Dialysis

Anyone with end stage renal disease qualifies them for Medicare coverage. Currently this amounts to about 11 million patients in the US, with over 350,000 of them on dialysis - so about 2% of Medicare patients are on dialysis. For one patient, for one year, Medicare pays $67,000 for dialysis totally over $20 billion per year for dialysis, which takes up close to 10% of their budget. This means that 2% of Medicare patients take up close to 10% of the Medicare budget! And the numbers are only increasing.

I find this disturbing for a few reasons. For one, patients on dialysis are generally relatively sick. The 5-year mortality rate for patients on dialysis is 60%. That means that even with dialysis, a very expensive intervention, 6 out of every 10 patients on dialysis still die within 5 years.

Secondly, it's ethically questionable to spend so much money on a relatively small number of people. With a limited budget, the money could be used in countless other ways to prolong the lives or improve the health of a greater number of patients. Given the fact that 60% of patients still die within 5 years of starting dialysis, the cost-effectiveness of this intervention seems very high.

Finally, irrespective of ethics or efficacy of the treatment, can the U.S. afford this at this time? With rising rates of kidney failure and more and more patients needing dialysis, it may not be a possibility for the United States to continue paying for dialysis for all patients in the future. Not really a question I'm qualified to answer.

So what's the answer? Once someone has Medicare and is on dialysis, it's definitely ethically questionable to take away that treatment and send them on their way towards death! I don't have any great solutions, but perhaps the government will eventually have to stop providing payments for dialysis, with some sort of grandfather clause for those already on dialysis.

Of course, I'm sure if someone I cared about, or I myself, were on dialysis, my opinions and thoughts would be completely different.

Medicare sucks

There are a lot of changes going on in health care. One is that pretty soon in Pennsylvania, it will be mandatory for hospitals to report hospital-related infections. Now, I believe this is a very good step overall. For one, it's important for hospitals to keep track of something like that, and to take steps to lower the numbers. It is probably impossible to completely eliminate it, but it's crucial to reduce it as much as possible. Although hospitals should already be taking measures to do so, I think mandatory reporting will go a long ways toward speeding hospitals along. Secondly, I think it's good that patients will be able to access this information and see the rates of hospital-related infections at different institutions. This may help them make health care decisions, which in turn, will pressure these institutions to lower their rates of hospital-related infections.

However, I also see some potential problems. For one, I have heard that Medicare is going to stop paying for hospital-related complications and infections. Now while I believe that many hospitals will be able to reduce these by quite a lot, hospital-related infections will never be completely eliminated. Let me give an example.

A patient comes in because he had a heart attack. He's on the older side, also has hypertension, and congestive heart failure. The heart attack really does a number on his heart and it starts failing. He can't pump his blood well, fluid builds up in his lungs, he can't breathe, and he gets sent to the ICU and gets intubated - that's getting a tube thrust down your pharynx so that you can breathe with the help of a machine. This is a life-saving intervention. Without it, this patient would have died. However, several days after intubation, the patient develops a rip-roaring pneumonia. He gets treated with antibiotics and gets better. Eventually, the patient's heart gets better, he gets extubated (the breathing machine is removed), has open-heart surgery and lives another happy 20 years.

A relatively high percentage of patients that are intubated develop pneumonia. While this is serious, it can be treated with antibiotics. Medicare is saying that they will not pay for the antibiotics, because this type of pneumonia is a hospital-related infection - even though this infection was the result of a life-saving intervention! This is not the only example of something like this - there are many others.

Who is going to pay for the cost then? The patients? No - they never have enough money. So it will go to the hospitals. They will have to eat the costs and make up for them by billing more for just about everything else. Would it be ethically okay for the hospital and doctors and nurses to say, well, this patient will probably develop pneumonia if we intubate him, and we won't get paid for that, so nevermind. Let's just let him die. Of course that would not be ethically acceptable, and of course that won't happen.

I think it's ridiculous and sustainable for neither the insurance companies nor the hospitals.

Paul Levy, the president and CEO of Beth Israel Hospital in Boston posted about this topic and I think he also brought up some very good issues.