OUR DIALYSIS POLICIES ARE DISASTROUS
Robert N. Sollod, Ph.D.
More than 35,000 people are dying unnecessarily every year in a government subsidized and monitored program. These are dialysis patients subsidized largely by Medicare. How is this number derived? The typical mortality rate for dialysis in industrialized countries is about ten percent on average. The US dialysis death rate is more than twice as much - currently twenty-two percent. Our deaths are over 65,000 a year instead of the 30,000 that would be the case if our death rate were the same as Italy's, France's, Germany's, or Canada's. America is an outlier in dialysis mortality in the industrialized world. For most of the 1990s, the situation was even worse - with a US mortality rate of twenty-five percent a year.
It is not easy fully to appreciate this high an incidence of mortality. It is worse than all but the bloodiest military service. The average life expectancy of a dialysis patient under current circumstances is only around three years - less than the life of most household pets. About 17,000 Americans each year are homicide victims. The 35,000 unnecessary deaths each year from dialysis treatment are twice the number of homicides and equivalent to US homicide and drug-related deaths combined.
What is the main reason for our unacceptably high death rate? It is the overall inadequacy of American dialysis - both in terms of quality and quantity. Given Medicare reimbursement policies, such an outcome should be no surprise. Payments for dialysis are fixed. There is no reward for more dialysis or for better dialysis. There is no reward for reducing mortality nor penalty for more deaths. Medicare does not provide funds for patient education or for technician training. There is no incentive for dialysis centers to provide services to help keep patients working so there is little or no effort spent in this direction in most centers. Improved quality of service leads to a decrease in the bottom line. Patient or "consumer" choice is limited, too, as mortality rate statistics of specific centers have not been required to be made accessible to prospective patients.
Many referring physicians are partners of profit-making centers - an apparent conflict of interest. Other conflicts of interest occur, as well. It appears that more dialysis and administration by subcutaneous injections reduce the need for an expensive genetically engineered medication, epogen. Th Medicare dialysis program spends over a billion dollars a year for this medication. Dialysis centers receive a cut of this money as does the drug company, Amgen. So it is not surprising that there has been little emphasis on reducing costs by increasing dialysis time or by encouraging subcutaneous injections of epogen.
Recent Senate hearings chaired by Senator Grassley concluded also that there was a lack of government oversight of dialysis centers. Only ten percent of centers are reviewed each year. Some centers provide excellent care, but others are usually unmonitored death traps. Centers with death rates of over fifty percent a year are allowed to continue functioning without
changing their procedures.
The number of unnecessary deaths caused by inadequacies in our treatment of dialysis is hundreds of times more than the loss of life caused by defective tires. It is a continuing problem. And this does not include the unnecessarily limited quality of life and unnecessary medical complications suffered by dialysis patients. With the increase in the elderly population and the rise in diabetes, we can expect more and more of us to require dialysis or to have a family member or friend on dialysis.
Our dialysis policy is having devastating results. Now is the time to demand a change in public policy to promote the well being of dialysis patients rather than simply maintain them at a precarious level of survival.
Robert N. Sollod, Ph.D.
Professor of psychology at Cleveland State University
I have been a dialysis patient for five years. I have published in dialysis journals, contributed to the recent Senate hearings and presented to health care providers on the experience of patients.
Department of Psychology
Cleveland State University
Cleveland, OH 44115