The Organization of Medical Care -- Lessons from the Medicare End Stage Renal Disease Program

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Abstract
National attention is currently focused on the organization of medical care in the United States. Competing groups with different ideas about reorganizing health care advance views based on socioeconomic hypotheses and evaluations of health care systems in other countries. The participants in the debate about the reorganization of U.S. health care have taken little notice of the experience with existing health care systems organized by our government. The Medicare program that provides treatment for patients with end-stage renal disease (ESRD) is 20 years old; recently, it has been the subject of extensive review and analysis1. Over the past 20 years, the Medicare End Stage Renal Disease Program has demonstrated many of the virtues and problems of modern high-technology medicine. Hundreds of thousands of Americans have enjoyed extra years of good-quality life because the program lowered financial barriers to lifesaving technology. However, the quality of life achieved by some patients on dialysis has been suboptimal, and costs have escalated far beyond the original expectations. The lessons of the End Stage Renal Disease Program have not been applied to the current debate about health care reform. My purpose is to review the program from this perspective. The dialysis machine has been described as “a metaphor for modern technological medicine”2; the implications of this metaphor for health policy deserve careful scrutiny.