A Tale of Two Cities: The Story of Dialysis in America

[Hemodoc]

A Tale of Two Cities: The Story of Dialysis in America
By Peter Laird MD,

The influences of two cities in America during the last fifty years is the tale of two cities taking the  technology of dialysis in two different directions. Truly, "It was the best of times, it was the worst of times..." Dr. Scribner in Seattle started the entire field of chronic hemodialysis by his inspiration in the middle of the night for the Scribner Shunt.

Belding Scribner: The Inventor of Shunt Dialysis

Scribner came upon his idea in 1960 after he saw a young man recover briefly following dialysis, only to die a few weeks later. At the time, haemodialysis could only be performed for a few cycles. In a painful procedure, glass tubes were inserted into a patient’s blood vessels, permanently destroying them for further access.

The patient weighed on Scribner’s mind until one night when he suddenly awoke with an idea of how to save patients with end stage kidney disease. He would fashion a loop between an artery and vein, allowing the device—rather than the patient’s own vessels—to be opened and closed with each cycle of dialysis. that it was just like turning on the light from the darkness.”

Dr. Scribner, a patient in his own right from chronic eye problems, immediately freely gave his invention to the medical world for one sole purpose, to save lives, profiteering never entered his mind.  This gift followed the example of Wilhelm Kolff, the inventor of the first workable dialysis machine who freely gave his invention to the medical world to save lives as well.

Kolff’s machine is considered the first modern drum dialyzer, and it remained the standard for the next decade. At the time of its creation, Kolff’s goal was to help kidneys recover. The brave doctor had no way of knowing that his invention was one of the foremost life-saving developments in the history of modern medicine.

After World War II ended, Kolff donated the five artificial kidneys he’d made to hospitals around the world, including Mt. Sinai Hospital in New York. Because of this unselfish act, doctors in many countries were able to learn about the practice of dialysis.

Wilhelm Kolff gave the blueprints of his machines to Dr. Thorn at Peter Brent Brigham Hospital in Boston.  They shipped 22 of these machines updated at Brigham hospital around the world between 1954 and 1962.  Yet, it was not until Dr. Scribner invented his shunt that chronic hemodialysis beyond one or two treatments became a reality. Dr. Scribner immediately set out on his most important mission, to make this new technology widely available and he was the driving force behind the 1973 Medicare legislation initiating the ESRD Medicare program. The Seattle experience brought forth the new field of bioethics and the first dialysis unit opened which still operates now as the Northwest Kidney Center in Seattle, a non-profit organization that is still a leader in dialysis inovation today.

However, in Boston, a new corporation sprang forth from among the Peter Brent Brigham doctors called National Medical Care, Inc.  After two years, in 1970, it became the first for-profit dialysis company. The era of altruistic innovations gave way to the era of grand profiteering on a monumental scale. Despite its initial humble beginnings with the Kolff-Brigham machine, Boston would become the most influential center of dialysis making the goals of for-profit dialysis as the standard of care in America.

Dr. Edmund G. Lowrie, in a 1978 Medicare hearing changed the face of dialysis in America from predominantly a home based therapy given three nights a week for a total of 27 hours, into the current ultra-short hemodialysis of 3-4 hours sessions, thrice weekly.

The politics of health cost containment: end-stage renal disease

R.A. Rettig (pages 132-133)

Dr. Edmund Lowrie of Peter Brent Brigham Hospital attacked the Seattle experience directly on two points: "our analysis indicates that the cost of self-care dialysis is not significatly less than limited care dialysis, and that the the indiscriminate use of home dialysis may lead to unacceptable patient mortality." . . . "After careful analysis," Lowrie claimed, "the only obvious reason for this inferior patient survival that we can think of is the indiscriminate use of home dialysis therapy." Lowrie's testimony created the impression that three-year survival ofhome patients in Seattle was unacceptably low. But as Blagg later pointed out, the 58% applied to all Seattle patients, center and home, and inclued elderly and diabetics insignificant numbers.50 "When we look at patient survival on home dialysis ," Blagg wrote, "and exlude the center dialysis patients, the 3-year survival in our program is 74 percent including diabetics; if we exlude diabetics, the 3-year survival rate in pateints aged 55 of less is 81 percent on home dialysis. . .

But the political damage had been done.

The cast was set once again by Edmund Lowrie, et al after the Boston based NCDS ( NCDS: Revisited Three Decades Later) pronounced Kt/V as the best measure of dialysis "adequacy" and for the next thirty years, outcomes in America plummited to the lowest of all developed nations while at the same time, the predominantly home based American therapy given to us from the Seattle model of care passed over to the Boston model of care in for-profit centers giving short, thrice weekly treatments.  At the time of the hearings in 1978 on the future of dialysis in America, where the best model we know today of home based, long nocturnal therapies, fell at the hand of what we now know is the incorrect testimony by Edmund Lowrie that in-center care was better, Dr. Lowrie was a high ranking corporate officer in the for-profit dialysis chain, National Medical Care, Inc. Indeed, he later became the president of this corporation. In response to the 1995 Kurt Eichenwald NY Times article, Death and Deficiency in Kidney Treatment, the dialysis industry responded in a letter to the editor: "There is no evidence that an adequate Kt/V delivered in 2.5 hours in[sic] inferior to the same dose delivered inefficiently in 4 or 5 hours. We believe it is to everyone's advantage - patient, provider and payor - to deliver high quality dialysis efficiently at a time of limited resources."

The story of National Medical Care, Inc. in my opinion, is one of obscene profits soon after the ESRD Medicare program began paying for all dialysis care in America .  Even Jack Anderson, the prototypical investigative reporter of decades past took notice of the "padding" of dialysis costs by National Medical Care, Inc: Clinics Pad Kidney Dialysis Costs. 

The story of dialysis in America truly follows the tale of two cities, that of Seattle giving us chronic hemodialysis, thrice weekly overnight at home for 27 hours weekly,  it gave us the first non-profit dialysis center, started the field of bioethics, and has continuously fought against those that have instead turned dialysis into one of the most outlandish profiteering medical schemes in history. Boston, on the other hand ultimately gave us National Medical Care, Inc., the NCDS and those that reduced a life saving technology done best at home into one, in my opinion, of death, despair and disability that we now own today as our American legacy of dialysis for the simple reason, in my opinion, of turning the highest profits. Improving dialysis care in America today can best be accomplished by simply turning time back to the Seattle model of care. 

The Boston experiment of dialysis care in America is a failed trial of medical care at best founded on the for-profit industry standards.  We can do better here in America, and it is my hope that we shall.

http://www.hemodoc.com/2010/12/a-tale-of-two-cities-the-story-of-dialysis-in-america.html

[MooseMom]

I just posted this query on your blog.  What can we patients do, right here right now, to fight this descent into dialysis-for-profit hell?  I don't know when I will have to start dialysis, but when it's time, what can I do not only for myself but also for other patients who may have to do incenter D because no other alternative is viable?  How do we change the template from what Boston gave us to what Seattle offers?

[mm2010]

Well written.  Thank your for sharing this very interesting prospective.  Excellent article.  I have no experience with dialysis treatments, or costs in the U.S, but I can say after visiting our center here in Oshawa Ontario, Canada, I was very impressed with the staff, the quality of our facility, and the options offered to patients. 

Here in Ontario, OHIP, (Ontario Hospital Insurance Plan) provides all the funding for our dialysis centers. I, like many of my fellow Canadians do not examine health care costs as a factor determining my quality of care.  The system here changes your expectations when it comes to health care services.  We all pay, its not optional, and we pay dearly.  In return, we expect world class care, and we expect our health care system to "spare no expense" if we need care.  Money certainly changes the game, and because I live in Canada, its very hard to imagine what life would be like if I couldn't afford to get sick.

Since the frequency and duration of dialysis is known to improve the quality of treatment, it seems many will be looking to change the way they receive their treatments.  Please keep the supporting articles that are strengthening this position coming.  Your knowledge and experience have given you a very unique opportunity to change the future of dialysis in both Canada and the U.S.  Again, great work.

[MooseMom]

So Mark, what is the usual schedule for a typical dialysis patient in Canada?  Is it not the thrice weekly in-clinic scenario?  Do Canadians get more frequent in-clinic dialysis that's paid for by your health system?

[Rerun]

Great post Peter.  Those of us who have lived long enough to be on both non-profit dialysis and for-profit dialysis can testify to this truth.  It has gone to hell and these dialysis centers are making tons of money off Medicare and sick people. 

I know my center has fought to keep it's Nocturnal shift but I like it and feel better than just 12 hours a week.

[galvo]

Very interesting article, Doc. Thanks.

[ChickenLittle56]

I have heard stories on how the previous clinic I attended changed dramatically after it gobbled up by a huge conglomerate. My friends who went there before the change preferred the non-profit than whats happening now.

[mm2010]

While I was visiting the center for my pulse treatments, (three days in a row) I met a woman there who told me she comes 3 times a week, but the center was very flexible and she could make adjustments to the schedule as required.  It was interesting to me that the center was so accomodating for her.  I think most people still do the minimum dialysis routine, since this is what is typically offered.  The center I visited did have patients doing more than the typical 3 days a week.

Its probably not going to change overnight, but as more and more people show the benefits of more frequent, slower dialysis, the centers will have to accomodate the patients.  The article written here goes a long way to showing how the medical profession has an opportunity to do the right thing, and treat the patient based on their needs, not the cost.  I will check with our center on my next visit what schedules they provide to accomodate for patients.

[MooseMom]

mm2010, why do you think that the "minimum dialysis routine" is what is typically offered?  Why is optimal dialysis not the "typically offered" way to go?

I don't mean to sound skeptical, but why do Canadian centers have to accomodate the patients?  Do dialysis patients have that much power in Canada?  If so, that's just wonderful!  The benefits of more frequent, slower dialysis are beyond debate, so who in Canada says otherwise (that goes back to my first question of why is this not the typically offered treatment?)?

[looneytunes]

very interesting article...goes along so well with my "soapbox" as to the amounts that are "billed" vs. the amounts that are "allowed" and paid.  The difference is a tax write-off for those corporations (we are supported through one of the biggest) and the patient care so often seems to be more affected by the amount that can be billed rather than what is best for the patient. 

[Bill Peckham]

mm2010, why do you think that the "minimum dialysis routine" is what is typically offered?  Why is optimal dialysis not the "typically offered" way to go?

I don't mean to sound skeptical, but why do Canadian centers have to accomodate the patients?  Do dialysis patients have that much power in Canada?  If so, that's just wonderful!  The benefits of more frequent, slower dialysis are beyond debate, so who in Canada says otherwise (that goes back to my first question of why is this not the typically offered treatment?)?

There is a puzzle. There is no unit in the world that is open seven days a week, no national system based on units being open seven days a week. To my knowledge every provider closes one day a week. This means that you might be able to get an extra run but it won't be routine, it isn't likely to be at your normal time or at a predictable time because you'll be fit in. To get four treatments in a week you'll need to run two days in a row: M-W-F with Saturday added on. Or T-T-S with an extra Monday for example.

In Australia it is routine to dialyze every other day at home but not incenter. Never incenter. Why? These are health systems where hospitalization and dialysis costs are paid out of the same pocket - there is no Part A/Part B wall as there is with Medicare. I would predict that routine EOD dialysis would save its cost in hospitalizations, yet no health system has tried keeping units open 7 days a week. So, it is a puzzle.

[MooseMom]

I find it fundamentally stupid to close any facility on any day if that facility that gives lifesaving treatment.  Why don't we shut hospitals one day a week?

Gosh, department stores are open seven days a week.  There are retail outlets that are open 24/7/365.  Is shopping more life-sustaining than dialysis?  I guess we as a society have decided that is indeed so.

[mogee]

Thanks for posting Dr. Laird.  I am always shocked by the way Americans stand by their horribly dysfunctional system of care, and even claim that it is superior to other systems.  The pursuit of profits can have devastating effects on the quality of medicine.  The failure to include a public option in "Obamacare" will ensure that profit seeking corporations will continue to dominate medicine and that America will be permanently bifurcated into medical haves and have-nots.  Thoughout the debate on health care reform, Republican scare mongers warned of "Canadian style" health care and its attendant failures.  Yet Canadians are overwhelmingly satisfied with their health care and any politician who attempts to fundamentally change the system will soon be voted out of office.  The father of Canadian universal health care, Tommy Douglas, was recently voted the "greatest Canadian" in a CBC television series to determine the greatest Canadian of all time.

It will be a long, long time before the United States has anything resembling effective and equitable health care.  And if they ever decide to control handguns and discontinue capital punishment they will be well on their way to joining the civilized world.

[MooseMom]

  The failure to include a public option in "Obamacare" will ensure that profit seeking corporations will continue to dominate medicine and that America will be permanently bifurcated into medical haves and have-nots. 

It's worse than that, though.  The current system will continue to ensure that the "haves" can be instantly turned into the "have nots" should they be struck down by a devastating illness or accident.

How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits.  We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.

My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis?  Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?

[mogee]

How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits.  We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.

My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis?  Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?

Universal dialysis through Medicare is dramatically different from universal health care.  My medical team does not just provide dialysis, but is concerned with my long-term health and well being.  Once dialysis is economically isolated from the rest of medicine there is no financial incentive to avoid medical complications and hospitalizations.  If a dialysis provider is paid the same rate for six hours of treatment as for three and a half, why would they offer the longer treatment?  One of the keys to the efficiency of Canadian care is the willingness to act preventatively, at some cost today, to save other higher costs later on.  Canadians can't have "any dialysis they want in whichever setting they want", but there are very strong incentives to keeping patients as healthy as possible.  In my hospital, the dialysis schedule is often tailored to the patients' needs.  For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager).  There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.

[Bill Peckham]

How the majority of US dialyzors receive dialysis is dictated purely by cost, not by health benefits.  We could argue the case of universal health care until the cows come home, but most dialyzors in the US ARE receiving "universal health care", ie Medicare, yet we still are not getting optimal dialysis.

My question remains, then for Canadians...yes, you have universal health care, but does it give you optimal dialysis or just adequate dialysis?  Can any dialyzor in Canada have any dialysis they want in whichever setting they want, and if so, will it all be paid for?

Universal dialysis through Medicare is dramatically different from universal health care.  My medical team does not just provide dialysis, but is concerned with my long-term health and well being.  Once dialysis is economically isolated from the rest of medicine there is no financial incentive to avoid medical complications and hospitalizations.  If a dialysis provider is paid the same rate for six hours of treatment as for three and a half, why would they offer the longer treatment?  One of the keys to the efficiency of Canadian care is the willingness to act preventatively, at some cost today, to save other higher costs later on.  Canadians can't have "any dialysis they want in whichever setting they want", but there are very strong incentives to keeping patients as healthy as possible.  In my hospital, the dialysis schedule is often tailored to the patients' needs.  For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager).  There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.

And yet the Canadians close their dialysis units once a week just like everyone else. And just like everyone else they see an increase in hospitalizations and sudden deaths during the forced weekend.

[MooseMom]

In my hospital, the dialysis schedule is often tailored to the patients' needs.  For example, a woman who became pregnant while on dialysis was given dialysis six times a week for two and a half hours (her son is now a teenager).  There will always be limits to patient care regardless of the structure of the health care system, but unfortunately in the United States such limits are for the benefit of the insurers and medical companies, not for the collective welfare of patients.

What you say about the US system is absolutely true.  But I would like some clarification on what the Canadian system actually provides.  So, in your hospital, the dialysis schedule is "tailored".  That's great if you are pregnant and your needs therefore change, but does this tailoring apply to all patients at any time they wish?  What if you become an informed dialyzor and come to realize that longer and more frequent sessions are better for your health...will you get those longer and more frequent sessions?  And why are there "always limits" to patient care?  Why does there have to be a limit to optimal dialysis?  Who gets to make that call? 

Let's talk about limits.  Yep, such limits in the US ARE for the benefit of whoever stands to make a profit, but if you are saying that limits in Canada are for the "collective welfare of patients", well, I need to ask how limiting dialysis is in the collective welfare of said patients.

[Rerun]

I can remember 25 years ago with the OLD Drake Willock Machines I could only STAND 3 hours!   They were LOUD and the blood pump clicked every revolution!  The lines would jump with each turn of the blood pump and you could not set the machine to take off a certain amount of fluid so you usually crashed!  It was awful.

So it was such a gift to have high flux dialysis.  I think that now we have nicer machines and all that we are coming around to longer dialysis.

[mogee]

MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up.  I have met patients who are getting more treatment time in-centre, but it is rare.  I don't know if it is available just for the asking.

In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding.  In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health.  The system works best when money is spent to get the greatest possible value.  Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained.  It may be in the interests of patients collectively.  It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are.  One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.

[MooseMom]

MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up.  I have met patients who are getting more treatment time in-centre, but it is rare.  I don't know if it is available just for the asking.

How many Canadian dialyzors know that longer, slower dialysis is better for their long term health?  No one wants to be hooked up longer than is necessary, but now many Canadian patients are educated in the benefits of longer dialysis?  Do they know they can ask for better treatment?  How many patients do you think would ask for better dialysis if they knew it was freely available?  What kind of pre-dialysis education does the Canadian system pay for?

In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding.  In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health.  The system works best when money is spent to get the greatest possible value.  Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained.  It may be in the interests of patients collectively.  It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are.  One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.

There are ample studies that prove that longer dialysis gives better results.  It only makes sense...longer dialysis more closely replicates normal renal function.  I don't think, however, that longer dialysis reduces anemia.  Hormone production is not something that a dialysis machine can do.  What longer dialysis DOES do, though, is better clear toxins and, more critically, reduces the cardiovascular stresses caused by rapid fluid removal/fluid overload.

It doesn't really matter from where the limits originate, whether it is from corporations or from the public good if you are the one whose life is being undervalued.  If you are the one who depends on dialysis to live, I don't think you are going to go to bed at night thinking, "I'm ok with getting less than optimal dialysis because I know there are other people who need tax dollars spent on their health, too.  If my treatments are keeping me alive but are causing damage at the same time, I'm ok with that because the public will somehow benefit.  And if the public have decided they are willing to risk having to spend even more money on me in the long run rather than a bit more now, that's just fine."

Who gets to decide upon the definition of "better value"?  It seems to me that if a patient needs blipomycin to live, but blipomycin gradually causes death after expensive hospitalizations, but by adding flopomycin you can reduce those bad results, you give flopomycin, too, because a bit more money spent now saves a lot of money down the line.  That's "better value", but that's not usually the way that politicians think.

[Bill Peckham]

MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up.  I have met patients who are getting more treatment time in-centre, but it is rare.  I don't know if it is available just for the asking.

In the U.S. the limits of health care are determined by the profitability of private medical enterprises and the willingness of Medicare/Mediacade to provide funding.  In Canada the limits are determined by the scarcity of resources and the allocation of limited tax dollars toward health.  The system works best when money is spent to get the greatest possible value.  Limiting dialysis may not be in the best interests of the dialysis patient, but it may enable more spending in other areas where better value can be obtained.  It may be in the interests of patients collectively.  It would be interesting to know how long term outcomes differ when patients get four, five and six hours of dialysis and what the associated costs are.  One of the benefits of longer dialysis is less anemia and therefore less need for EPO preparations, which are costly.

That doesn't hold up because going every other day should decrease spending on hospitalizations. For a Canadian provence to offer EOD dialysis would cost around $3,000/year. I would bet that an EOD schedule would on average save a hospitalization which on average costs more than $3,000.

It's no use saying patients don't want every other day schedules - it has never been offered other than at home where it is quite popular.

The critique of the Canadian system is that it is not entrepreneurial, it is good at doing what it has always done but it doesn't advance care in the same way the US system does. I think it is fair to say that the world benefits from the innovation produced by the US system. Look at who wins the international awards - Nobel; Lasker. If the US innovated and offered EOD schedules showing the benefits to patients, providers and payers Canada and other first world systems would be quick to follow.

[RenalSurvivorDotCA]

MooseMom, one of the reasons 4hx3d of dialysis is standard for in-centre treatment in Canada as well is that patients do not want to spend more time hooked up.  I have met patients who are getting more treatment time in-centre, but it is rare.  I don't know if it is available just for the asking.

How many Canadian dialyzors know that longer, slower dialysis is better for their long term health?  No one wants to be hooked up longer than is necessary, but now many Canadian patients are educated in the benefits of longer dialysis?  Do they know they can ask for better treatment?  How many patients do you think would ask for better dialysis if they knew it was freely available?  What kind of pre-dialysis education does the Canadian system pay for?

I don't think ANY In-Center units anywhere in North America are open 7 days a week. Our unit does advocate home hemodialysis to the patients who show an interest/aptitude in it. I put my own needles in and pretty much take care of all my settings/alarms for the entire run. They jumped to their feet when I asked about the home hemo program. Even home hemo is not 7 nights a week; it is 6 nights and you can choose your night off. Obviously 8 hrs x 6 nights = 48 hours of low and slow dialysis is much better than 15 hours of high flow dialysis.

The home hemo program is fully paid for by the province and they will also provide the RO units and reimburse us for the plumbing and electrical enhancements we have to make to our homes. I would suspect that the main reason they advocate it is 1) it frees up a chair in-center and 2) no cost except the supplies.

In answer to your question: No, in Canada you cannot ask for more that 3 x per week  (in-center) regularly. There have been times where I was up a lot of fluid and needed a 4th treatment to get it all off by Friday but that was only a couple of times in my 8 years.

[Hemodoc]

Sadly, as much as Canada offers above and beyond what America offers, even Australia and New Zealand with the highest home hemo rates in the world only offer the "ultra-short" 3-4 hour thrice weekly sessions outside of the home program and some nocturnal in-center thrice weekly.

I would also call attention to the fact that this problem eclipses politics.  Bill and I are in complete agreement on dialysis issues, yet our political views are not in such agreement.  That has never kept either of us from a close and rewarding collaberation to fix dialysis for the last three years.  You wouldn't know that if you placed labels on our politics.

I would hope that this example would resolve into common ground of simply doing what is medically correct, since there is NOWHERE in the world right now that offers dialysis 7 days a week no matter how progressive or conservative a government is in place. It is not about being liberal or conservative, democrat of republican, American or Canadian, but simply placing the standard of care of optimal dialysis as a simple humanitarian effort on ALL sides. Sometimes, even gun toting Republicans have a heart and do what is right.

[MooseMom]

I'm sure even gun toting Republicans can develop ESRD.

I am not sure I'd want to rely solely on humanitarianism to achieve access to optimal dialysis for all.  That implies "charity", and I for one don't want to be looked at as a charity case.  It seems to me that there has to be an economic incentive to keeping people out of the hospital, and if optimal dialysis achieves that, then that's where our resources should go.  Hospitalizations are incredibly expensive.  Cut down the in-clinic infection rates and offer more dialysis (thus decreasing the risk of cardiovascular problems), and you keep people out of the hospital and you save money.  Bingo.  I'm sure it's not quite that easy but then again, maybe it is.

[Hemodoc]

I'm sure even gun toting Republicans can develop ESRD.

I am not sure I'd want to rely solely on humanitarianism to achieve access to optimal dialysis for all.  That implies "charity", and I for one don't want to be looked at as a charity case.  It seems to me that there has to be an economic incentive to keeping people out of the hospital, and if optimal dialysis achieves that, then that's where our resources should go.  Hospitalizations are incredibly expensive.  Cut down the in-clinic infection rates and offer more dialysis (thus decreasing the risk of cardiovascular problems), and you keep people out of the hospital and you save money.  Bingo.  I'm sure it's not quite that easy but then again, maybe it is.

Dear Moosemom, I think it is just that simple which gives me fits on why we haven't adopted optimal dialysis years ago. It saves hospitalization and direct dialysis costs to place people on optimal regimens. That is quite well demonstrated in many studies.  My main point above is that many people like to couch this issue in polarizing terms when it is not about that at all. I don't think that is helpful rhetoric since we will need both sides of the aisle to fix this problem.

I did come across an article out of Canada I believe, calculating how much it would cost to improve survival and their conclusion was that it would bankrupt the system in that specific province.  I have always wondered if there was not some sort of survival calculation and the number of dialysis patients that would be in the system if people lived for 10 years instead of 3-5 on dialysis.  Perhaps they have done that same calcuation in Washington but would never publicly admit it.  In any case, it is complete madness to continue the current substandard care and on top of that to make obscene profits off of our death and suffering at the same time.