PEDIATRICS Vol. 93 No. 2 February 1994, pp. A46
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THIS FEDERAL HEALTH PLAN WORKED TOO WELL

J. F. L. MD

Before okaying any plan that attempts to increase access to health care while harnessing costs, congress ought to re-examine the government-funded End-State Renal Disease program. It shows that per-treatment costs can be controlled by setting limits on what providers are paid, but controlling the volume is vastly more complex...

A program that initially served 11,000 people today serves 165,000 and is expected to soon have 300 000 beneficiaries...

First year costs were $229 million and reached $1 billion by 1977. In 1991, the program cost $6.6 billion.

Even so, efforts by Medicare, which administers the program, to control perpatient costs have been a great success. Administrators capped the reimbursement rate early and steadfastly refused to raise it—not even to compensate for inflation. Twice the rate was lowered. Thus, the cost in constant dollars of a dialysis treatment has fallen 61%—$54 from $138...

Today dialysis patients are older and sicker, and people over age 65 form the fastest growing group of new users. Among the aged beneficiaries are people in a persistent vegetative state and nursing-home residents who go to dialysis centers on stretchers...

In Britian it is rare for anyone over age 55 to go on dialysis, largely because the British health-care system contains an implicit bias against providing dialysis for any kidney patient with multiple serious disorders, which elderly patients almost always have. As a result, for every million people in Britain, 154 are on dialysis; in the U.S., 539 people out of every million are on dialysis.