Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SATURDAY, June 25, 1994 TAG: 9407070075
SECTION: EDITORIAL PAGE: A-9 EDITION: METRO
SOURCE: By NEWELL R. FALKINBURG,M.D.
DATELINE: LENGTH: Long
Although we had four dialysis stations at our hospital, prohibitive costs made it impossible for many patients in need of dialysis to get treatments. These patients had neither choices, options, nor rights in their quest for this very expensive life-sustaining treatment.
Because there were many more patients than could be accommodated, a decision had to be made about who would and would not receive dialysis. A committee was formed that decided which patients would live and which would die. The committee, consisting of the nephrology physician-chief, his associate, a chaplain, chief dialysis nurse and one or two civic leaders, met monthly, or as needed, to make its decisions. Eligible patients had to be less than 55 years of age; have no complicating diseases such as heart disease, diabetes, cancer, collagen diseases, etc.; and had to be healthy, having only the problem of kidney failure. They also had to be productive and employed. Financial affluence was considered, although not heavily. Patients who couldn't dialyze at the hospital were required to train and do their treatments at home with machines purchased at their own expense. In-center chronic dialysis treatment cost approximately $30,000 a year; home hemodialysis cost $12,000 to $15,000 per year. This sum was, of course, out of reach for most Americans.
At one committee meeting, a 32-year-old engineer, father of three with chronic renal failure, was presented for consideration. He was healthy, except for well-controlled high blood pressure. He was intelligent, compliant and employed. There was only one dialysis spot available. Competing with him was a 28-year-old housewife, mother of two, with polycystic kidney disease and secondary end-stage kidney failure, who also needed dialysis. After a long, arduous debate, the committee gave the spot to the engineer because he was a breadwinner. As difficult as it seems, it was decided the mother could be more easily replaced. That day, the committee played God.
Even in the early '70s, this was considered to be a somewhat less than outstanding social circumstance. As one might expect, it didn't take long for our well-meaning Congress to begin holding hearings, evaluating this situation. Robert Dole, the current Senate minority leader, was on the hearing committee, as was Ted Kennedy and other legislators active in health-care issues. A patient from the University of Washington in Seattle came to Washington, D.C., with his hemodialysis machine, and performed a dialysis treatment before this committee. It was then decided that the Medicare program would be expanded to include the end-state kidney disease. To this day, it's the only ``disease'' covered by Medicare.
My friends, this is health-care rationing! You'll see and hear many definitions, but the above scenario truly describes the phenomenon as it is: The resources are there, a patient needs them, but cannot have them because of cost and/or availability. The cost to the patient may be his or her life or, with luck, only some inconvenience.
In the United Kingdom, very few patients receive chronic dialysis therapy, as compared with the United States. These patients rarely have associated diseases in addition to their kidney failure. Those who do, die. In the United Kingdom, very few patients above the age of 50 are on dialysis. In the United States, the average age exceeds 60 years. Why? In the United Kingdom, it takes months or years to get routine hernia repairs or other necessary, but not urgent, treatments. This, too, is health-care rationing, but cost to the patient isn't his life. It's his time and associated inconvenience.
It's the high cost that bedevils our American health-care system. Our government and insurance industry have so distorted health-care economics that prices have skyrocketed out of reach for most. The high cost and overuse of technology, though subordinate, are major contributors as well. A largely ignored issue, but central to the health-care debate, continues to be unwillingness of Americans to take responsibility for their choices. It's an indisputable fact that our lifestyle choices put us in the position of requiring much more, and more costly, health care earlier in our lives. These issues are mentioned as areas of potential solutions to the problem, rather than to prosecute or fix blame. We're all in this together, and I believe real solutions can be found.
You never hear the ``r'' word mentioned in Washington. What you hear instead is the term ``global budgeting,'' which is the coward's parlance for health-care rationing. (At least in Oregon, they call a spade a spade.) Don't be fooled; the concept of global budgeting (when the money is gone, you wait or die) is the tacit rationing of health care. It's a quick and inadequate fix, making it unnecessary to isolate and address the difficult root causes of our high costs and the hard choices we have to make to make our great health-care system work for everyone.
Think of it: When the money is gone, you wait or you die. This is what happened 25 years ago when I was a student, and it was the excuse government used to involve itself in American medicine. Cowards and incompetents have come full circle, bringing us back to square one! What an interesting and awakening odyssey it's been - the stuff from which cynicism is bred.
Newell R. Falkinburg, M.D., is president of the Roanoke Valley Academy of Medicine.
by CNB