The Coming Fiscal Crisis

Abstract

SummaryNephrologists in the United States face a very uncertain economic future. The astronomical federal debt and unfunded liability burden of Medicare combined with the aging population will place unprecedented strain on the health care sector. To address these fundamental problems, it is conceivable that the federal government will ultimately institute rationing and other budget-cutting measures to rein in costs of ESRD care, which is generously funded relative to other chronic illnesses. Therefore, nephrologists should expect implementation of cost-cutting measures, such age-based rationing, mandated delayed dialysis and home therapies, compensated organ donation, and a shift in research priorities from the dialysis to the predialysis patient population. Nephrologists also need to recognize that these changes, which are geared toward the population level, may make it more difficult to advocate effectively for the needs of individual patients.

Renal unit characteristics and patient education practices that predict a high prevalence of home‐based dialysis in Australia

“…Home dialysis is more cost effective than centre based dialysis and therefore current healthcare systems operating within economic and resource restraints need to prioritize the modifiable factors that can maximize home dialysis rates . The high ratio of patients per pre‐end stage educators indicates that patient education has a low priority in hospital budgets.…”

The Evolving Ethics of Dialysis in the United States

“…When considering the just allocation of limited Medicare funds, the utility of dialysis for an individual is not merely compared with the utility to another patient with advanced kidney disease, but to payment for coronary stent placement, supporting cancer research, or instituting preventive health programs. Some calculations using QALYs suggest that dialysis provides relatively little value as compared with other health care measures (24,50). From an egalitarian perspective, it is unclear why ESRD should be uniquely supported when we are unable or unwilling to do the same for other chronic diseases such as heart failure, lung disease, and cancer (50)(51)(52).…”

“…Some calculations using QALYs suggest that dialysis provides relatively little value as compared with other health care measures (24,50). From an egalitarian perspective, it is unclear why ESRD should be uniquely supported when we are unable or unwilling to do the same for other chronic diseases such as heart failure, lung disease, and cancer (50)(51)(52). Questions such as "On what basis should financial resources be allocated?"…”

Patient-Centered Care

“…In short, the goal is to deliver better care at lower cost (1). The Medicare ESRD program is among the CMS-funded programs in which valuebased purchasing will be implemented (2). Increases in Medicare spending, particularly in the Medicare ESRD program, have provided the major impetus for these proposed changes (2)(3)(4).…”

“…The Medicare ESRD program is among the CMS-funded programs in which valuebased purchasing will be implemented (2). Increases in Medicare spending, particularly in the Medicare ESRD program, have provided the major impetus for these proposed changes (2)(3)(4). In 2010, 7.9% of all Medicare expenditures were spent on the 1.3% of Medicare beneficiaries with ESRD (5).…”