A shocking and important investigation by the nonprofit journalism group ProPublica has found that kidney dialysis patients are more likely to die in the U.S. than in almost any other industrialized nation, U.S. patients die at nearly twice the rate of similar patients in Italy, for example — despite the fact that end-stage kidney disease is one of the only conditions for which Americans are guaranteed universal access to care at any age.
Dialysis costs the American taxpayers $20 billion a year, reporter Robin Fields writes, but thousands of patients continue to die because of poor quality of care. Fields writes:
Over the course of more than a year, ProPublica reviewed thousands of inspection reports and interviewed more than 100 patients, advocates, doctors, policy makers, researchers and industry experts to get a grasp on American dialysis. The findings were bleak: At clinics from coast to coast, patients commonly receive treatment in settings that are unsanitary and prone to perilous lapses in care. Regulators have few tools and little will to enforce quality standards. Industry consolidation has left patients with fewer choices of provider. The government has withheld critical data about clinics’ performance from patients, the very people who need it most. Meanwhile, the two corporate chains that dominate the dialysis-care system are consistently profitable, together making about $2 billion in operating profits a year.
The article shows the complexity of providing universal care through for-profit businesses, illustrating how perverse incentives in payment policies create a situation in which patient care is measured in quantity rather than quality. Dialysis patients get too many drugs (which nets profits for the clinics that are dispensing them), for instance, but not enough oversight of dialysis procedures by doctors and nurses (which costs companies money).
Fields’s investigation also describes how at least one American hospital had a “death panel” — then called a “God committee” — which determined who was worthy of access to life-saving but limited (and expensive) dialysis treatments, based on patients’ health, income and even social worth, before Medicare began guaranteeing dialysis treatment to all patients in 1972.
The article reveals a system of care wracked with incompetence, physician error and dangerous standards of practice — designed to increase profits rather than patient survival. The main problem is that Medicare’s payment scheme created incentives for private industry to move in and largely take over the business of end-stage renal disease.
But the article concludes on a lopsided note, seemingly blaming the provision of universal care itself for the problems, rather than singling out specific issues like fee-for-service systems that incentivize cheap care instead of good care:
[A]s care expands and the national health care debate staggers on, our four-decade experiment with dialysis is worth bearing in mind. All too often, patients get caught in a vise between bureaucracy and the bottom line. As dialysis shows, guaranteeing access can come at a steep price — in dollars and in lives.
In the end, that statement misses the larger point: without access or with limited access, even more lives would be lost.