Monday, September 26, 2011

Dialysis: continued debate about tragic choices, and how to finance not having to make them

This recent story about who pays for dialysis for uninsured illegal immigrants reminds me of the initial stories of how Medicare came to cover dialysis, making kidney disease unique in the way it is financed. There is a special horror in denying routine life saving treatment to patients who will die without it. That is, emergency rooms aren't supposed to deny treatment to anyone, but dialysis only becomes an emergency when regular access is denied...but we haven't done a great job of figuring out the financing.

Here's the NY Times story on illegal immigrants, by Kevin Sack: Deal Reached on Dialysis for Immigrants

"Twenty-one illegal immigrants will continue to receive regular dialysis at no cost for three years under an agreement disclosed Friday by Atlanta’s public hospital, Grady Memorial, and the world’s largest dialysis provider, Fresenius Medical Care.

"The deal solves an impasse created when a previous one-year contract between Grady and Fresenius expired on Aug. 31 and the dialysis provider refused to serve patients who showed up for their regular thrice-a-week treatments.

"The patients spent the past week seeking care in Atlanta-area emergency rooms, including Grady’s, which are required by federal law to screen and treat those at risk of impairment or death.

"In some instances, ailing patients were turned away by emergency room doctors who determined that their elevated potassium levels and fluid retention were not yet severe enough to justify emergency treatment. Each renal patient’s need for dialysis is different, but those unable to artificially clean the toxic substances from their blood can die in as little as two weeks.
"The patients’ odyssey began two years ago when Grady closed its outpatient dialysis clinic, where many had received free treatment for years. Illegal immigrants are not eligible for Medicare, which covers most dialysis costs for American citizens. After the immigrants filed a lawsuit and gained news media attention, the hospital agreed to pay Fresenius to care for them during a transitional period. Other than the past week, it has never ended.

"Under the new contract, Grady agrees to pay Fresenius $15,500 per patient per year for treatment at the company’s outpatient clinics. That is less than half of the $750,000 flat fee Grady paid Fresenius for the yearlong contract that just ended.

"Grady, which receives direct appropriations from two county governments, faces a budget shortfall of more than $20 million this year. It maintained in negotiations that it could not afford to pay Fresenius the previous rates."

Here's a previous post on how dialysis entered Medicare:

The special (Medicare) status of kidney disease

" In Seattle, in response to financial limitations, access to dialysis was restricted through explicit rationing carried out by an anonymous lay committee — an approach that was laid bare for the American public in a Life magazine article in November 1962.2 Elsewhere, decisions limiting access to dialysis were tacitly incorporated into traditional medical decision making. Dialysis highlighted the tragic choices that had to be made when fundamental societal values encountered problems of scarcity.
"In November 1971, a patient received dialysis — albeit very briefly — at a hearing of the House Committee on Ways and Means."


And here's a post on the continued debate about tragic choices, even without the added distraction of immigration status: 

Medicare payments for dialysis

The New York Times describes the growing federal expenses for dialysis, and some surrounding controversy: When Ailments Pile Up, Asking Patients to Rethink Free Dialysis

"Of all the terrible chronic diseases, only one —end-stage kidney disease — gets special treatment by the federal government. A law passed by Congress 39 years agoprovides nearly free care to almost all patients whose kidneys have failed, regardless of their age or ability to pay.

"But the law has had unintended consequences, kidney experts say. It was meant to keep young and middle-aged people alive and productive. Instead, many of the patients who take advantage of the law are old and have other medical problems, often suffering through dialysis as a replacement for their failed kidneys but not living long because the other chronic diseases kill them. 

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