Thursday, September 26, 2019

The Artless Art of Negotiation

Negotiation is a skill I sorely lack. My brothers still crack up when they recall me negotiating with a former boss on a raise. "Eighty thousand", he said. "Can we do Eighty five?", I asked hesitantly. I did not want to embarrass him. "Done Kamal." When I recounted this conversation that evening to my brothers and parents, they gave me a thorough dressing down.

Over the years, I have seen several people negotiating, first hand. As is usually the case, people start at something less than what they are willing to pay or more than what they are willing to sell at. Eventually after some back and forth, they settle on a price.

Both parties usually know that there is some leg room. Both negotiate accordingly.

I have been a part of several discussions where people say they have "put their best foot forward" and have not "left anything on the table". All MBA jargon. But that is never the case. Half an hour into the negotiations and you will see that they still have a better foot to put forward and had actually left something on the table.

Why do we do that? Wouldn't life be much simpler if people directly quoted what they were willing to sell at? Or state what they were willing to pay? Wouldn't a lot of time be saved?

You might say I am not being practical. You might say that things don't work that way.

You might give me the following argument. Let's say someone is willing to sell something at Rs. 1,000. Usually they would start at say, Rs. 1,400 and then during the course of the negotiations, come down to Rs. 1,000. The problem here is the perceived value of the product in the eyes of the buyer. If the buyer thinks the product is worth Rs. 1,200. During negotiations, the price finally decided might be Rs. 1,100. In this case, the seller has got Rs. 100 more than what he had thought he could get. The buyer paid Rs. 100 less than what he was ready to pay. So, you might argue that both have actually "won".

You might be right from one perspective.

However, if both parties did not leave any room for negotiations, then what might have happened? The seller would have quoted Rs. 1,000 and the buyer would have happily bought it thinking he got a great deal where he saved Rs. 200. The seller got what he wanted though you might say he could have got Rs. 200 more.

When you think about it, over a long enough time, it all evens out. But my financially savvy friends would argue against allowing "a long enough time" to even things out. They would want to get the best out of every single deal.

I simply feel that stating your best price (either while buying or selling) saves a lot of time and at the end of your life, you would neither save or lose much by that approach. Provided, of course, that everyone follows this approach.

Until then, dene ka bolo?

Saturday, September 21, 2019

Cost of Home Hemodialysis in India

After my last post, I got several enquiries on what exactly the cost of Home Hemodialysis in India was. I was also requested to create a separate post on this and so here it is.

The cost can be broken into two: Initial Cost and Recurring Cost.

The Initial Cost includes the cost of setting up the system at home including the machinery, plumbing and electrical connections. The Recurring Cost includes the cost of the consumables, the salary of the technician, water, electricity, maintenance cost of HD machine and RO plant etc.

We must bear in mind that each of these costs would vary greatly depending on location, frequency and duration of the dialysis sessions, type of dialyser, whether the dialyser and bloodline is being reused or not etc.

The numbers provided here are approximate ranges and will vary based on several factors. 

Initial Cost:

HD Machine - New: Rs. 5.5 - 6 L
RO Plant - New: Rs. 1-1.5L
Electrical and Plumbing: Rs. 50-75K
Bed: 0 to Rs. 1L (depending on whether you would use your own current bed or maybe a multifunction bed which allows you to move it to the Trendelenburg position (in case of low BP) etc.)

Recurring Cost:

Cost of a dialyser and bloodline is the same as that you probably pay at your current centre (Rs. 500 - Rs. 1000 for the dialyser depending on whether you are using low flux, middle flux or high flux and between Rs. 150 - 175 for the bloodline). The cost per session of this can be brought down if you reuse the dialyser.

Rest of the consumables would cost around Rs. 300-400 assuming a four hour session. For a nocturnal session, it would be slightly higher, maybe around Rs. 500-600.

Technicians would charge anywhere between Rs. 400 to Rs. 1000 per session depending on the location.

You would also need to spend some amount on maintenance of the RO and the HD machine.


Initial cost: Rs. Rs. 7L to Rs. 10L depending on various options (everything new, for second hand, refurbished stuff, maybe about 60-70% of this)

Recurring cost: Rs. 1200 to Rs. 3500 per session

Nowadays, several dialysis providers also provide home hemodialysis services where they will take care of everything. This will include setting up the infrastructure, supplying consumables, arranging a technician and taking care of biomedical waste and machine maintenance. This will be more expensive though.

So, if you do the same frequency and duration as in your current hospital based dialysis centre, the monthly cost can come to around the same as that you are paying now. The initial cost is something that needs to be considered though. This can also be reduced if you go for a refurbished machine. There is a small chance of the machine giving problems though.

The beauty of home hemodialysis though is when you do it more frequently and for longer durations. For example, doing five nights a week, for 7-8 hours each night can improve clinical outcomes and quality of life dramatically. Several people report an almost normal quality of life with this regimen. Studies have also shown that the outcomes with this modality rival that of a deceased donor kidney transplant.

My own experience with this modality has been excellent. Honestly, I have got my life back and I have documented this in great detail on this blog as well. The return on investment has truly surpassed all expectations for me.

Saturday, September 14, 2019

Myth: You have to be rich to do Home Hemodialysis in India

I was diagnosed with Kidney Disease in July 1997. Ours was a middle class family. Both my parents had their entire lives' savings wiped out in the first few years of my being diagnosed with Kidney Disease. I started working part time only after I switched to PD in 1999. Effigent happened in 2000. For the first few years of Effigent, I drew only a nominal salary.

I started doing Daily Nocturnal Home Hemodialysis in May 2006. NephroPlus was not started until December 2009. I hadn't even met Vikram.

So I got onto Home Hemodialysis when our financial condition was still precarious. Well, it was not like we couldn't make ends meet. We had money for the basics of life. Not a whole lot more.

But despite all this we could make it work. My mother took a bank loan for the HD machine. We dug into our finances for the RO and so on and got started.

The point I am trying to make is that you don't really need to be stinking rich to be on home hemo. You do need guts though. To undergo a therapy which only a very small number of people are doing requires some courage. But hey, if I could do it thirteen years ago when home hemo was only something you read about on the internet, with all the advancements that have happened since then, it should almost be a piece of cake now!

One major challenge that you associate with hemodialysis is averted to a large extent if you do more frequent, long duration dialysis at home. That way, since the fluid weight gain is not a whole lot, you are removing fluid at a low, gentle rate and that reduces the chances of any complications while on dialysis.

Yes, you do need a good technician. This is true for India. At least in my experience, I find it easier to do home hemo if you have a tech supporting you. This could be a family member as well. The trouble though is that training for home hemo is practically non-existent in India. In such cases, techs are ideal. They like the extra money. You get the comfort.

You can also get all the consumables on your own and manage the entire process end to end on your own. If you do that, the cost is going to probably be around the same as that you are paying in the centre, give or take.

There are companies that provide home hemodialysis. If you don't want to take the hassle of managing the entire process yourself, this could be useful. You may not even need to pay upfront for the machine. Everything is taken care of for you by them.

But if you have it in you to manage everything on your own and can put in a small initial investment, then home hemo can actually cost about the same as your neighbourhood dialysis centre. You need the courage. It is possible though.

Sunday, September 8, 2019

Daily nocturnal home hemo gives me everything I want from life except the ability to travel longer

I am really grateful for the ability to dialyse at home five nights a week, seven to eight hours each night. This modality has given me the freedom to live an unfettered life. I don't bother much about what I eat or drink. I am able to work for long hours. I am able to swim, to do strength training. I am leading an almost normal life except for the dialysis I need to undergo at night. I do have some medical issues from time to time which are mostly (apart from the bone issues) resolved by some form of treatment.

There is however one thing that I miss and that is the ability to travel for more than one night away from home. I skip dialysis these days on Wednesdays and Saturdays. I plan all my travel so that I spend a maximum of one night away from home - typically Wednesdays or Saturdays. I am flexible with the non-dialysis days at times and I might take another night off instead of those days. But I have almost decided not to take more than one night off away from nocturnal hemo.

You might think why I can't travel longer and get a few dialysis sessions at a centre?

Well, I have done that several times in the past. I have blogged extensively about those trips in this blog. My longest trip away from home has been three weeks long. But I hated the idea of going for dialysis during a holiday.

Once you get used to getting dialysis at home, especially the longer duration, more frequent sessions, believe me, it is very difficult to go back, even for a short duration to getting the four hour sessions in the centre. Also while some centres do offer nocturnal, it's just not the same as getting dialysis at home. The quiet, the dark room, the complete lack of disturbance are very conducive to a peaceful night of sleep.

Also, when I travel, dialysis is the last thing I want to think about. I would like to enjoy the place, the food, the hotel and so on. Who really wants to be lying in a bed with two thick needles in your arm?

People often ask me why I can't get a machine such as the NxStage System One which affords the ability to travel while getting your same home regimen while traveling. I would love to. Trouble is the company won't. I have been in touch with them and they have no plans of coming to India. Recently the company got acquired by Fresenius and that increases the chance of the machine coming to India by about 0.1%. Let's see where that goes.

I might be sounding like I am complaining but no, I have no right to complain. Given my circumstances, I think daily nocturnal itself is a boon and I can never be grateful enough. Just that I miss long travel. Period.