah. 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.

26:52Jordan Harbinger: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.

27:15Jessica Wynn: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. Right. But we will pay forever for the extremely expensive treatment because I'm going to go out on a limb here and say a public school teacher in Detroit does not make ninety thousand dollars 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.

27:51Jordan Harbinger:Maybe we could pay our teachers more, you know.

27:53Jessica Wynn:Or like give them insulin so they don't die. I mean, come on, man. Better health care. Right, exactly. Okay. How much are we talking about here total for the dialysis for everybody in America?

28:04Jordan Harbinger: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.

28:29Jessica Wynn:For sure. Yeah, I can. I mean, those numbers are staggering. $50 billion every year. That is serious.

28:36Jordan Harbinger:Yeah. And follow that money. You know, two companies, DeVita and Fresenius, control about 70 % of all dialysis clinics in America.

28:46Jessica Wynn: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.

28:57Jordan Harbinger:Yeah, you're not wrong. I mean, it's effectively a duopoly. Yeah. So Davida has about twenty eight hundred clinics for Zenius has about twenty six hundred. And together they treat roughly half a million dialysis patients. So this level of concentration is extraordinary, even by American health care standards.

29:17Jessica Wynn:I want to be clear for legal reasons. I have 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 what 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?

29:47Jordan Harbinger:Yeah, I mean, it's consolidation over decades. So dialysis requires expensive equipment, trained 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.

30:14Jessica Wynn:And patients, again, can't shop around. You're just trying not to die. And it's so long that you're just going to go to the one that's near you, kind of. Yeah.

30:21Jordan Harbinger: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 wait for that better deal. You know, you can't delay. It's not like choosing a gym or whatever.

30:42Jessica Wynn:Yes, this is life or death. Anytime I want to buy electronics, my brother-in-law is like, wait for Black Friday. And it doesn't matter if it's December. He'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. Yeah, you can't go like, oh, they usually offer a coupon. I'm going to hold off till Monday.

31:01Jordan Harbinger:Right. Waiting for that Groupon doesn't happen. And that lack of choice matters when you look at who controls the industry. So DeVita's 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 DeVita Village. And they did these company chants at meetings, all this weird stuff.

31:31Jessica Wynn:chance okay so i'm gonna 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 as a knight on john oliver is that this guy yeah yeah yeah yeah yeah yeah i can't imagine doing that but i guess you know when you're making a hundred million dollars a year

31:52Jordan Harbinger:yeah right um but it's davidate it's italian for giving life so there's a right sentiment there i I guess. But yeah, managers would lead these synchronized chants with everyone putting their hands in the air. It was meant to build unity and mission. But none of these people are on dialysis.

32:12Jessica Wynn:Well, we don't know that. But yeah, that's true. But also, I don't know, man, I'm on the fence because a lot of organizations do that sports teams do that nonprofits 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. I don't know. You probably need a little bit of a morale boost to work in a place like this. I don't know.

32:40Jordan Harbinger: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 culty to me, I guess.

32:53Jessica Wynn: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 is hard.

33:07Jordan Harbinger:That's not exactly who I'm describing.

33:10Jessica Wynn:OK, 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. You know, 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 hungry and in a bad mood. Yeah. The issue, I suppose, is when chanting is happening inside a multibillion dollar company whose primary customer is Medicare. That's a problem.

33:29Jordan Harbinger: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.

33:50Jessica Wynn:Yes. So our government is cutting enormous, enormous checks to these companies, these two companies.

33:57Jordan Harbinger:And it's been happening since 1972. That's when Congress passed a law making kidney failure the only disease where Medicare covers everyone, regardless of age. OK, you're 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.

34:18Jessica Wynn: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.

34:25Jordan Harbinger:Right. It sounds great. It was great, but it also created something unique in American health care, guaranteed indefinite payment. So this creates stable, recurring revenue and financial success becomes tied to keeping patients on dialysis, not necessarily getting them off it.

34:44Jessica Wynn: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 I don't want people to think like, how dare you? I work so hard in this dialysis clinic. It's we're not talking about you. We're talking about the pencil pushers.

34:59Jordan Harbinger:Of course not. I mean, it's important to remember, doctors want to help patients, but the 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, but not necessarily to get them off dialysis.

35:27Jessica Wynn: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. This is the ideal customer for them.

35:45Jordan Harbinger:Right. That math is undeniable. So a patient on dialysis is worth$90 ,000 a year, every year indefinitely. A patient who gets a kidney transplant costs Medicare about$110 ,000 for the surgery. Then they get covered for their immunosuppressant drugs, but they're off dialysis permanently.

36:05Jessica Wynn:Huh. Okay. So from a business perspective, once again, transplants are actually bad.

36:10Jordan Harbinger: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.

36:29Jessica Wynn:Okay, so how does that play out? What does that look like?

36:31Jordan Harbinger: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, right? Organ donation, right. The average wait time is three to five years. You know, some people can wait eight, 10 years. And during that time, they're on dialysis.

36:54Jessica Wynn:Wow, because there aren't enough kidneys to go around to people who need them. Right. That's the idea.

36:58Jordan Harbinger: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 wait list is complicated.

37:12Jessica Wynn:How is it complicated? Remind me. I don't remember this.

37:15Jordan Harbinger:Right. Right. So 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.

37:28Jessica Wynn: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.

37:36Jordan Harbinger: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.

37:45Jessica Wynn: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.

37:52Jordan Harbinger:If you're a loner, sorry.

37:54Jessica Wynn: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 who have more social support have better outcomes, I assume. Correct. Oh, gosh, there's this is some dystopian ish, man.

38:11Jordan Harbinger:So it just ends up that clinics aren't always aggressive about pushing people through that process.

38:16Jessica Wynn:OK, I'm going to say why not, even though I already know the answer. But go ahead. Why not?

38:20Jordan Harbinger:There's no financial incentive.

38:22Jessica Wynn:OK.

38:23Jordan Harbinger:So, in fact, evidence suggests clinics are slower to refer patients for transplants.

38:28Jessica Wynn:Color me surprised.

38:29Jordan Harbinger:Yeah, right. There was a study in the Journal of the American Society of Nephrology, which found patients at for-profit dialysis clinics were 64 % less likely to get on the transplant wait list compared to the patients at non-profit clinics.

38:46Jessica Wynn:Wow, 64 % less likely. That's not subtle. That might not be an accident, Jess.

38:51Jordan Harbinger: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.

39:30Jessica Wynn:per gallon. And don't forget, marathon stations are packed with all the conveniences you need to stock up and live life on the go. Marathon, where fun runs on full. Available at participating marathon locations. Terms and conditions apply. See MarathonRewards.com for details. This episode is brought to you in part by Lufthansa. When people talk about travel, they usually focus on the destination, the hotel, the restaurants, all the stuff that happens after you land. But the flight is part of the experience too. Just like a great hotel can shape an entire trip, so can a great flight. That's exactly what Lufthansa Allegris is built around.

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40:24Jessica Wynn:You've got the suite, the privacy seat, and the extra long bed, the extra space seat, and the classic seat so you can choose what works for you. And that's what I like most. It feels elevated but still practical. More privacy, more comfort, more thoughtful design for the way people actually travel now. Visit Lufthansa.com and search for Allegris to learn more. Lufthansa Allegris. All it takes is a yes. Limited availability on select routes. More routes coming soon. Don't forget about the Jordan Harbinger subreddit. If you are a Redditor, you can talk about episodes, sponsors. There's a meme thread in there.

40:52Jessica Wynn:There's a lot of fun back and forth with listeners. Gabriel's in there. Bob's in there. There's a lot of great conversation with the crew and a lot of other show fans. So come join us in the Jordan Harbinger subreddit. Now, back to Skeptical Sunday. Yeah, so if you're at a for-profit clinic, they're just quietly not really wanting to help you leave. And in 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.

41:21Jessica Wynn: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. Like all guests are kind of created equal. Right. Right.

41:30Jordan Harbinger:So they're just numbers.

41:32Jessica Wynn:Yeah. They're not entry in a spreadsheet. This is so gosh, this is Black Mirror without like the cool, unique technology on screen. Exactly. Well, I guess it does. A dialysis machine is pretty cool tech. So maybe it's just Black Mirror.

41:44Jordan Harbinger: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 are juggling huge caseloads. Clinics are understaffed. And if the company's revenue depends on keeping chairs filled, you know, what gets prioritized?

42:10Jessica Wynn:Yes, the chairs. That's what we were just sort of implying earlier, right? It's the chairs that get prioritized. Of course.

42:16Jordan Harbinger:You know, there was a whistleblower lawsuit filed in 2015. It was one of several, but where a former DaVita employee alleged the company systematically discouraged transplant referrals. So DaVita denied it and settled. But the allegation was that staff were told not to educate patients too much about transplants.

42:38Jessica Wynn: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.

42:46Jordan Harbinger:I know. It's subtle. You know, it's not a written policy.

42:50Jessica Wynn:No, because they would be sued into oblivion if it were written down anywhere. Of course.

42:54Jordan Harbinger: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 billed treatments, are you celebrating when patients leave?

43:06Jessica Wynn:No, but this is psycho, Jessica. This is psycho nonsense.

43:11Jordan Harbinger:I 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, transplants are actually cheaper. You know, Medicare saves about$270 ,000 over, you know, like 10 years per transplant patient versus dialysis. Wow.

43:32Jessica Wynn:So even if you strip away morality, pure math says transplants win. But since they don't benefit the people currently making money. Correct. Yeah.

43:40Jordan Harbinger: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.

43:54Jessica Wynn:Are nonprofit clinics better? Because it seems to me, right, like I said before, their outcome is like get as many people out of here. Yeah, I mean, they seem to be.

44:03Jordan Harbinger:They seem to be for sure. So studies show nonprofit 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 nonprofits, they just don't have the capital to expand at the same pace. So the consolidation continues and the profit motive grows.

44:31Jessica Wynn:Yeah. So that reinforces why home dialysis isn't pushed. Yeah.

44:35Jordan Harbinger:Right. It makes less money for clinics. And when patients dialyze 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 bill you for add-ons and, you know, and less ability to keep you just in their ecosystem.

44:52Jessica Wynn: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?

45:02Jordan Harbinger:There's upselling at the dialysis clinic. Oh my God.

45:05Jessica Wynn:I hate I hate this. This episode is terrible.

45:08Jordan Harbinger:For medications, they want to sell you vitamin supplements, iron infusions, you know, 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.

45:37Jessica Wynn:Oh no, I know where this is going. Oh gosh.

45:40Jordan Harbinger:So suddenly epigen doses, they skyrocketed. It became just a profit center. And these higher doses increased risks of heart attacks and strokes. DeVita and Fresenius were among the biggest purchasers of Epigen in the world. And that manufacturer, Amgen, was making billions.

46:02Jessica Wynn:This is crazy to me, man. 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.

46:15Jordan Harbinger:Yeah, exactly.

46:16Jessica Wynn:So giving them a drug that they don't need that increases that risk is you're 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 of somebody who's high risk over the course of 800 ,000 Americans doing this three times a week, someone has died from this.

46:38Jordan Harbinger:Oh, yeah. It's incredibly depressing.

46:41Jessica Wynn:So the manufacturer's making billions off of selling this drug to these clinics that are upselling it slash giving it out when people don't necessarily need it because they can bill Medicaid for it. Right. Or Medicare for it. So what what happened?

46:54Jordan Harbinger:So Medicare changed how it paid for the drug. So they bundled it into the overall dialysis payment. So there was no incentive to overprescribe and clinics couldn't bill extra for higher doses. And guess what? Usage dropped immediately.

47:11Jessica Wynn:Funny how that works. That's disgusting. Yeah, that's disgusting.

47:15Jordan Harbinger: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.

47:29Jessica Wynn:So when the financial incentive disappeared, suddenly patients didn't need as much of this drug.

47:33Jordan Harbinger:And both companies have paid massive fraud settlements over the past 15 years. DeVita has paid around a billion dollars for various allegations.

47:45Jessica Wynn:Wow. Imagine being that general counsel and your job is just to deal with fraud allegations. And you're like, OK, so we definitely did this. Let's negotiate the fine.

47:53Jordan Harbinger:Yeah, I'm sure they have a chant for that. Oh, yeah.

47:56Jessica Wynn: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.

48:17Jordan Harbinger:And crazy that they can afford it and stay in business.

48:21Jessica Wynn:No cost of doing business is how that's why they still exist. Otherwise, this would be, oh my gosh.

48:26Jordan Harbinger:Yeah, there was a$495 million in just one case for allegedly billing Medicare for drug waste.

48:34Jessica Wynn:Oh my gosh.

48:36Jordan Harbinger:$34 million just in 2025, last year, for illegal kickbacks to nephrologists. Fresenius has been sued for allegedly performing unnecessary vascular access surgeries to generate additional revenue. The lawsuit claimed these surgeries weren't medically necessary, but they were really profitable.

48:55Jessica Wynn:Oh my gosh. So they're paying doctors, nephrologist is 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, a 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.

49:31Jessica Wynn: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 up there. This is that is up there.

49:40Jordan Harbinger:It's terrifying. Allegedly.

49:41Jessica Wynn:Yeah, allegedly. Sorry, sorry, sorry. Yes, allegedly. Allegedly they're doing this.

49:45Jordan Harbinger:But that 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.

49:56Jessica Wynn:Who's regulating all this?

49:58Jordan Harbinger: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 they're required to administer is 62 questions long. And so that's insane. And less than 30 percent of patients even respond to it.

50:43Jessica Wynn:And that doesn't actually help patients?

50:45Jordan Harbinger: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 ProPublica a few years ago that found wide variation in mortality rates between clinics, and some had death rates 50 % higher than the national average.

51:13Jessica Wynn:Oh, my gosh, that's significant. OK, so how is that possible, though, if they're all regulated?

51:18Jordan Harbinger:Because the regulations don't measure quality of life or long term outcomes very well. They measure things like, is the water clean? Are infections logged? Are treatments happening on schedule?

51:31Jessica Wynn:You know? Yeah. OK, this almost sounds like soft regulatory capture. Yeah, soft is right. Meaning not like cartoon villain corruption, just regulators maybe slowly over time getting too cozy with the industry they're supposed to oversee. Same language, same incentives. I mean, if there's a duopoly, 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.

51:57Jordan Harbinger:And when these two giant companies with enormous resources are running the show, they have sway over how the rules are written.

52:05Jessica Wynn:Yeah, that's what I mean. Yeah. Yeah.

52:07Jordan Harbinger:So they submit comments on proposed regulations. They're the ones funding studies. They hire former CMS officials as consultants. They spend about two million dollars each on federal lobbying. And so over time, the regulatory environment just becomes comfortable for them.

52:26Jessica Wynn:That is bleak. That is complicated, but bleak. Also, I don't know. Side note here, but it is amazing how low that number is. Two million dollars each. It kind of sounds like a lot, but give me a break. You only need two 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 costs.

52:50Jordan Harbinger:Yeah, which shouldn't surprise anyone.

52:53Jessica Wynn:I would have thought you had a zero on the end to the amount that they had to lobby to get this stuff. I mean, I guess it's every year, but still, come on. Wow.

53:00Jordan Harbinger: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.

53:18Jessica Wynn: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.

53:24Jordan Harbinger: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.

53:36Jessica Wynn:OK, 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.

53:49Jordan Harbinger:Well, 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 a 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.

54:30Jordan Harbinger:Then the cycle starts again.

54:31Jessica Wynn:Wow, three times a week.

54:33Jordan Harbinger: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.

55:00Jessica Wynn: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 and appointments, like, that's it. You just can't go.

55:14Jordan Harbinger:Right. 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 couldn't make it work.

55:23Jessica Wynn:Oh, man.

55:24Jordan Harbinger: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. Your 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.

56:01Jessica Wynn:I know someone's thinking it, so I'm just going to say Right. I guess if you date somebody who's on dialysis, you should also maybe be on dialysis. Right. And then you just hang out at the clinic, your appointments up and you yeah, you go and you say, hey, we want two chairs 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.

56:33Jessica Wynn:I don't I don't know.

56:34Jordan Harbinger:I didn't read about what it does to your libido, but it can't be good. Yeah.

56:38Jessica Wynn:And just like you do. 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. It's sad that this is just accepted as normal for these people. This is just their life now. That's depressing.

56:52Jordan Harbinger: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 versus suffering. Like you're supposed to be grateful because the machine is keeping you alive, which it is, but that doesn't mean the system is okay.

57:12Jessica Wynn:Right. You can say this keeps people alive and still say, hey, the way we built this is insane.

57:17Jordan Harbinger: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.

57:32Jessica Wynn:So what are the clinics like? What is a day of dialysis like in this place?

57:38Jordan Harbinger:Yeah. So, I mean, it varies. But the typical setup is a large room with maybe, you know, 20 to 30 reclining chairs arranged in rows. 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.

57:59Jessica Wynn: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?

58:04Jordan Harbinger: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 anything. That's what I'm thinking. Yeah. 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 endure.

58:29Jessica Wynn: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.

58:41Jordan Harbinger:Thinking of you.

58:41Jessica Wynn: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?

58:50Jordan Harbinger:So this is a major issue. Nurses and techs 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 infection statistics we talked about, that's 36 % of deaths of people on dialysis are from infection. So this is an abstract, you know, understaffing kills people.

59:27Jessica Wynn:So people are dying because clinics save money on labor.

59:31Jordan Harbinger:I mean, that's the implication. So you maximize profit by minimizing labor costs. And in health care, that means worse outcomes.

59:39Jessica Wynn: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.

59:47Jordan Harbinger:Oh, my gosh. Yeah, COVID was catastrophic for dialysis patients. So even though dialysis was still available during lockdown, 25 percent 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.

1:00:14Jessica Wynn: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.

1:00:23Jordan Harbinger: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.

1:00:41Jessica Wynn:So a global pandemic with a lethality of one in four in the target population that we're talking about now had to happen for the system to prioritize the thing that was better and cheaper for patients all along. That's yeah. OK, if you weren't angry before, you should be now.

1:00:58Jordan Harbinger:Yeah. And Medicare started pushing harder for home dialysis. But progress is slow because the financial incentives, they haven't fundamentally changed.

1:01:08Jessica Wynn:Nothing says modern healthcare like we can keep you alive, but only in the most expensive and depressing way possible. More on that in just a moment.

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1:02:19Jessica Wynn:Thank you for listening to and supporting the show. Your support of our sponsors keeps the lights on around here. All of the deals, discount codes, and ways to support the show are searchable and clickable on the website at jordanharbinger.com slash deals. Please consider supporting those who support the show. Now for the rest of Skeptical Sunday. 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.

1:02:45Jordan Harbinger:Right. They just have a kidney vending machine. Yeah.

1:02:49Jessica Wynn:That's Japan. But yeah, go ahead.

1:02:53Jordan Harbinger:And the problem is in Japan, it's someone else's kidney. Right. 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%.

1:03:10Jessica Wynn:Wow, 70%. That's incredible.

1:03:13Jordan Harbinger:Because they prioritize it. They train patients, they provide support, and they make it the default option unless there's a reason not to.

1:03:21Jessica Wynn:Right, okay.

1:03:22Jordan Harbinger:And their outcomes are better. They have lower mortality. They have better quality of life.

1:03:26Jessica Wynn:Yeah, because you're at home with your family chilling, watching It's a Wonderful Life or something with this little thing beeping next to you. You don't have to schlep 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.

1:03:44Jordan Harbinger: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.

1:04:06Jessica Wynn:What about transplants? Do other countries do that stuff better? I know that's a different episode.

1:04:10Jordan Harbinger: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. In America, we're opt-in. And their transplant rates are among the highest in the world.

1:04:28Jessica Wynn:We have opt-in here, yeah? You have to elect to do it.

1:04:31Jordan Harbinger: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.

1:04:54Jessica Wynn:Okay.

1:04:54Jordan Harbinger:There's all kinds of issues. And these are growing, but they're logistically complex and really underfunded.

1:05:01Jessica Wynn:What about artificial kidneys, speaking of vending machines, right? Is that science? I mean, this vending machine thing is fake, obviously, but artificial kidneys, is that science fiction still at this point? Or are we, how's that looking?

1:05:12Jordan Harbinger: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, you know, development is expensive. The path to FDA approval would be really long. We're just not there yet.

1:05:40Jessica Wynn:I see. And the dialysis industry, I'm guessing they're not involved in funding all this research.

1:05:45Jordan Harbinger: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.

1:06:00Jessica Wynn:So innovation is happening despite the industry, not because of it.

1:06:03Jordan Harbinger: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.

1:06:14Jessica Wynn:OK, so because the quietest tragedy in all this is lack of prevention, right?

1:06:19Jordan Harbinger: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. Nephrologists, the kidney doctors, they're among the lowest paid specialists. And there's a shortage of them. So primary care doctors are overworked and often don't catch kidney disease until it's advanced.

1:07:03Jordan Harbinger:The screening's really inconsistent. The education's really minimal. You know, we're back to patients, like rationing insulin.

1:07:10Jessica Wynn:Because prevention doesn't really make money and you can't bill Medicare for something that never happens.

1:07:15Jordan Harbinger:Right. Prevention means nothing dramatic happens. There's no emergency. There's no machine. There's no chair. There's no$90 ,000 a 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, indefinite treatment and no cure.

1:07:48Jessica Wynn:By the way, I want to say real quick, I know someone's going to be like, no, Medicaid also pays for part of dial. 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 off in an email, we know it's just we're trying to keep it simple. OK, what would proper prevention look like here?

1:08:09Jordan Harbinger: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 nephrology 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.

1:08:33Jessica Wynn:Right. We just don't.

1:08:34Jordan Harbinger: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.

1:08:47Jessica Wynn:You've spent a lot of time on this. When you talk to patients, what do they want?

1:08:51Jordan Harbinger: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.

1:09:13Jessica Wynn:Well, do they feel like the system is trying?

1:09:16Jordan Harbinger: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, 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 doctor's appointments or insurance, even if they were working two jobs or they lived in neighborhoods where the only nearby food was fast food.

1:09:52Jessica Wynn:So the system failed them and then they blame themselves. That's heartbreaking. Yeah.

1:09:57Jordan Harbinger:And then the system locks them into this permanent treatment while profiting from it. So it's hard not to see it as exploitation.

1:10:04Jessica Wynn:I'm sympathetic to the whole like personal choice thing. But I don't know when you talk about like the food desert thing and the medical thing And then 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. Like, come on, guys.

1:10:23Jordan Harbinger: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.

1:10:43Jessica Wynn:Okay. And what does better look like?

1:10:45Jordan Harbinger: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 bioengineered organs, whatever works.

1:11:20Jessica Wynn:All of which would reduce revenue for the current players.

1:11:23Jordan Harbinger:Exactly. So it won't happen without political will. You know, 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.

1:11:41Jessica Wynn:And industry has money and lobbyists and patient groups that they fund. Right.

1:11:46Jordan Harbinger:And nobody wants to be accused of rationing care or letting people die. So the conversation doesn't happen. We just keep writing checks and the system continues.

1:11:56Jessica Wynn:How do we change that?

1:11:57Jordan Harbinger: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 the scale of this, that half a million Americans trapped in a system optimized for profit, not outcomes, where 60 % won't survive five years, where infections kill more than a third of the patients, where people are choosing death over continuing treatment, you know, maybe if people realize that, there'd be pressure for reform.

1:12:32Jessica Wynn:But it requires people to care about something that maybe doesn't affect them directly at the moment.

1:12:37Jordan Harbinger:I know, for now. But kidney disease is growing. Diabetes is growing. Hypertension 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.

1:12:50Jessica Wynn:Yeah, that's bleak, man.

1:12:52Jordan Harbinger: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.

1:13:08Jessica Wynn: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.

1:13:14Jordan Harbinger:Yeah, I mean, you'd think. But when profit is the organizing principle, alive becomes the acceptable outcome. Everything else seems optional.

1:13:24Jessica Wynn:So what do we tell people? What's the action item here, the takeaway?

1:13:28Jordan Harbinger:I mean, you know, if you have diabetes or hypertension, manage it aggressively. Get your kidney checked regularly. It's just a blood test and a 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.

1:14:00Jessica Wynn:And politically?

1:14:01Jordan Harbinger: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 percent of dialysis deaths involving infection. It's unacceptable.

1:14:27Jessica Wynn: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.

1:14:37Jordan Harbinger:Right. I mean, I want to emphasize here dialysis saves lives. But the business model was built for permanence, not prevention, mobility or cure.

1:14:48Jessica Wynn:Yeah, that's a strange place for medicine to end up.

1:14:50Jordan Harbinger: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.

1:15:12Jessica Wynn:Thank you, Jess. I feel depressed discovering kidneys have a$50 billion industry built around them or failed kidneys.

1:15:19Jordan Harbinger:Yeah, you're welcome. You know, I'm happy to contribute to the existential dread here.

1:15:24Jessica Wynn: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 who'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.

1:15:54Jessica Wynn:Terrible. I'm ashamed of you.

1:15:56Jordan Harbinger:I'm sorry to disappoint you.

1:15:57Jessica Wynn:And thank you all so much for listening. Topic suggestions for future episodes of Skeptical Sunday to me, Jordan at jordanharbinger.com. advertisers, deals, discounts, ways to support the show, all at jordanharbinger.com slash deals. I'm at jordanharbinger on Twitter and Instagram. You can also connect with me on LinkedIn. You can find Jessica on her multiple sub stacks 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 nevermetjessicas. That's plural for some reason. This show is created in association with Podcast One.

1:16:28Jessica Wynn:My team is Jen Harbinger, Jace Sanderson, Tata Sadowskis, Robert Fogarty, Ian Baird, Gabriel Mizrahi in the house as well. Our advice and opinions are our own. And yeah, I'm a lawyer, 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 could use a good dose of the skepticism and knowledge that we doled out today.

1:16:58Jessica Wynn:In the meantime, I hope you apply what you hear on the show so you can live what you learn. And 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.

1:17:17Jordan Harbinger: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. And they're in the air as well. And so they get smaller and smaller and smaller. They're called nanoplastics. And the smaller they get, 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. It's in the plants. It's in meat. It's in every, it's all over the place.

1:17:53Jordan Harbinger: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, fermentable fiber, prebiotics, right? Those are all sort of interchangeable ways of saying soluble fiber. Fruits, fruits 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. Beta-glucans 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.

1:18:30Jordan Harbinger: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.

1:18:45Jessica Wynn:Catch the full conversation with Dr. Rhonda 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.