End Stage Renal Disease is one of the most complicated health states, both in economic and medical terms. This paper presents a review of article written by J.D. Sullivan (2010) and titled “End Stage Renal Disease economics and the balance of treatment modalities.” The paper answers a number of questions related to the economics and ethics of the existing treatment modalities for patients with ESRD. Reimbursement mechanisms for the most common treatment modalities are described.
Keywords: ERSD, kidney disease, reimbursement, treatment modality.
End Stage Renal Disease Economics and the Balance of Treatment Modalities
Renal disease remains one of the most complicated, destructive, and expensive health problems. Urine production is a very complicated process, and kidneys fulfill the role of the body’s chemists (Sullivan, 2010). This is why any problem with kidneys necessarily results in serious health complications and increases the burden of financial costs on the health care system. At least 26 million patients in the U.S. are impacted by chronic kidney disease (CKD), while millions of others face the risks of developing it (Sullivan, 2010). Not surprisingly, the diagnosis raises numerous economic questions and ethical concerns. The existing reimbursement mechanisms have many advantages and weaknesses. Yet, it is the conflict between the cost-effectiveness of treatment modalities and providers’ profitability strivings that adds to the burden of health care costs and does not allow reducing the scope and incidence of kidney problems.
Sullivan (2010) describes the existing reimbursement mechanisms for various kidney therapies. In terms of hemodialysis, the reimbursement structure is based on the assumption that patients attend the outpatient center three times a week, to spend between 3.5 and 4.5 hours connected to medical equipment (Sullivan, 2010). The same amount of money is paid for the seven-day therapy to patients on peritoneal dialysis. The reimbursement system for both types of therapy includes the basic treatment and additional payments for testing and ancillary drugs (Sullivan, 2010). Prescriptions for peritoneal dialysis are paid in the same way and amount as the prescriptions for hemodialysis, but certain non-government payers may treat PD and hemodialysis as two separate payment structures (Sullivan, 2010). The difference in costs between PD and hemodialysis is attributed to the cost of ancillary drugs: patients assigned to PD usually face fewer medical complications and, for this reason, do not need as many drugs as patients on hemodialysis to achieve the desired level of wellbeing (Sullivan, 2010).
The economics of the End Stage Renal Disease program deserves special attention. The history of the program dates back to 1973, when the amount of health care services available to patients with renal disease changed dramatically (Sullivan, 2010). Under the new program, almost every citizen would be entitled for tax dollars’ coverage for renal disease, regardless of age (Sullivan, 2010). The basic argument behind the program was that transplants would help keep the costs of renal disease low; simultaneously, hemodialysis would become a role model of universal health care for individuals with ESRD (Sullivan, 2010). Unfortunately, the program failed its mission to become a universal health model. On the contrary, it drove the costs of health care and became a real problem for American taxpayers. As a result, less than 1% of Medicare population consumes more than 6% of its total budget, raising the question of economic feasibility in the context of ESRD.
Today’s patients with renal disease face several treatment options. These options are called ‘treatment’, because renal disease cannot be cured. The best treatment option both in terms of economics and health outcomes is kidney transplantation (Sullivan, 2010). Even when an ideal match of the patient and transplant has been achieved, this patient will have to take immunosuppressive drugs to avoid kidney rejection (Sullivan, 2010). However, the lack of available organs keeps the rates of kidney transplantation in the U.S. very low, although the remarkable cost-effectiveness of transplantation can hardly be disregarded.
Those who are unlucky to get a kidney transplant have to choose between hemodialysis and peritoneal dialysis. The former is the most common life-supporting treatment for patients with ESRD. Hemodialysis is performed in an outpatient center, which most patients visit three times a week (Sullivan, 2010). The effectiveness of this treatment modality is offset by the amount of time patients must spend on hemodialysis. It is due to hemodialysis that many patients cannot afford working full-time or drop entirely out of the workforce (Sullivan, 2010). Peritoneal dialysis differs greatly from hemodialysis in that it involves the use of the patient’s peritoneal cavity, does not require visiting the outpatient center, and takes place seven days a week (Sullivan, 2010). The most common types of peritoneal dialysis are Continuous Ambulatory Peritoneal Dialysis and Continuous Cycling Peritoneal Dialysis (Sullivan, 2010). The former requires multiple exchanges of dialysate during one day, whereas the latter presupposes using the “cycling” machine connected to the patient during the night sleep (Sullivan, 2010). Although the risks of inflammation are high, PD is a better alternative to hemodialysis.
The economics of ESRD is associated with numerous ethical controversies. While providers are struggling to enhance their profitability, patients suffer the lack of transplantation opportunities and are not given any treatment choice. Dialysis companies face increased fixed asset investments, and they are willing to send more patients to hemodialysis, working as a joint venture with nephrologists (Sullivan, 2010). As a result, not health but economics becomes the primary criterion of decision making in medicine. This is also why few patients are assigned to peritoneal dialysis. It carries the lowest costs from the payers’ perspective, but it is not very profitable for health providers (Sullivan, 2010). Consequently, medical care provided to patients with ESRD does not fulfill the promise of improved health and wellbeing and operates merely as a factor of increased profitability for care providers.
Millions of Americans suffer from chronic kidney diseases. Despite the dramatic advancements in medicine, the country has been mostly unsuccessful in its struggle against ESRD. The main problems facing patients with ESRD are associated with an ongoing conflict between providers’ profitability goals and the overall cost-effectiveness of the existing treatment modalities. At present, kidney transplantation is the most promising treatment method for patients with ESRD, but the availability of transplants is low. Peritoneal dialysis leads to improved health outcomes and is more cost-effective than traditional hemodialysis, but dialysis providers are not willing to lose their share of profits and have patients switched to PD. As a result, care provided to ERSD patients does not fulfill its treatment promise and simply serves an effective source of material profits for medical service providers.