By Bill Peckham
In January this year HDC published an article by Dr. Agar, Home Dialysis Central Beware What You Wish For, Or How Good Dialysis Got Gazumped. First I should confess my astonishment that Gazumped is a word. Second, I second his view that there is much wisdom to be found in reading the history of dialysis, for instance:
Richard Rettig’s seminal bio-medical paper from 1991, Origins of the Medicare Kidney Disease Entitlement: The Social Security Amendments of 1972 … is compelling reading.
Rettig’s 1972 report and many of his other reports, e.g. 1996 2001 2011, are online and he was the primary editor of the 1991 IOM report Kidney Failure and the Federal Government also available online.
Dr. Agar’s telling of the history misses an import logic underpinning the creation of the 1972 ESRD entitlement. In 1972 Congress voted a "review/extension of Medicare and Medicaid" AND expanded Medicare to cover the disabled. For the first time people could qualify for Medicare coverage if they qualified for disability under Social Security - if they were unable to work and otherwise qualified. The concern was that people who needed to use dialysis, were Medicare qualified, and wanted Medicare coverage would leave the workforce to file for (and receive) disability. Therefore, rather than say ESRD is the only disease that lets you use Medicare, it is more accurate to say that ESRD is the only disease that lets you use Medicare and keep your job.
The ESRD entitlement does not give people Medicare coverage for dialysis, being disabled gives people Medicare coverage for dialysis. The ESRD entitlement gives people who are covered under Medicare the opportunity to keep working. In 1972 the fear was that given the new disability entitlement dialysis patients would quit their jobs to qualify. The ESRD exception meant people could have Medicare and keep their jobs. This was the logic that calmed republican members of the House Ways and Means committee, though it is fun to imagine doe eyed fiscal conservatives dazzled into acquiescence by Scribner’s silky smooth cost estimates.
I’m not exactly sure who is gazumping who in Agar’s telling, but I don’t think it is fair to say:
The estimates were, in hindsight, wildly short of the true mark for all three: incidence, prevalence and cost.
Scribner wasn’t predicting future incidence, prevalence; his initial estimates were off but not wildly. As to cost, was he wrong? $17,000 incenter cost in 1974 would be about $90,000 today, twice what Medicare actually spends for a year of dialysis per beneficiary. Agar does not say what he would advise Scribner et al. to do differently. Knowing what he knows now what message from the future would he have for his colleagues if he were able to travel back to 1972? Was there a path that led to a brighter future where home modalities thrive ungazumped??
Maybe? I’ve seen enough movies to know that a frequent outcome of time travel is something ironic and often tragic, but I’d tell Scribner, “it is too soon for Medicare to pick winners and losers among therapies not well understood. If Medicare pays more for incenter they’ll promote the rise of incenter for profit dialysis. Scrib, can I call you Scrib?, when they ask you for a cost estimate (and they will ask you!) just keep it simple, $17,000 to $20,000 per patient per year but we are hopeful less expensive approaches will prove out; that we will see as dialysis use increases per beneficiary per year cost decline and quality improve year after year.
Oh and Scrib. Thank you. Thank you so much for everything you’ve done and everything you are going to do.”