By Peter Laird, MD
The NY Times stirred up the waters of debate on the Federal ESRD with it’s provocative article titled When Ailments Pile Up, Asking Patients to Rethink Free Dialysis. The author, Gina Kolata in my opinion promotes the concept that the Federal ESRD program is essentially a failure in that far too many of the patients treated are at the end of their lives and are given futile and costly care that does not extend any meaningful life:
Dialysis is difficult, especially for the old and sick. Most of the nation’s 400,000 dialysis patients spend several hours, three days a week, hooked up to a machine, and additional time traveling back and forth to the clinic.
They have to restrict salt and fluids, and the procedure is so exhausting that some patients rest for the remainder of the day. Although dialysis may alleviate symptoms like fluid accumulation in the legs or lungs, it can lead to dizziness, weakness, leg cramps, nausea and other problems. Complications like bloodstream infections or clogged blood vessels where the dialysis needles are placed are common, often requiring surgery or hospital stays. Ultimately, about one patient in five is unwilling to go on with it. . .
Meanwhile, costs are soaring — end-stage kidney disease will cost the nation an estimated $40 billion to $50 billion this year. And doctors are recommending dialysis sooner, even though recent studies have found that an early start confers no additional benefit.
The author’s statement that the ESRD program adds $40 billion to $50 billion this year when in actuality the costs for the Federal government are half that number, around $20 billion, about 6-7% of the total Medicare budget. Certainly this is a large sum, but the remainder is from private insurance coverage which private citizens have paid through their own contributions.
In addition, the ESRD program is a limited program for patients less than 65 who are not already enrolled in Medicare. Bill Peckham had a very interesting post a short while back breaking down the fact that of the 400,000 dialysis patients in America, only about 24,000 are less than the age of 65. Those over the age of 65 are covered by the Medicare bill passed in 1965 by Lyndon Johnson. Thus, by Bill’s account, the total ESRD program costs are in the neighborhood of $1 billion, and certainly less than $2 billion. Further, the NY Times graph on this issue starts at the age of 65, once again, all of these dialysis patients are covered by ordinary Medicare, not the ESRD program for patients less than the age of 65 .
In addition, the NY Times lists the common complications of the current American style dialysis therapy predominated by the large for-profit dialysis organizations correctly, but fails to show that was not the original intent of the ESRD program either. In 1973, the in-center costs for hemodialysis were ~$30,000 per year, while the home dialysis costs were ~$7000 a year for an established patient and double that for the first year of home dialysis noted in an article by Richard Rettig, yet, America abandoned the home program in favor of the in-center “lousy care” we have today. In addition, the standard of care was dialysis in home thrice weekly, overnight for 8-9 hours yielding rehabilitated patients most of whom still worked. If we are going to discuss the original intentions of the ESRD program, let’s likewise discuss the initial conditions and how the program has degenerated into by virtue of the undue influence of for-profit dialysis companies.
Lastly, reading through the responses and comments to this article I was struck by the number of people who genuinely fear the loss of autonomous control over end of life decisions if the government were to act upon the ideas promoted by this author. The benefits of optimally performed dialysis restores life at a significant cost savings.
Instead of focusing on the small percentage of elderly patients who truly have in many ways come to the end of their life with difficult decisions to make, let us keep our focus on the overwhelming majority of patients who benefit from this life saving treatment and return to the principles present at the origin of the ESRD program in 1973. Short sighted cost cutting is what got us into this mess in the first place being penny wise and pound foolish with a shadow of the intended dosage of dialysis now the standard of care. No wonder we keep discussing our poor outcomes, how could they be otherwise when you give too little and not enough of proper dialysis as practiced in the 1960’s. If there are any stories that the NY Times needs to tell, that is the one we should hear.